Serving Southern and Central Wisconsin
Enrollment in this Plan is limited see page 8 for requirements
Enrollment code
W41 Self only
W42 Self and family
Visit the OPM website at http www opm gov insure
and
This Plan's website at http www unityhealth com
Authorized for distribution by the
United States Office of
Personnel Management
RI73 317
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Unity Health Plans 2000
Table of Contents Page
Introduction 3
Plain language 3
How to use this 4
brochure
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 6
Section 3 How to get benefits 8
Section 4 What to do if we deny your claim or request for service 12
Section 5 Benefits 14
Section 6 General Exclusions Things we don't cover 24
Section 7 Limitations Rules that affect your benefits 25
Section 8 FEHB facts 27
Inspector General Advisory Stop Healthcare Fraud 31
Summary of Benefits Inside back cover
Premiums Back cover
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Unity Health Plans 2000
Introduction
Unity Health Plans Insurance Corporation 840 Carolina Street Sauk City WI 53583 1374
This brochure describes the benefits you can receive from Unity Health Plans under its contract CS2268 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 6 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 Unity 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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Unity 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
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Unity Health Plans 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 when you receive
services 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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Unity Health Plans 2000
Section 2 How we change for 2000 Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
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
You may review and obtain copies of your medical records on request You may ask that a physician
amend a record that is not accurate relevant or complete If the physician does not amend your record
you may add a brief statement to the record
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 Plan Your share of the non postal premium will increase by 5.3 for Self Only or decrease by 3.5 for Self
and Family
The plan now pays 100 of the first 300.00 per occurrence for ground ambulance service and 10 of
the first 1,000.00 per occurrence for air ambulance transportation You pay 20 for charges in excess
of these amounts see page 17 Previously we paid 100 for ambulance transportation
The plan has added Hospice Care benefits see page 17 Previously there were no benefits for Hospice
Care
The plan has changed the extended care benefits to 120 day per calendar year see page 17 Previously
the plan provided 90 days of extended care benefits per confinement
The plan no longer has a 25.00 Urgent Care Center visit copay for emergency services see page 19
Previously you paid 25.00 for emergency visits to Urgent Care Centers
The plan now limits coverage of accidental injury to sound natural teeth to 1,000.00 see page 23
Previously there was no maximum
The drug copay is now 5 for generic drugs and 10 for brand name drugs Previously the drug copay
was 7
Insulin can be purchased for one copay per 102 units whereas previously it was one copay per vial
Implanted time release medications such as Norplant are now covered you pay 20 where previously
these were excluded from coverage Norplant removal prior to the end of the five 5 year implantation
period when the removal is not medically necessary is excluded
Appetite suppressants are also excluded where previously they were covered See page 22
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Unity Health Plans 2000
Section 2 How we change for 2000 continued
Coverage is provided for medically necessary diagnostic procedures and medically necessary surgical or
non surgical treatment including but not limited to intra oral splint devices for the correction of
temporomandibular disorders caused by congenital developmental or acquired deformity disease or
injury Coverage is limited to procedures or devices used to control or eliminate infection pain disease
or dysfunction You pay nothing up to 1,250 per year and all charges thereafter see page 15
Previously this coverage was not provided
The Plan now pays for cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction following a hospital confinement for a Phase II program at a Plan facility for up to 36 sessions
in a 12 week period you pay nothing Previously the Plan paid cardiac rehabilitation following a heart
transplant bypass surgery or a myocardial infarction provided at a Plan facility for up to 3 months you
paid nothing
The Plan now pays for Plan authorized dental anesthesia services for dental care when the member is a
child under the age of 5 the member has a chronic disability that meets all of the conditions under s
230.04 9r a 2 of Wisconsin law or the member has a condition that requires hospitalization or general
anesthesia for dental care you pay nothing Previously this was not a covered service
Breast reconstruction of affected tissue incident to a mastectomy is covered under the reconstructive
surgery benefits Previously this was not listed in the brochure
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Unity Health Plans 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice
service area Our service area is the Wisconsin counties of
Adams Dane Grant Jefferson Richland
Chippewa Dodge Green Juneau Rock
Columbia Eau Claire Green Lake Lafayette Sauk
Crawford Fond du Lac Iowa Marquette Vernon
Waushara
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 pay for You must share the cost of some services This is called either a copayment a set dollar amount or
services coinsurance a set percent of charges Please remember you must pay this amount when you receive services
After you pay 4,200 in copayments or coinsurance for one family member or 11,000 for two or more
family members you do not have to make any further payments for certain services for the rest of the year
This is called a catastrophic limit However copayments or coinsurance for your prescription drugs dental
services or certain durable medical equipment items do not count toward these limits and you must
continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider
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
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Unity Health Plans 2000
Section 3 How to get benefits continued
