in benefitssee page 3
Enrollment Code
J61 Self Only
J62 Self and Family
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www vytra com
Authorized for distribution by the
RI 73 294
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Vytra Health Plans 2000
Table of Contents Page
Table of Contents i
Introduction 1
Plain language
1
How to use this brochure
2
Section 1 Health Maintenance Organizations 2
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 16
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 19 20
Section 8 FEHB FACTS 21 24
Notes 25 27
Inspector General Advisory Stop Healthcare Fraud 28
Summary of benefits 29
Premiums 30
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Vytra Health Plans 2000
Introduction
Vytra Healthcare d b a Vytra Health Plans Corporate Center 395 North Service Road Melville NY 11747 3127
This brochure describes the benefits you can receive from Vytra Health Plans under its contract CS2206 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 Vytra Health Plans 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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Vytra Health Plans 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
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
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Vytra Health Plans 2000
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 office visits
changes 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 you 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 Your share of the non postal premium will increase by 23.2 for Self Only or 18.9 for Self and Family
this Plan Home visits by a nurse are now subject to a 10 copay per visit See page 9
Benefits are now provided for the psychiatric aspects of substance abuse in addition to benefits provided for
mental conditions See page 13
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Vytra Health Plans 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 Our service area
Plan's service is Nassau Suffolk and Queens Counties on Long Island New York
area 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 I You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance
pay for services a set percentage of charges Please remember you must pay this amount when you receive services except for inpatient hospitalizations durable medical equipment and diagnostic testing non experimental transplants mastectomies
surgical treatment of morbid obesity prosthetic appliances allergy serum mammograms and well child
care
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider who
submit claims 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 the 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 my Vytra Health Plans is an Individual Practice Association HMO who provides care to plan members That means
health care we provide a broad range of medical benefits including unlimited hospitalization Medical benefits are provided for your premium with few if any additional out of pocket expenses to you
Furthermore as an IPA HMO you receive care the way you're used to through a private doctor's office If your
present doctor is a Plan participant you can stay with him her This way you can maintain or establish the doctor
patient relationship you are familiar with Otherwise you select a doctor from our list
When you join Vytra Health Plans we will ask you to select a primary care doctor He she becomes your family
doctor arranging for referrals to specialists If hospitalization is necessary your admission will occur at the
hospital in which your doctor has admitting privileges Your primary care doctor becomes the manager of your
care and through him her you have available all of the services we provide Adult female members also have the
option of selecting a participating Ob Gyn
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 Services of other providers are covered only when there has been a referral by the member's primary
care doctor with the following exceptions a woman may see her Plan gynecologist for her annual routine examination
this also includes a certified nurse midwife and all members may see participating Chiropractors Podiatrists
or Ophthalmologists without a referral from a primary care doctor Member's seeking treatment for Mental
Conditions Substance Abuse must contact Value Behavioral Health VBH at 1 800 528 3918 for a referral to a
participating provider VBH will determine and authorize the appropriate number of visits A referral from your
PCP is not required
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Vytra Health Plans 2000
Section 3 How to get benefits continued
The Plan's provider directory lists primary care doctors generally family practitioners pediatricians and internists
with their locations and phone numbers and notes whether or not the doctor is accepting new patients
Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the
Marketing Department at 516 694 4480 You can also find out if your doctor participates with this Plan by calling
this number If you are interested in receiving care from a specific provider who is listed in the directory call the
provider to verify that he or she still participates with the Plan and is accepting new patients Important note
When you enroll in this Plan services except for emergency benefits are provided through the Plan's delivery
system the continued availability and or participation of any one doctor hospital or other provider cannot be
guaranteed
If you enroll you will be asked to let the Plan know which primary care doctor s you've selected for each member
of your family by sending a selection form to the Plan If you need help choosing a doctor call the Plan Members
may change their selection by notifying the Plan 30 days in advance
If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services until the Plan
can arrange with you to be seen by another participating doctor
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 I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will make the
