Serving Central and Southern Alabama For
benefits
changesin
page 3 see
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
AA1 Self only
AA2 Self and family
Special Notice This Plan has eliminated a portion of its Service Area for 2000 Therefore this Plan will no
longer be offered to Federal employees and annuitants in the State of Mississippi rather it will be offered
only to Federal employees and annuitants in central and southern Alabama If you are enrolled in this Plan
and live or work in one of the following areas you must select another plan during Open Season to continue
to receive full Plan benefits George Hancock Harrison Jackson Pearl River and Stone counties in southern
Mississippi If you live or work in one of these areas and do not select another FEHB plan you must travel to
a county in the Service Area i e central or southern Alabama and be seen by a Plan provider in order to
receive full Plan benefits
Visit the OPM website at http www opm gov insure
and
this Plan's website at http primehealthonline com
Authorized for distribution by the
United States Office of Personnel Management
Retirement Insurance
RI 73 280
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PrimeHealth of Alabama Inc 2000
Table of Contents
Page
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 6
Section 4 What To Do If We Deny Your Claim or Request For Service 7 8
Section 5 Benefits 9 18
Section 6 General Exclusions Things We Don't Cover 19
Section 7 Limitations Rules That Affect Your Benefits 20 21
Section 8 FEHB FACTS 22 25
Inspector General Advisory Stop Healthcare Fraud 26
Summary of Benefits 29
Premiums 30
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PrimeHealth of Alabama Inc 2000
Introduction
PrimeHealth of Alabama Inc
1400 University Blvd S
Mobile AL 36609
This brochure describes the benefits you can receive from PrimeHealth of Alabama Inc under its contract CS 2116 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 PrimeHealth of Alabama Inc as this Plan throughout this brochure even though 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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PrimeHealth of Alabama Inc 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
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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PrimeHealth of Alabama Inc 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 To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits
This year you have a right to more information about this Plan care management our networks
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 non postal premium will increase by 12.6 for Self Only and by 17.6 for Self and
Plan Family
The Plan has eliminated a portion of its Service Area for 2000 Therefore this Plan will no longer be
offered to Federal employees and annuitants in the State of Mississippi rather it will be offered only to
Federal employees and annuitants in central and southern Alabama If you are enrolled in this Plan and
live or work in one of the following areas you must select another plan during Open Season to continue
to receive full benefits George Hancock Harrison Jackson Pearl River and Stone counties in southern
Mississippi If you live or work in one of these areas and do not select another FEHB plan you
must travel to a county in the Service Area i e central or southern Alabama and be seen by a Plan
provider in order to receive full Plan benefits See front cover and page 4
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PrimeHealth of Alabama Inc 2000
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
Plan's service Our service area is
area Alabama Autauga Baldwin Bullock Chilton Clarke Coosa Dallas Elmore Escambia Lowndes
Macon Mobile Montgomery Tallapoosa and Washington counties
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
Your out of pocket expenses for benefits under this Plan are limited to the stated copayments for a few
benefits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't 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 PrimeHealth of Alabama Inc is a Mixed Model Plan MMP using the services of both Group Practice
my health and Individual Practice Physicians Members are free to choose their primary care doctor from the
care Plan's list of participating providers and are not limited to specific group practices or locations PrimeHealth's network currently consists of over 700 physicians and 20 hospitals throughout central
and southern Alabama
PrimeHealth of Alabama Inc is a state licensed HMO wholly owned by the University of South
Alabama Foundation Founded in 1984 PrimeHealth is now Alabama's oldest HMO The Plan
operates in accordance with Alabama HMO regulations as directed by the Alabama Department of
Public Health and meets all statutory requirements of the Alabama Departments of Insurance and
Public Health
The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services particularly
those of specialists are obtained It is the responsibility of your primary care doctor to obtain any
necessary authorizations from the Plan before referring you to a specialist or making arrangements for
hospitalization Services of other providers are covered only if you have been referred by your primary
care doctor with the following exceptions a woman may see her Plan gynecologist for her annual
routine examination without a referral and routine eye and dental care also do not require a referral
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PrimeHealth of Alabama Inc 2000
How To Get Benefits continued
What do I do if Call us We will help you select a new one
my primary
care physician
leaves the
Plan
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist
I need to go will make the necessary hospital arrangements and supervise your care
into the
hospital
What do I do if First call our customer service department at 800 544 9449 If you are new to the FEHB Program we
I'm in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when I your former plan will pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or
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
specialty care 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
when creating your treatment plan
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a
I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us
specialist when you must receive treatment from a specialist who does Generally we will not pay for you to see a
I enroll specialist who does not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive
my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the
Plan
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PrimeHealth of Alabama Inc 2000
How To Get Benefits continued
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue
have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy
provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or this
Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
Program 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 Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize recommending follow up care Before giving approval we consider if the service is medically necessary
medical and if it follows generally accepted medical practice
services
How do you PrimeHealth reviews requests from providers to consider benefit coverage of new technology and or
decide if a new application of existing technology Examples of technology include drugs biologicals diagnostics
service is devices therapeutics and procedures The technology must be approved by the appropriate government
experimental or regulatory body and scientific evidence must be published in peer review journals The technology
investigational must be demonstrated to improve health outcomes outweighing any harmful effects of the procedure or device
Requests for coverage are presented to the Plan Medical Director who consults with appropriate
specialists Applications for new technology or requests for new application of existing technology are
presented to the Utilization Management Committee for review and recommendations Recommendations
are then sent to the Benefits Committee for consideration as an addition to the Plan's approved
benefit packages
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PrimeHealth of Alabama Inc 2000
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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or
OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service
What if I have a Call us at 800 544 9449 and we will expedite our review
serious or life