Who provides my Unity Health Plans is a mixed model HMO contracting with individual physicians local community clinics and
health care the University of Wisconsin UW Medical Center group When you enroll each member must select a primary care doctor from our list of over 600 participating primary doctors Approximately 3000 doctors are available by
referral for specialty care Please choose your doctor carefully your choice is very important Your primary
care doctor provides or obtains authorizations for all treatments and services covered by Unity Health Plans
Your doctor will coordinate and manage your entire health program You need the expert advice that your
primary care doctor can provide Together you can develop the health care program that is best suited to your
lifestyle
Your primary care doctor can take care of most problems directly If other services are necessary he or she will
direct you to the right sources for x rays lab test or whatever you may need Your primary care doctor will
decide if you need to see another doctor All referrals except for those indicated below to other doctors
including oral surgeons eye doctors etc must be made in writing by your primary care doctor before you see
them
What do I do if Call us at 800 362 3310 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 or receive outpatient services your primary care
need to go into physician or specialist will make the necessary hospital arrangements and supervise your care Your Plan doctor
the hospital must obtain authorization from us before you are hospitalized or receive outpatient services
All hospital admissions and outpatient services are subject to utilization review This ensures timely delivery of
services and avoids hospitalizations that are not necessary Medical information regarding the requested
services is reviewed to promote quality health care and cost effective delivery of care in the most appropriate
setting or level of service that can be safely provided
What do I do if First call our customer service department at 800 362 3310 If you are new to the FEHB Program we will
I'm in the arrange for you to receive care If you are currently in the FEHB Program and are switching to us your former
hospital when I 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
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Unity Health Plans 2000
Section 3 How to get benefits continued
How do I get Your Primary Care Provider can take care of most of your needs directly but when it's determined that specialty
specialty care care is necessary your primary care physician will arrange your referral to a specialist Your Primary Care Provider will make a written referral request and submit it to Medical Management for review IMPORTANT
Do not self refer If you do so without the prior approval of your Primary Care Provider Unity Health Plans
will not cover the charges A referral does not guarantee payment You must obtain all services according to the
benefits covered under your health insurance plan
Plan benefits are covered only when and if they are medically necessary and appropriate for the treatment of
your condition All elective or planned procedures or services must be prior authorized at least 24 hours in
advance by your admitting physician When arranging for medical services remember that you must receive
services at a participating plan provider except in the case of emergency
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 and obtain an authorization from Unity's Medical
Management 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 Call your primary care physician who will arrange for you to see another specialist You may receive services
my specialist from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your
have a serious provider for up to 90 days after we notify you that we are terminating our contract with the provider unless the
illness and my termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your
provider leaves OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you
Plan leaves the enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or
Program 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
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Unity Health Plans 2000
Section 3 How to get benefits continued
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 and if
medical services it follows generally accepted medical practice
As a managed care organization Unity Health Plans is interested not only in the quality of medical services you
receive but also in carefully managing your benefit resources as well Case Management Specialists assist you
and your physicians in the coordination of complex cases that require highly skilled specialty care Through ongoing
evaluation a treatment plan is carried out so that needed services are implemented in a cost effective and
organized manner
All Case Management Specialists involved in making decisions regarding your healthcare are qualified health
professionals and have appropriate state licensure All decisions are supported by written clinical criteria and
review procedures Questions about medical necessity and treatment are subject to review and decision by
Unity Health Plans Medical Director All of Unity's Health Services programs are directed toward evaluating
utilization and quality of health care services
How do you Experimental or investigational treatment or services are those drugs procedures surgeries equipment and
decide if a service devices that do not meet each of the criteria below as determined by Unity Health Plans 1 the services must
is experimental have FDA approval 2 scientific evidence must permit conclusions concerning the effect on health outcome
or investigational and 3 the research and experimental stage of the development of the treatment or service must be completed These types of treatment or services are subject to review by Unity Health Plans in accordance with the policies
and procedures of the Unity Health Plans Technology Assessment Sub Committee Copies of these policies and
procedures may be obtained by calling Unity Health Plans Customer Service at 800 362 3310
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Unity 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 in 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 at 800 362 3310 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
denied my that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
request for care Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that may
