Optima Health Plan 2000
A Health Maintenance Organization
For changes
Serving Hampton Roads Virginia area in benefits
Enrollment in this Plan is limited see page 4 for requirements see page 3
Enrollment code
9R1 Self only
9R2 Self and family
Optima Health Plan has a
commendable accreditation
from the NCQA See the 2000
Guide for more information on
NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www optimahealth com
Authorized for distribution by the
United United States States Office Office of of Personnel Personnel Management Management
Retirement Retirement and and Insurance Insurance Service Service
Optima Health Plan 2000
Table of Contents
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 8
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB Facts 21
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits Inside Back Cover
Premiums Outside Back Cover
Optima Health Plan HMO 2000 i
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Optima Health Plan HMO 2000
Introduction
Optima Health Plan
4417 Corporation Lane
Virginia Beach VA 23462
This brochure describes the benefits you can receive from Optima Health Plan HMO under its contract CS 2842 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 3 Premiums are listed at the end of this brochure
Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to Optima Health Plan HMO as this Plan throughout this brochure although in other legal documents you will see a plan
referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Optima Health Plan HMO 2000
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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Optima Health Plan HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
Section 2 How We Change For 2000
Program wide This year you have a right to more information about this Plan care management our networks Changes facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until
the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record
you may add a brief statement to it If they do not provide you your records call us and we will assist
you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Your share of the premium will increase by 21.2 for Self Only or 27.3 for Self and Family
Plan Under the limited benefits provision coverage for Clinical Trials for Treatment Studies on Cancer
will be provided for Phase II III IV The clinical trial or study must meet eligibility requirements of
the Plan to be included for coverage under this benefit See page 10
Under the Mental Conditions and Substance Abuse provision coverage for biologically based mental
illness shall not be different or separate from coverage for any other illness condition or disorder for
the purposes of determining durational limits episode or treatment limits copayments or coinsurance
See page 14 for the definition of biologically based mental illness
Under the Limited Benefits provision the cardiac pulmonary and vascular rehabilitation benefit
will no longer require a 10 copayment per visit See Page 10
The copayment charge for primary care office visit will increase from 5 to 10
The copayment charge for specialist visit following a referral will increase from 10 to 15
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Optima Health Plan HMO 2000
Changes to this Under the Prescription Drug Benefits the following changes will be made See Page 14
Plan continued The copayment charge for prescription drugs will increase from 6 to 8 per prescription or
refill
For one copay members may now obtain one rescue inhaler or two maintenance inhalers
Currently members pay one copay for one rescue inhaler or one maintenance inhaler
For one copay members may now receive two vials of insulin Currently members receive one
vial per copay
Diabetic supplies coverage will be expanded to include benefits for prescribed diabetic supplies
and equipment Previously only testing strips and lancets were covered See Page 15
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our
Plan's service service area is The Hampton Roads area of Virginia including the cities of Chesapeake Hampton
area Newport News Norfolk Poquoson Portsmouth Suffolk Virginia Beach and Williamsburg as well as the counties of Charles City Gloucester Isle of Wight James City King William Mathews New
Kent Surry and York
Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another plan
If your dependents live out of the area for example if your child goes to college in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates
in other areas If you or a family member move you do not have to wait until Open Season to change
plans Contact your employing or retirement office
How much do You must share the cost of some services This is called either a copayment a set dollar amount or
I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 1,000 in copayments or coinsurance for one family member or 2,000 for two or
more family members you do not have to make any further payments for certain services for the rest
of the year This is called a catastrophic limit However copayments or coinsurance for your
prescription drugs dental services preventive vision services and outpatient mental health substance
abuse services do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
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Optima Health Plan HMO 2000
Do I have to You normally will not have to submit claims to us unless you receive emergency services from a
submit claims provider who does not contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year
you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides Optima Health Plan has developed a partnership with approximately 1,615 physicians in the Hampton
my health Roads Area The Plan has approximately 644 primary care doctors 971 specialists and 12 hospitals
care participating You must receive all your health care from plan participating doctors Your Primary Care Physician will coordinate all the care and services you receive from the Plan
When you enroll you and each covered member of your family must select a Primary Care Physician
PCP from the list of family practice doctors internal medicine doctors or pediatricians in the Plan's
provider directory You should receive a directory when you enroll or you can call Member Services
to request a directory Look in the directory to find a doctor's specialty office location telephone
number and notes on whether or not the doctor is accepting new patients You may want to call the
doctor and check to see if he or she is still participating in the Plan You can also call member
services to find out if a doctor participates in the Plan
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if Talk to your Primary care doctor If you need to be hospitalized your primary care physician or
I need to go specialist will make the necessary hospital arrangements and supervise your care
into the
hospital