need to go into necessary hospital arrangements and supervise your care The plan will provide benefits for covered services
the hospital only when the services are medically necessary to prevent diagnose or treat your illness or condition Your Plan doctor must obtain the Plan's determination of medical necessity before you may be hospitalized referred for
specialty care or obtain follow up care from a specialist
What do I do if First call our customer service department at 516 694 4480 If you are new to the FEHB Program we will arrange
I'm in the hospital for you to receive care If you are currently in the FEHB Program and are switching to us your former plan will pay
when I join this for the hospital stay until
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
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Section 3 How to get benefits continued
How do I get Your primary care physician will arrange your referral to a specialist Except in a medical emergency or when a
specialty care primary care doctor has designated another doctor to see his or her patients you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services Referral to a participating
specialist is given at the primary care doctor's discretion if non Plan specialists or consultants are required the
primary care doctor will arrange appropriate referrals
When you receive a referral from your primary care doctor you must return to the primary care doctor after the
consultation unless your doctor authorizes additional visits All follow up care must be provided or authorized
by the primary care doctor Do not go to the specialist for a second visit unless your primary care doctor has
arranged for and the Plan has issued an authorization for the referral in advance
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 I Your primary care physician will decide what treatment you need If they decide to refer you to a specialist ask
am seeing a if you can see your current specialist If your current specialist does not participate with us you must receive
specialist when treatment from a specialist who does Generally we will not pay for you to see a specialist who does not
I enroll participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive services
specialist leaves from your current specialist until we can make arrangements for you to see someone else
the Plan
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your
a serious illness provider for up to 90 days after we notify you that we are terminating our contract with the provider unless the
and my provider termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your
leaves the Plan or OB GYN until the end of your postpartum care
this Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll
Program 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 recomauthorize
medical mending follow up care Before giving approval we consider if the service is medically necessary and if it follows
services generally accepted medical practice
How do you decide Vytra Health Plans maintains advisory committees The Technology Review Committee and the Pharmacy and
if a service is Therapeutics Committee to review and determine medical necessity of new technology and pharmaceuticals
experimental or These committees are comprised of independent physicians pharmacists and other professionals For a more
investigational detailed explanation of this evaluation process please contact the Plan
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Vytra Health Plans 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 refusal OPM will
OPM to review a determine if we correctly applied the terms of our contract when we denied your claim or request for service
denial
What if I have a Call us 516 694 4480 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 OPM so that they
denied my can give your claim expedited treatment too Alternatively you can call OPM's health benefits Contract Division
request for care III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that may cause
and my condition permanent loss of bodily functions or death if they are not treated as soon as possible
is serious or life
threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or
time limits 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
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Section 4 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 Contract
mail my disputed Division III P O Box 436 Washington D C 20044
claim
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your only
upholds the Plan's 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 review on the
I file a lawsuit 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 to
the Privacy Act 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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Vytra Health Plans 2000
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 10 for a doctor's house call or for home visits by nurses
The following services are included and subject to office visit copay unless otherwise stated
Preventive care including well baby care no copay for well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through 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 no copay
Routine immunizations and boosters no copay if part of a well baby care visit
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays no copay
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care
by a Plan doctor copay for the initial 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 the 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
Diagnosis and treatment of diseases in the eye
Allergy testing and treatment including test and treatment materials such as allergy serum no copay for
allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Nonexperimental transplants including cornea heart heart lung lung single and double kidney pancreas
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 non lymphocytic 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 no copay
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 no copay