threatening condition
and you haven't
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening
condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are not
or life threatening treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits 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 addi
tional information
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What To Do If We Deny Your Claim Or Request For Service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following information
OPM
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
Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs
mail my disputed Contracts Division 3 P O Box 436 Washington DC 20044
claim to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the Plan's your only recourse is to sue
denial 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
I 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
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us
the Privacy Act 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
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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 office visit copay 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 nothing for a
doctor's house call or home visits by nurses and health aides
The following services are included and are subject to the office visit copays unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through 39 one mammogram during
those five years for women age 40 through 49 one mammogram every one or two years for
women 50 through 64 one mammogram every year and for women 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 test and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor office visit copay applies to first visit only The mother at her
option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
cesarean 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 including injectable contraceptives such as
Depo Provera and implantable drugs such as Norplant
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of the
device is covered except for cochlear or penile implants
Cornea heart heart lung kidney liver lung single or double and pancreas kidney 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 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
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Medical and Surgical Benefits continued
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces
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
Blood and blood derivatives
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CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Medical and Surgical Benefits continued
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 other procedures involving the teeth or intra oral areas surrounding
the teeth are not covered including 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 that 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 is provided on an inpatient or
outpatient basis for up to two months per condition if significant improvement can be expected within
two months you pay a 10 copay per outpatient session 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
Diagnosis and treatment of infertility is covered you pay a 10 copay The following types of
artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI you pay a 10 copay 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 is
provided for up to a 36 week program you pay 10 for the program
Prosthetic devices such as artificial limbs and internal lenses following cataract removal are limited to
the initial device only with the exception of coverage for breast prostheses surgical bras and their
replacements
Durable medical equipment such as hospital beds wheelchairs oxygen tents and crutches are
covered You pay 20 of charges up to a maximum Plan payment of 2,000 per member per calendar
year
What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Medical and Surgical Benefits continued
Chiropractic services
External lenses such as eyeglasses or contacts following cataract removal
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as near
sightedness myopia farsightedness hyperopia and astigmatism blurring
Podiatric services
Foot orthotics
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits 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
Blood and blood derivatives
Extended care The Plan provides a comprehensive range of benefits for up to 60 days per calendar year when fulltime
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 a 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 Care shall not exceed 180 consecutive days beyond
initial approval by the Plan
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a plan doctor determines there is a need
procedures 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 Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification 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
16 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
medical endangers your life or could result in serious injury or disability and requires immediate medical or
emergency 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 If you are in an emergency situation please call your primary care doctor In extreme emergencies if
within the you are unable to contact your doctor contact the local emergency system e g the 911 telephone
service area 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 unless it was not reasonably possible to do so It is your responsibility to ensure that the
Plan has been timely notified
If you need to be hospitalized in a non Plan facility 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 25 per hospital emergency room visit or 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 Benefits are available for any medically necessary health service that is immediately required because
outside the of injury or unforeseen illness
service area 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
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency copay
is waived
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Emergency Benefits continued
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 Elective care or non emergency care
covered 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 upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
providers 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 the 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 7
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Mental Conditions Substance Abuse Benefits
Mental conditions
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
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 30 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay a 10 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter These 30 days of inpatient care can be exchanged on a two for one basis for up to 60 days of
day treatment
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
covered 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 that is 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 and to the extent shown below the services necessary for diagnosis and
treatment
Outpatient care Up to 30 outpatient visits to Plan providers for treatment each calendar year you pay a 10 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the benefit
period all charges thereafter These 30 days of inpatient care can be exchanged on a two for one basis
for up to 60 days of day treatment
What is not Treatment that is not authorized by a Plan doctor
covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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PrimeHealth of Alabama Inc 2000
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 31 day supply You pay a 10 copay per prescription unit or refill for generic drugs
or for name brand drugs
You pay a 10 copay per prescription unit or refill for generic or name brand drugs when generic
substitution is not permissible When generic substitution is permissible i e a generic drug is available
and the prescribing doctor does not require the use of a name brand drug but you request the name
brand drug you pay the price difference between the generic and the name brand drug as well as the 10
copay per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Nonformulary drugs will be covered when prescribed by a Plan doctor
The Plan's drug formulary has been established by the Plan's Pharmacy and Therapeutics Committee
which is composed of physicians from various medical specialties They review medications in all