What do I do if First call our Member Services department at 757 552 7550 or 1 800 206 1060 If you are new to the
I'm in the FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program
hospital when and are switching to us your former plan will pay for the hospital stay until
I join this You are discharged not merely moved to an alternative care center or
Plan The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist listed in the Plan's provider
specialty care directory
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our
criteria and obtain all necessary authorizations when creating your treatment plan You will need to
return to your PCP after all the authorized visits have been used for further evaluation of your
treatment plan
What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a
if I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you to
I enroll see a specialist who does not participate with our Plan
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What do I do if Call your primary care physician who will arrange for you to see another specialist You may
my specialist leaves receive services from your current specialist until we can make arrangements for you to see someone
the Plan else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue
serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
provider leaves the Plan the provider unless the termination is for cause If you are in the second or third trimester of
or this Plan leaves the pregnancy you may continue to see your OB GYN until the end of your postpartum care
Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program
If you are in your second or third trimester your new plan will pay for the OB GYN care you receive
from your current provider until the end of your postpartum care
How do you decide if Our Plan considers published peer reviewed medical literature about the efficacy and improvement
a service is experimental outcomes of technology along with the United States Food and Drug Administration approval for
or investigational marketing of medical devices drugs or biologicals for a particular diagnosis or condition
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a serious Call us at 757 552 7550 or 1 800 206 4060 and we will expedite our review
or life threatening
condition and you
haven't responded to
my request for service
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What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform
my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life
or life threatening threatening conditions are ones that may cause permanent loss of bodily functions or death of they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information
What do I send Your request must be complete or OPM will return it to you You must send the following
to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the
review request
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
the Plan's denial your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
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Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions
of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the
court record
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 per office visit
copay for primary care a 15 per office visit copay is required for a visit to a specialist doctor but no
additional copay for laboratory tests and x rays Within the Service Area house calls will be provided
if in the judgment of the Plan doctor such care is necessary and appropriate you pay 10 copay for a
doctor's house call and for a doctor's after hours office visit or house call within the service area You
pay nothing for home visits by nurses and health aides A specialist doctor is a doctor other than a
family practitioner internist or pediatrician
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for
women age 50 through 64 one mammogram every year and for women age 65 and above one
mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor you pay a one time charge of 50 per pregnancy The mother at
her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the
Plan is terminated during pregnancy benefits will not be provided after coverage under the Plan
has ended Ordinary nursery care of the newborn child during the covered portion of the mother's
hospital confinement for maternity will be covered under either a Self Only or Self and Family
enrollment other care of an infant who requires definitive treatment will be covered only if the
infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services and contraceptive injections You pay a 15
copay per Depo Provera injection Diaphragms are covered for the fitting only and are subject to
the 10 15 office visit copays the cost of diaphragms is covered under Prescription Drug
Benefits The cost of IUDs and the fitting and insertion of such devices are covered subject to the
10 15 office visit copays
Diagnosis and treatment of diseases of the eye
Allergy care Copayments will be required for allergy shots as follows a 5 copay will apply per
single injection a 10 copay will apply for multiple injections There is a 25 copayment for
allergy testing
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What is covered The insertion of internal prosthetic devices such as pacemakers and artificial joints
continued Cornea heart heart lung lung single and double kidney kidney pancreas and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem
cell and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and
testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when
approved by the Plan Medical Director Treatment for multiple myeloma and epithelial ovarian
cancer may be provided in a non randomized clinical trial Related medical and hospital expenses
of the donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers at no additional cost to you
Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of
fractures and excision of tumors and cysts All services and supplies necessary for the treatment of
temporo mandibular joint TMJ syndrome are covered if medically indicated Care must be received
from a Plan Primary Care Physician or by referral to a Plan oral surgeon All other procedures
involving the teeth or intra oral area surrounding the teeth are not covered excluding any dental
care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational therapy is provided on an
inpatient or outpatient basis for up to three months per condition if significant improvement can be
expected within three months you pay nothing for inpatient therapy you pay a 15 copay per visit
for outpatient therapy Speech therapy is limited to treatment of certain speech impairments of
organic origin Occupational therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily living
Durable medical equipment such as wheelchairs and hospital beds The Plan covers the first
1,000 of charges per member per calendar year You pay all charges above the 1,000 maximum