and my condition cause permanent loss of bodily functions or death if they are not treated as soon as possible
is serious or life
threatening
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Unity Health Plans 2000
Section 4 What to do if we deny your claim or request for service continued
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 12 days
of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we do not answer within 30 days In this
case OPM must receive your request within 120 days of the date we asked you for additional information
What do I send Your request must be complete or OPM will return it to you You must send the following information
to 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 Those who have a legal right to file a disputed claim with OPM are
the 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 3 P O Box 436 Washington D C 20044
claim to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your only
upholds the recourse is to sue
Plan's 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review on
if I file a lawsuit 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 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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Unity 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 10 per visit 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 for home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups Mammograms are covered as follows for women age 35 through age 39 one mammogram during these
five years for women age 40 through 49 one mammogram every one or two years for women age 50
and above one mammogram every year In addition to routine screening mammograms are covered
when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays Complete maternity care for all covered females including prenatal delivery and postnatal care by a Plan
doctor 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 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
Cornea heart kidney liver and pancreas 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
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity Orthopedic devices such as braces you pay 20 of charges
Durable medical equipment such as wheelchairs and hospital beds you pay 20 of charges Chiropractic services
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 except where noted
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Unity Health Plans 2000
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
Diagnostic procedures and medically necessary surgical and non surgical treatment including intraoral splint
devices for the correction of temporomandibular joint disorders are covered when all of the following criteria
are met the condition is caused by congenital developmental or acquired deformity disease or injury under
the accepted standards of the profession of the participating provider rendering the service the procedure or
device is reasonable and appropriate for the diagnosis or treatment of the condition and the purpose of the
procedure or device is to control or eliminate infection pain disease or dysfunction All services must be
prior authorized by Unity Health Plans and provided by a participating provider You pay nothing up to
1,250 per year and all charges thereafter
All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered including
surgical procedures for the correction of functional deformities of the mandible and maxillae
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 their attending physician will decide whether or not to have breast reconstruction surgery
following a mastectomy including whether or not to have surgery on the other breast in order to produce a
symmetrical appearance Please be reminded that for any reconstructive surgery your Plan doctor must obtain
authorization from Unity Health Plans
Short term rehabilitative therapy physical speech and occupational is provided on an outpatient basis for
up to three months per condition if significant improvement can be expected within three months It is
provided on an inpatient basis for up to two months per condition if significant improvement can be expected
within two months you pay nothing 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
Prosthetic devices such as artificial limbs are limited to the initial device only you pay 20 of charges
Breast prostheses including the surgical bra for an external prosthesis are covered following a mastectomy
you pay 20 of charges We also provide medically necessary breast replacement prostheses and bras you
pay 20 of charges Lenses following cataract removal are limited to the initial device only you pay
nothing
Diagnosis and treatment of infertility as well as the following types of artificial insemination are covered
intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay
nothing 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
following a hospital confinement for a Phase II program at a Plan facility up to 36 sessions in a 12 week
period you pay nothing
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Unity Health Plans 2000
Section 5 Benefits continued
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining or
covered continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Plastic surgery primarily for cosmetic purposes
Transplants not listed as covered Hearing aids
Long term rehabilitative therapy Homemaker services
Repairs or replacement of durable medical equipment Foot orthotics
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Unity Health Plans 2000
Section 5 Benefits continued 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
Extended care The Plan provides a comprehensive range of benefits for up to 120 days per calendar year when full time
skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered
including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility
when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home up to six 6 months per
member per year Services must be authorized in advance by the Plan and provided under the direction of a
Plan doctor
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay nothing service
up to 300 per occurrence for ground ambulance transportation and 1000 per occurrence for air ambulance
20 of changes thereafter
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Unity Health Plans 2000
Section 5 Benefits continued
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures 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 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 21 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