therapeutic categories based on safety effectiveness and cost Selected high risk or high cost medications
require prior authorization to be eligible for coverage If a patient requires medication that is not on
the Drug Formulary the physician must complete a medical exception form explaining the necessity and
indicate the patient's past therapeutic failures and FAX the completed form to the Plan's Pharmacy
Benefits Manager to allow for process and payment on the non covered medication
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs contraceptive devices including contraceptive diaphragms
Insulin copay applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin syringes needles glucose test tablets and test tape dextrose
strips and or sticks lancets and alcohol pads
Intravenous fluids and medication for home use covered implantable drugs such as Norplant and some
injectable drugs such as Depo Provera are covered under Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs are subject to dosage limits set by the Plan Contact the Plan for details
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available
covered Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Disposable medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Smoking cessation drugs and medication including nicotine patches
Drugs for weight loss and appetite suppressants
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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Other Benefits
Dental care
What is covered The following preventive services are covered when provided by participating Plan dentists you pay a 10 copay per visit
Prophylaxis cleaning twice a year
Annual topical application of fluoride
Preventive dental instructions
X rays including bite wings
Oral exam and treatment plan
Vitality test
Oral cancer exam
Accidental Restorative services and supplies necessary to promptly repair or replace sound natural teeth including
injury benefit the first dental prosthesis such as a crown or bridge Services must be provided within three 3 months of the date of the injury unless the member's medical condition indicates the dental care must be
delayed The need for these services must result from an accidental injury Dental services for the
treatment of injury caused through activities of daily living such as eating are not covered You pay
nothing
What is not Other dental services not shown as covered
covered
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 to provide a written lens prescription for eyeglasses may be obtained from Plan
providers once every 24 months for members age 18 and older and once every 12 months for members
under age 18 You pay a 10 copay per visit
What is not Corrective lenses or frames including the fitting of lenses
covered Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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PrimeHealth of Alabama Inc 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
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
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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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 re enroll
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 When anyone has coverage with us and with another group health plan it is called double coverage
insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage 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 Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that
are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries 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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Rules That Affect Your Benefits continued
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 proceed
ing 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 We do not cover services and supplies that a local State or Federal Government agency directly or
Government indirectly pays for
Agencies
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Section 8 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 to
information about information about your health plan its networks providers and facilities You can also find out about
your HMO 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 800 544 9449 or write to 1400 University Boulevard S
Mobile AL 36609 You may also contact us by fax at 334 380 3236 or visit our website at
www primehealthonline 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 The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums premiums begin January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
when I retire 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 unmarried dependent children under age 22 including any foster or step children your employing or
available for my 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
family and me
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
22 another FEHB plan
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PrimeHealth of Alabama Inc 2000
FEHB FACTS continued
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and subro
gating claims
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 We will send you an Identification ID card Use your copy of the Health Benefits Election Form
cards 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 We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if
my enrollment in You will receive an additional 31 days of coverage for no additional premium when
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
spouse coverage under 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 ex spouse'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
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PrimeHealth of Alabama Inc 2000
FEHB FACTS continued
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
Key points about TCC
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 can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
coverage 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
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PrimeHealth of Alabama Inc 2000
FEHB FACTS continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other
Plan Coverage coverage within 63 days of 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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PrimeHealth of Alabama Inc 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 800 544 9449 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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Notes
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Notes
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PrimeHealth of Alabama Inc 2000
Summary of Benefits for PrimeHealth of Alabama Inc 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 13
Extended care All necessary services up to 60 days per year You pay nothing 13
Mental conditions Diagnosis and treatment of acute psychiatric conditions for 30 days of
inpatient care per year You pay nothing 16
Substance abuse Up to 30 days per year in a substance abuse treatment program
You pay nothing 16
Outpatient care Comprehensive range of services such as diagnosis and treatment of
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 nothing per house call by doctor 16
Home health care All necessary visits by nurses and health aides You pay nothing 10
Mental conditions Up to 30 outpatient visits per year You pay 20 of charges 16
Substance abuse Up to 30 outpatient visits per year You pay 20 of charges 16
Emergency care Reasonable charges for services and supplies required because of a
medical emergency You pay a 25 copay to the hospital for each
emergency room visit and any charges for services that are not covered
by this Plan 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 10 copay per prescription unit or refill 17
Dental care Accidental injury benefit you pay nothing Preventive dental care you pay a 10 copay per visit 18
Vision care One refraction once every 24 months for members 18 and older once every 12 months for members under 18 you pay a 10 copay per
visit 18
Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits 4
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2000 Rate Information for
PrimeHealth of Alabama Inc
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
NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Govt Your Govt Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Self Only AA1 7640 2547 16554 5518 9041 1146 9041 1146
Self and Family AA2 17597 7401 38127 16035 20774 4224 20102 4896
30 32