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Limited Benefits Orthopedic devices such as braces and prosthetic devices such as lenses following cataract
continued removal initial device only are covered The Plan covers the first 3,000 of charges per member per calendar year You pay all charges above the 3,000 maximum The initial surgically implanted
prosthetic device is not subject to the 3,000 coverage limit The replacement of prosthetic devices
for infants children up to age 18 due to growth or surgical revision of an amputation are covered
when determined to be medically necessary even if the infant's child's condition resulted from an
injury or illness which occurred prior to becoming a member under this Plan Breast prostheses
and surgical bras as well as their replacement are covered
Diagnosis and treatment of infertility is covered you pay 50 of charges The following types
of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay 50 of charges cost of donor sperm is not
covered Fertility drugs are not covered Other assisted reproductive technology ART procedures
such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
pulmonary rehabilitation and vascular rehabilitation is provided for up to 90 consecutive days from
the start of rehabilitation You pay nothing for the inpatient or outpatient rehabilitation
Diabetic supplies including 50 strips and lancets per month are covered for each member who
successfully completes the Sentara Diabetes Management Program Classes You must call 1 800
SENTARA 1 800 736 8272 to be enrolled in this class Pre authorization is required for
additional prescribed supplies and equipment for the treatment of insulin dependent insulin using
gestational and noninsulin using diabetes
Artificial Limb Services including repair and replacement will be covered up to a 3 000 annual
maximum
Early Intervention Services are covered according to VA state mandate for members age 0 to 3
for up to 5,000 per member per calendar year Early Intervention Services means medically
necessary speech and language therapy occupational therapy physical therapy and assistive
technology services and devices for dependents from birth to age three who are certified by the
Department of Mental Health Mental Retardation and Substance Abuse Services as eligible for
services under Part H of the Individuals with Disabilities Act Medically necessary early
intervention services for the population certified by the Department of Mental Health Mental
Retardation and Substance Abuse Services shall mean those services designed to help an
individual attain or retain the capability to function age appropriately within his environment and
shall include services the enhance functional ability without effecting a cure
Coverage for Clinical Trials For Treatment Studies on Cancer are covered if treatment or
studies are being conducted in a Phase II III or IV clinical trial Coverage may be provided for a
Phase I clinical trail on a case by case basis The clinical trial must meet all eligibility
requirements of the Plan to be included for coverage under this benefit
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What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Homemaker services
Long term rehabilitative therapy
Chiropractic services
Replacement repair and duplicates of durable medical equipment
Foot orthotics i e custom shoes custom inserts for shoes or boots
Disposable appliances equipment or supplies with the exception of disposable syringes
Blood and blood derivatives not replaced by the member
Speech therapy for developmental delay stammering
Hospital Extended Care Benefits
What is covered Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit with no dollar or day
limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary
services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits up to 100 days per calendar year when full time
skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate
as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are
covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a plan doctor who certifies that the patient is in the terminal stages of illness
with a life expectancy of approximately six months or less You pay nothing
Ambulance care Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a
25 copay per trip
Limited Benefits Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient detoxification Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate
See page 13 for nonmedical substance abuse benefits
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What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if
the service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel
that you are a Plan member so they can notify the Plan You or a family member should notify the
Plan within 48 hours It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If
you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a
Plan hospital you will be transferred when medically feasible with any ambulance charges covered in
full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is
waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because
the service area of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If
a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
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Emergencies outside the
service area continued
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is
waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service
area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care
non Plan providers for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the
Plan along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If
it is denied you will receive notice of decision including the reasons for the denial and the provisions
of the contract on which denial was based If you disagree with the Plan's decision you may request
reconsideration in accordance with the disputed claims procedure described on page 6
Mental Conditions and Substance Abuse
Mental conditons
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness or disorders The
medical management of mental conditions will be covered under this Plan's Medical Surgical
Benefits provisions Related drug costs will be covered under this Plan's Prescription Drug Benefits
and any costs for psychological testing or psychotherapy will be covered under this Plan's Medical
Conditions Benefits
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 15 copay per 1 hour visit for each covered visit 10 per 1 2 hour session and 5 per
15 minute session for visits 1 20 You pay 50 of charges for each visit for visits 21 40 and all
charges thereafter
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Optima Health Plan HMO 2000
Mental Conditions
continued
Inpatient Care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 daysall charges thereafter These inpatient days may be exchanged on a two for one basis for days where