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity no copay
Durable Medical Equipment such as wheelchairs and hospital beds Diabetic supplies such as
Glucose monitors pumps lancets etc are covered as durable medical equipment and must be
obtained at participating durable medical equipment vendors at no cost to you no copay
Chiropractic services
Prosthetic appliances such as artificial limbs and lenses following cataract removal and breast
protheses and surgical bras following mastectomies as well as their replacement no copay
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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Section 5 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 that has resulted in a functional defect or that has
resulted from injury or surgery that has produced a major effect on the member's appearance and 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 consecutive months per condition if significant improvement can be expected within two
months you pay a 10 copay per session Occupational and speech therapy are limited to treatment of certain
impairments as a result of stroke
Diagnosis and treatment of infertility is covered you pay a 10 copay The following types of artificial insemination
are covered 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 assistive productive 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 you pay
a 10 copay per visit
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining
covered or continuing employment insurance or attending school or camp or travel Reversal of voluntary surgically induced sterility
Plastic surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Transplants not listed as covered
Orthopedic devices such as braces foot orthotics
Long term rehabilitative therapy
Home health aides
Hospital Extended The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under
Care Benefits the care of a Plan doctor You pay nothing All necessary services are covered including
Semi private 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 for up to 45 days 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 including intravenous fluids and medications and equipment ordinarily provided
or arranged by the skilled nursing facility when prescribed by a Plan doctor
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Vytra Health Plans 2000
Section 5 Benefits continued
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
Ambulance Service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of
detoxification 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 non medical substance
abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
Hospitalization for dental services except for covered oral surgery and
covered accidental injury dental benefit
Emergency
Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe requires
Medical immediate medical or surgical care Some problems are emergencies because if not treated promptly they might
emergency 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 you are
within the service unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the
area 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 member of your family should notify the Plan within 48 hours It is your
responsibility to ensure that the Plan has been timely notified
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Vytra Health Plans 2000
Section 5 Benefits continued
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 25 charge is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required because of injury or
outside unforeseen illness
the service area 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 which are covered benefits of this Plan If the emergency results in admission to a hospital the 25 charge 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
Full term deliveries
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
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt
non Plan providers 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 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 8
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Vytra Health Plans 2000
Section 5 Benefits continued
Mental Conditions
Substance Abuse
Benefits
Mental conditions Please refer to the Table of Contents in your medical directory for information about obtaining referrals authorizations for Mental Conditions Substance Abuse treatments
What is covered To the extent shown below this 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 to determine the appropriate treatment for a short term psychiatric condition
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay for the first 3 visits a 25 copay per visits 4 20 all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for first 30 days all charges thereafter
What is Care for psychiatric conditions which in the professional judgment of Plan doctors are not subject to significant
not covered improvement through 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 This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric
What is covered aspects of substance abuse including alcoholism and drug addiction the same as for any other illness or condition Services for the psychiatric aspects are provided in addition to the mental conditions benefits
shown above
Outpatient care Up to 60 outpatient visit's for the treatment of alcoholism and drug addiction you pay a 10 copay for each covered visit all charges thereafter
Inpatient care See Limited benefits under the Hospital Extended Care Benefits section on page 11
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Vytra Health Plans 2000
Section 5 Benefits continued
What is not Treatment that is not authorized by a Plan doctor
covered
Prescription Drug
Benefits
What is covered Prescription drugs prescribed by a doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply or 100 unit supply or one commercially prepared unit i e one inhaler one vial ophthalmic medication or
insulin You pay a 5 copay for drugs 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 Vytra Health Plans drug formulary is developed based