Hospital care related to non covered procedures
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Unity Health Plans 2000
Section 5 Benefits continued Emergency Benefits
What is a A medical emergency is a medical condition that manifests itself by acute symptoms of sufficient severity
medical including severe pain to lead a reasonably prudent layperson to reasonably conclude that a lack of medical
emergency attention will likely result in any of the following 1 Serious jeopardy to the member's health
2 Serious impairment to the member's bodily functions
3 Serious dysfunction of one or more of the member's body organs or parts
Emergencies Some problems are emergencies because if not treated promptly they might become more serious examples
within the service include deep cuts and broken bones Others are emergencies because they are potentially life threatening such
area 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
If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are
unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the
nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so
they can notify the Plan You or a family member must notify the Plan within 2 business days 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 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 a non Plan facility 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 for emergency services that are covered benefits of this Plan If the
emergency results in admission directly from the emergency room to a hospital the emergency care copay is
waived
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Unity Health Plans 2000
Section 5 Benefits continued
Emergencies Benefits are available for any medically necessary health service that is immediately required because of injury
outside the 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 services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission directly from the emergency room to a hospital the emergency care copay is
waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not 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 With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
for non Plan receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of
providers 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 12
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Unity Health Plans 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
Mental For services contact Unity Health Plans at 800 362 3310
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 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay nothing for each covered visit all charges thereafter
Transitional care Up to 15 days of transitional care per calendar year you pay nothing
Inpatient care Up to 30 days of hospitalization per calendar year you pay nothing
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
Psychological treatment of behavior and conduct disorders developmental delay and marriage counseling
Substance
abuse
What is covered The 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 20 outpatient visits to Plan providers for treatment each calendar year you pay nothing for each covered visit all charges thereafter
Transitional care Covered under mental conditions described above
Inpatient care Covered under mental conditions described above
What is not covered Treatment that is not authorized by a Plan doctor
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Unity Health Plans 2000
Section 5 Benefits continued 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 no more than a 34 day supply or 100 unit supply whichever is less or one commercially prepared unit i e
one inhaler one vial ophthalmic medication You pay a 5 copay per prescription unit or refill for generic
drugs and a 10 copay for name brand drugs when a 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 difference between the generic drug 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 Covered medications and accessories include
Drugs for which a prescription is required by law Oral and injectable contraceptive drugs up to a three cycle supply may be obtained for a single copay
charge
Contraceptive diaphragms and IUDs Insulin with one copay charge per 102 units
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution
or equivalent and acetone test tablets
Disposable needles and syringes needed to inject covered prescribed medication Intravenous fluids and medication for home use and some covered injectable drugs are covered under
Medical and Surgical Benefits
Drugs to treat sexual dysfunction
What is not Drugs available without a prescription or for which there is a non prescription 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 Medical supplies such as dressings and antiseptics
Implanted time release medications such as Norplant Smoking cessation drugs and medication including nicotine patches
Drugs for cosmetic purposes Drugs to enhance athletic performance
Fertility drugs Appetite suppressants
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Unity Health Plans 2000
Section 5 Benefits continued Other Benefits
Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair sound natural teeth The need for these services
benefit must result from an accidental injury Coverage for injuries resulting from eating accidents is excluded Treatment must begin within three 3 months of the accident You pay nothing up to 1,000 per accident all
charges thereafter
Dental Anesthesia services for dental care is covered when the member is a child under the age of 5 the member has a
Anesthesia chronic disability that meets all of the conditions under s 230.04 9r a 2 Of Wisconsin law or the member has
Services a condition that requires hospitalization or general anesthesia for dental care All services must be prior authorized by Unity Health Plans 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 annual eye refraction to provide a written lens prescription for eyeglasses may be obtained from Plan
providers One eye exam every calendar year may be obtained without a referral more than one exam in a 1
year period requires a referral from your primary care doctor You pay nothing
What is not Glasses frames corrective lenses except for initial acquisition following cataract surgery
covered Eye exercises
Dispensing fees
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Unity 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
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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Unity 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 reenroll