members are treated on a day to day basis and released at the conclusion of treatment each day
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for
any other illness or condition
Outpatient care Services for the psychiatric aspects are provided in conjunction with the mental conditions benefits
Inpatient care shown above Outpatient visits to Plan mental health providers for treatment are covered as well as inpatient services necessary for diagnosis and treatment The mental conditions benefits visit day
limitations and copays apply to any covered substance abuse care
What is not covered Treatment that is not authorized by a Plan doctor
Biologically based The following diagnoses are defined as biologically based mental illness as they apply to adults and
mental illness children schizophrenia schizoaffective disorder bipolar disorder major depressive disorder panic disorder obsessive compulsive disorder attention deficit hyperactivity disorder autism and drug and
alcohol addiction Coverage for biologically based mental illness shall not be different nor separate
from coverage for any other illness condition or disorder for the purpose of determining durational
limits episode or treatment limits copayments or coinsurance
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply You pay an 8 copay per prescription unit or refill except as
noted below If a brand name drug is dispensed when a generic equivalent is available you pay the
amount by which the cost of the brand name drug exceeds the cost of the generic equivalent in
addition to the 8 copayment unless your doctor has specified that only a brand name is sufficient
and the Plan has determined that the brand name medication is medically necessary
Optima Health Plan HMO 2000 14
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What is covered Prescription drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's Drug
continued Formulary Nonformulary drugs will be covered when prescribed by a Plan doctor A formulary is a list of drugs covered by the Plan and this list is updated on a regular basis The Plan's formulary is
determined by reviewing pertinent medical literature provider feedback and changes improvements
in medical technology A copy of this Plan's current drug formulary is available by contacting the
Plan
Maintenance medications may be purchased through the Plan's Mail Order Prescription Drug
Program Prescription drugs prescribed by a Plan or referral doctor will be dispensed for up to a 90
day supply you pay two prescription drug copays per prescription unit or refill Call 800 346 9113
Monday Friday 8 a m to 9 p m and Saturday 9 a m to 5 p m EST or for 24 hour access to the
Automated Refill Line call 1 800 342 5441 You may also write to PharmaCare Direct P O Box
18910 Fairfield OH 45018 9945
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Members pay one copay per vial per tube of ointment cream per 8 ounces of oral liquid or per
34 day supply of pills or tablets up to a maximum of 150 tablets
Members pay one copay per one rescue inhaler or two maintenance inhalers
Oral contraceptive drugs a one month supply may be obtained for an 8 copay charge
Injectable contraceptive drugs you pay a 15 copay
Contraceptive diaphragms IUDs are covered under Medical and Surgical Benefits
Members pay one copay per 2 vials of Insulin
Implanted time release medications such as Norplant For Norplant you are covered for one
insertion and one removal in five years Exceptions may be made if medically necessary The
reinsertion will be subject to the same requirements for referral and copayment You must have
the prescription filled at the pharmacy not the physician's office and pay the 8 copay charge at
the pharmacy
Diabetic supplies including insulin syringes and needles
Disposable needles and syringes needed to inject covered prescribed medication you pay an 8
copay per one month supply
Coverage for four 4 pills per prescription drug copay for Viagra to treat sexual dysfunction
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Appetite suppressants or other weight management medications
Medical supplies such as dressings and antiseptics
Drugs used for the primary purpose of treating infertility
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Diabetic supplies except as listed above
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Optima Health Plan HMO 2000
Other Benefits
Accidental Dental Injury Benefit
What is covered Restorative services and supplies necessary to promptly repair but not replace sound natural teeth injury benefit are covered The need for these services must result from an accidental injury You pay
the following copays
Primary care doctor's office 10
Specialist doctor's office 15
Hospital Nothing
Outpatient surgery Applicable copay above
What is not covered Other dental services not shown as covered
See Non FEHB Benefits section for information about a preventive dental benefit available to FEHB
members
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions once every 12 months which include the written lenses prescription may be
obtained from Plan providers You pay a 15 copay per visit
Vision care services are administered by Vision Service Plan VSP Select a Participating vision
provider from the VSP list and call him or her directly to schedule an appointment If you need
assistance or to obtain a current list of VSP providers call VSP at 1 800 877 7195 Pay your copay
when services are received If the vision provider determines that you need additional medical care
you should contact your PCP for a referral
In an emergency you can call VSP or you can call a participating VSP vision provider who will
verify your eligibility through VSP In the event you are unable to obtain services from a VSP vision
provider within 24 hours you may receive an eye exam from a non VSP vision provider and receive
a 30 reimbursement for those services
You can receive your reimbursement by sending your itemized statement along with your benefit
form to VSP Claims must be submitted within six months after services are rendered
What is not covered Corrective eyeglasses and frames or contact lenses including the fitting of the lenses Eye exercises
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Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but
are made available to all enrollees and family members who are members of this Plan The cost of the benefits described
on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB
deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims
procedures
1 The Plan offers or coordinates a number of programs such as weight management PCP referral required health
education and preventive care for high risk pregnancies The member may be responsible for costs associated with
these programs Please contact a Member Services representative for further details