on the advice and recommendation of independent physicians and pharmacists and represents many of the
medicines most commonly prescribed Vytra Health Plans formulary is reviewed and or revised on a quarterly
basis More information can be obtained upon request
Covered Drugs for which a prescription is required by law
medications and Contraceptive devices
accessories Oral contraceptive drugs up to a three cycle supply may be obtained for a single copay charge
include Insulin with a copay charge applied to each vial Diabetic supplies including insulin syringes needles glucose test tablets and test tape dextrose strips and or
sticks alcohol wipes
Disposable needles and syringes needed to inject covered prescribed medication
Vitamins
Intravenous fluids and medications for home use are covered under Medical and Surgical Benefits
Limited Benefit Smoking cessation drugs and medications when obtained in connection with an approved smoking cessation program Reimbursement up to 25 for drugs and medications is provided following submission of certificate of
completion of program A maximum of 3 per lifetime
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 Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
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Vytra Health Plans 2000
Section 5 Benefits continued
Other Benefits
Dental care
What is covered The following preventive and diagnostic services are covered up to a maximum of 500 per year You pay 20 of charges after a 50 deductible
Dental prophylaxis or cleaning not more than 1 in a 6 consecutive month period
Fluoride treatment limited to 1 service in a 12 consecutive month period
Oral hygiene instruction
Sealants
Clinical oral examination not more than 1 exam in a 6 consecutive month period
Bitewing x rays limited to l service in a 6 consecutive month period
Full mouth or panorex x rays limited to 1 service in a 36 consecutive month period
Other dental x rays as necessary
Accidental injury Emergency care when authorized for accidental injury to sound natural teeth In addition this Plan will provide
benefit follow up dental services in connection with accidental injury to sound natural teeth within 12 months of the accident The need for these services must result from an accidental injury occurring while the member is covered
under the FEHBP Program you pay nothing
What is not Other dental services not shown as covered
covered
Chiropractic Care
How to access Your chiropractic benefit with Vytra is offered through Access Managed Health Care This benefit is a direct
care access benefit which means you do not need a Primary Care Physician referral to go to the chiropractor You can call any one of the chiropractors listed in the chiropractic medical directory to make an appointment or you can call
1 800 789 AMHC with any questions you may have
What is covered Coverage for basic chiropractic care as determined medically necessary by AMHC which include
Treatment
X Rays
Modalities such as
electrical stimulation
ultrasound
diathermy traction
high volt galvanic hydrocolator and cryotherapy
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Vytra Health Plans 2000
Section 5 Benefits continued
What is not The member is responsible for the same copayment as a physicians office visit
covered Treatment for personal comfort or convenience
Chiropractic equipment
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Vytra Health Plans 2000
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 and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure
Dental Care Service Members may choose the Comprehensive Option and receive all the following benefits through a participating Healthplex dentist To access dental benefits fill out a dental application and mail directly to Enrollment
Dept Healthplex Inc 60 Charles Lindbergh Blvd Uniondale NY 11553
Diagnostic Preventive Services You Pay Root Canal Therapy You Pay
Oral Exam limit 2 x per year No Charge Pulpotomy 70.00
Full Mouth X rays 1 x in 36 months No Charge Pulp Capping Indirect 10.00
Cleaning of Teeth Pulp Capping Direct 25.00
prophylaxis polishing 1x in 6 months No Charge Root Canal Therapy One Canal 250.00
Bitewing Series No Charge Root Canal Therapy Two Canals 290.00
Single Films periapical or bitewing No Charge Root Canal Therapy Three Canals or more 360.00
Fluoride Treatment 1 x in 12 months No Charge Apicoectomy with retrograde 225.00
Specialty Consultation No Charge
Clinical Oral Cancer Exam No Charge Periodontics
Emergency Treatment No Charge Scaling of Teeth Per Quad 65.00
Occlusal Film No Charge Subgingival Curettage Per Quad 65.00
Bitewings two films No Charge Gingivectomy Per Quad 90.00
Panoramic Film No Charge Mucogingival Surgery Per Quad 360.00
Cephalometric X Ray No Charge Osseous Surgery Per Quad 360.00
Diagnostic Models No Charge
Prophylaxis child No Charge Prosthetics Fixed Removable Acrylic w Metal Crown 300.00
Restorative Porcelain Crown 350.00
Silver Amalgam One Surface 25.00 Porcelain w Metal Crown 450.00
Silver Amalgam Two Surfaces 40.00 Stainless Steel Crown 110.00
Silver Amalgam Three Surfaces or More 55.00 Cast Post 150.00
Composite Filling One Surface 40.00 Recementation Per Crown 70.00
Composite Filling Two Surfaces 50.00 Acrylic w Metal Crown or Pontic 325.00
Composite Filling Three Surfaces 60.00 Porcelain w Metal Crown or Pontic 450.00 Recementation Bridge 75.00
Oral Surgery Full Upper or Lower Denture Inc Adjustment 525.00
Routine Extraction First Tooth 35.00 Partial Upper or Lower Denture Cast Chrome Base 550.00
Surgical Extraction 65.00 Denture Adjustments 30.00
Soft Tissue Impaction 100.00 75.00
Partial Bony Impaction 155.00
Full Bony Impaction 220.00 Orthodontic
Alveolectomy Per Quad 50.00 Maximum case fee 24 months 2,000.00
Benefits on this page are not part of the FEHB Contract
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Vytra Health Plans 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 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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Vytra Health Plans 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 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