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 You must
insurance tell us if you or a family member has double coverage You must also send us documents about other insurance
coverage 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 them
beyond our In 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
responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
injuries 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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Unity Health Plans 2000
Section 7 Limitations 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 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
Government indirectly pays for
Agencies
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Unity Health Plans 2000
Section 8 FEHB FACTS
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
to information information about your health plan its networks providers and facilities You can also find out about care
about your HMO 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 800 362 3310 or write to 840 Carolina Street Sauk City WI
53583 1374 You may also contact us by fax at 608 643 2564 or visit our website at www unityhealth 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
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 the
when I retire 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 unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for me authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22
and my family years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give
birth or add a child to your family You may change your enrollment 31 days before to 60 days after you
give birth or add the child to your family The benefits and premiums for your Self and Family enrollment
begin on the first day of the pay period in which the child is born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan
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Unity 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
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 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
cards or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter If you enrolled through Employee Express you can request a confirmation letter
from their Help line at 912 757 3030
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
conditions in this 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
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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Unity 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 If you are leave Federal service your employing office will notify you of your right to enroll under TCC You
TCC 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
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Unity Health Plans 2000
Section 8 FEHB FACTS continued
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 pay
coverage your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You
must apply in writing to us within 31 days after you receive this notice However if you are a family member
who is losing coverage the employing or retirement office will not notify you You must apply in writing to us
within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer
questions about your health and we will not impose a waiting period or limit your coverage due to pre existing
conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Certificate of how long you have been enrolled with us You can use this certificate when getting health insurance or other
Group Health health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new
Plan Coverage 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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Unity 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 800 362 3310 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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Unity Health Plans 2000
Summary of Benefits for Unity 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 t he
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 Hospital Comprehensive range of medical and surgical services without dollar or day limit
Care Includes in hospital physician 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 17
Extended All necessary services up to 120 days per calendar year You pay nothing 17
Care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of
conditions inpatient care per year You pay nothing
Substance 21
abuse
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 checkups and routine immunizations laboratory tests and X rays
complete maternity care You pay a 10 copay per office visit 14
Home health All necessary visits by nurses and health aides You pay nothing 14
care
Mental Up to 20 outpatients per year You pay nothing per visit 21
conditions
Substance
abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay for each emergency room visit or non Plan
urgent care facility visit a 25 copay for a physician's office visit for out of area
emergency services and any charges for services that are not covered by this Plan 19
Prescription drugs Drugs prescribed by a Plan physician dentist and obtained at a Plan pharmacy You pay a 5 copay per generic prescription unit or refill and a 10 copay per
name brand drugs when a generic substitution is not permissable 22
Dental care Accidental injury benefit You pay nothing up to 1,000 per accident 23
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Unity Health Plans 2000
Summary of Benefits for Unity Health Plans 2000 continued Page Vision care One refraction annually 23
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 4,200 per Self Only or 11,000 Self and Family
enrollment per calendar year covered benefits will be provided at 100 This
copay maximum does not include charges for prescription drugs certain durable
medical equipment dental care or vision care 8
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Unity Health Plans 2000
2000 Rate Information for
UNITY HEALTH PLANS INSURANCE CORPORATION
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 refer 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
Southern Central Wisconsin
High Option
Self Only W41 74.68 24.89 161.81 53.93 88.37 11.20 88.37 11.20
High Option
Self and W42 175.97 78.07 381.27 169.15 207.74 46.30 201.02 53.02
Family
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Unity Health Plans 2000
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