2 Dental care Up to two preventive dental care visits per member per calendar year Oral examination routine
prophylaxis cleaning bitewing x rays as necessary and fluoride treatment for children under age 18 will be
provided at each visit you pay a 50 copay per visit
Benefits on this page are not part of the FEHB contract
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Optima Health Plan HMO 2000
Section 6 General Exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred
services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
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Optima Health Plan HMO 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want
to re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833
Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage
coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan
is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer
we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages
you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
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Optima Health Plan HMO 2000
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cofer services and supplies that a local State or Federal Governnment agency directly or
Agencies indirectly pays for
If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it
malpractice claim must go to binding arbitration Contact us about how to begin our binding arbitration process
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Optima Health Plan HMO 2000
Section 8 Limitations FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right
information about to information about your health plan its networks providers and facilities You can also find out
your HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 757 552 7401 or write to
Optima Health Plan
4417 Corporation Lane
Virginia Beach VA 23462
You may contact Member Services at 757 552 7550 or 1 800 206 1060
TDD 757 552 7120 or 1 800 225 7784
You may also contact us by fax at 757 552 8919 or visit our website at www optimahealth com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
And premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled
I retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of
Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are available unmarried dependent children under age 22 including any foster or step children your employing or
for me and my family retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled
in another FEHB plan
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Optima Health Plan HMO 2000
Are my medical We will keep your medical and claims information confidential Only the following will have access
Records and to it
claims records
confidential OPM this Plan and subcontractors when they administer this contract Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan
ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your exspouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not
elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
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Optima Health Plan HMO 2000
What is TCC Key points about TCC
Continued You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC
in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline
How do I convert You may convert to an individual policy if
to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have
to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
insurance or other health care coverage You must arrange for the other coverage within 63 days of Health Plan Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
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Optima Health Plan HMO 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 757 552 7550 or 1 800 206 1060 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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Optima Health Plan HMO 2000
Summary of Benefits for Optima Health Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change
your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of
this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar
or day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 8
Extended All necessary services up to 100 days per calendar year You pay nothing 11
Care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days
conditions of inpatient care per year You pay nothing 13
Substance abuse Covered under mental conditions 14
Outpatient Comprehensive range of services such as diagnosis and treatment of
Care illness or injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations
laboratory tests and X rays complete maternity care You pay a 10
copay per office visit 15 copay per specialist doctor's office visit 10
per house call by a doctor 10 per hospital outpatient visit 8,9
Home health All necessary visits by nurses and health aides You pay nothing 9
care
Mental conditions Up to 40 outpatient visits per calendar year You pay a 15 copay per outpatient
Visit for visits 1 20 and 50 of charges for visits 21 40 13
Substance abuse Covered under mental conditions 14
Emergency Reasonable charges for services and supplies required because of a medical
care emergency You pay a 50 copay to the hospital for each emergency room visit other copays and any charges for services that are not covered by this
Plan 12,13
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay
drugs a 8 copay per prescription unit or refill If a brand name is chosen you pay the 8 copay plus the difference between the brand name and generic drug 14,15
Dental care Accidental injury benefit You pay the appropriate copay under emergency benefits on page 16 depending on where care is received for emergency
care 16
Vision care Refraction once every 12 months You pay 15 per visit 16
Out of pocket Copayments are required for a few benefits however after your out of pocket
maximum Expenses reach a maximum of 1,000 per Self Only or 1,000 per each Family Member not to exceed 2,000 per Self and Family enrollment per calendar
Year covered benefits will be provided at 100 This copay maximum does not
Include prescription drugs dental vision or outpatient mental conditions
substance abuse service
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2000 Rate Information for
Optima Health Plan Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide
for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred
to as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee
but not a member of a special postal employment class refer to the category definitions in The Guide to Federal
Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies
to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or
associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Peninsula Southside Hampton Roads
Self 9R1 78.83 28.34 170.80 61.40 93.06 14.11 93.26 13.91
Only
Self and 9R2 175.97 77.62 381.27 168.18 207.74 45.85 201.02 52.57
Family
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