insurance coverage When anyone has coverage with us and with another group health plan it is called double 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
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Vytra Health Plans 2000
Section 7 Limitations Rules that affect your benefits Continued
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide them In
beyond our that case we will make all reasonable efforts to provide you with necessary care
control
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that another person
responsible for caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds
injuries 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
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 We do not cover services and supplies that a local State or Federal Government agency directly or indirectly
Government pays for
Agencies
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Vytra Health Plans 2000
Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan
its networks providers and facilities You can also find out 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 516 694 4000 or write to Vytra Health Plans 395 North Service Road Melville NY 11747
You may also contact us by fax at 516 719 0911 or visit our website at www vytra com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees
information about Health Benefits Plans brochures for other plans and other materials you need to make an informed decision
enrolling in the 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 premiums
benefits and begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin
premiums January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB
when I retire 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 unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for my authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of
family and me 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 21
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Vytra Health Plans 2000
Section 8 FEHB FACTS continued
Are my medical We will keep your medical and claims information confidential Only the following will have access to it
and claims
records OPM this Plan and subcontractors when they administer this contract
confidential This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating 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 SF 2809 or the
cards 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 you enrolled in this
conditions Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my 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 your former
spouse coverage 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
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Vytra Health Plans 2000
Section 8 FEHB FACTS continued
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
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 in TCC If you leave Federal service your employing office will notify you of your right to enroll under 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 convert to You may convert to an individual policy if
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 23
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Vytra Health Plans 2000
Section 8 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 that indicates how
Certificate of long you have been enrolled with us You can use this certificate when getting health insurance or other health
Group Health care coverage You must arrange for the other 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
Plan Coverage 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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Vytra Health Plans 2000
Notes
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Vytra Health Plans 2000
Notes
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Vytra Health Plans 2000
Notes
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Vytra Health Plans 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 516 694 4480 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
Vytra Health Plans 2000
Summary of Benefits for Vytra Health Plans 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 DOCTOR
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 10
Extended Care
All necessary services up to 45 days You pay nothing 10
Mental Conditions
Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 13
Substance Abuse Covered
under Hospitalization Benefits 10 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 or for a house call by a doctor 9 10
Home Health
Care All necessary visits by nurses and health aides You pay a 10 copay 9
Mental Conditions
Up to 20 outpatient visits per year You pay a 10 copay per visit for
visits 1 3 a 25 copay per visit for visits 4 20 13
Substance Abuse
Up to 60 outpatient visits per year You pay a 10 copay per visit 13
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 benefits of this Plan 11 12
Prescription drugs
Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy
You pay a 5 copay for drugs per prescription unit or refill 14
Dental care
Accidental injury benefit You pay nothing Preventive dental care
You pay 20 of charges after a 50 deductible up to a 500 maximum 15
Chiropractic Care
Coverage for basic chiropractic care as determined medically
necessary which includes treatment x rays and modalities you pay a
10 copay 15 16
Vision care No current benefit
Out of pocket
Your out of pocket expenses for benefits covered under this Plan are
maximum
limited to the stated copayments which are required for a few benefits 4
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2000 Rate Information for
Vytra Health Plans
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 Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Queens Nassau Suffolk Counties
Self Only J61 78.83 33.35 170.80 72.26 93.06 19.12 93.26 18.92
Self and Family J62 175.97 117.51 381.27 254.60 207.74 85.74 201.02 92.46
30 32