Pages 1--24 from Untitled

For changes
to benefitssee page 3

Serving The Greater Oklahoma City and Greater Tulsa Oklahoma areas
Enrollment code
2N1 Self Only
2N2 Self and Family

See the FEHB Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www pacificare com

Authorized for distribution by the
UNITED
STATES

United States Office of Federal Employees OFFICE Personnel Management
Health Benefits Program OF

MANAGEMENT
Retirement and Insurance PERSONNEL RI 73 396 1
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PacifiCare of Oklahoma 2000
Table of Contents

Introduction 1
Plain Language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4 5
Section 4 What to do if we deny your claim or request for service 6 7
Section 5 Benefits 7 15
Section 6 General Exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16 17
Section 8 FEHB FACTS 17 20
Inspector General Advisory Stop Healthcare Fraud 20
Summary of Benefits 21
Premiums 22

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PacifiCare of Oklahoma 2000
Introduction
This brochure describes the benefits you can receive from PacifiCare of Oklahoma under its contract CS2225 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 negotiated 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 PacifiCare of Oklahoma 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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PacifiCare of Oklahoma 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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PacifiCare of Oklahoma 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes

preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services or you may have to submit claim
forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copayment of 10 for all changes 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 See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we
will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to Your share of the non postal premium will increase by 0.4 for Self Only or will decrease this Plan 5.4 for Self and Family
Effective January 1 2000 the Plan has eliminated the following service areas in the Southwestern Oklahoma counties of Cado Comanche Cotton Custer Greer Harmon
Jefferson Kiowa Stephens Tillman and Washita and the cities of Blair and Warren and zip code 73526 in Jackson county
General anesthesia for certain dental procedures is covered for members age 8 and younger or severely disabled
Maintenance drugs up to a 90 day supply may be obtained through mail order for the cost of two copayments
Orthopedic devices prosthetic devices and durable medical equipment are covered in full Substance abuse benefits are now covered separately from mental health benefits and are
subject to its own maximums Speech and hearing benefits are no longer covered except hearing screenings
Out of Pocket Maximums catastrophic limit have increased to 600 per Self Only enrollment or 1,800 per Self and Family enrollment
Copayments for pre natal care are waived after the first 10 copayment

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PacifiCare of Oklahoma 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Our Plan's service service area is
area All of the following counties in Greater Oklahoma City and Tulsa Canadian Cleveland Creek
Grady Lincoln Logan Mayes McClain Okmulgee Osage Pottawatomie Rogers Seminole Wagoner and Washington and cities and towns which consist of the following zip codes

73003 73007 73008,73010 73013 73016 73019 73020 73022 73026 73027 73028 73034,73036 73037 73044 73045 73049 73050 73054 73056 73058 73059 73063 73064
73065 73066 73068 73069 73070 73071 73072 73073 73078 73083 73084 73085 73089 73090 73097 73099,73100 73199 73762 74002 74008 74011 74020 74021 74023 74026
74031 74032 74033 74035 74036 37 74039 74041 74043 74044 74047 74050 74053 74054 74055 74059 74060 63 74066 74067 74070 74073 74074 76 74079 74080 74081
74082 74085 74101 08 74110 74112 74114 17 74119 20 74126 37 74145 49 74152 53 74155 74157 59 74169 70 74337 74352 74353 74421 74429 74436 74446 74454 74458
74466 74467 74477 74484 74538 74801 74802 74824 74826 74830 74832 74834 74837 74838 74840 74849 74851 74852 74854 74855 74857 74864 74866 74867 74868 74869
74873 74875 74878 74881 74884
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other health
care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office

How much do You must share the cost of some services This is called a copayment a set dollar amount or I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 600 in copayments for one family member or 1,800 for a family 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 for your prescription drugs dental services inpatient mental health and rehabilitation for substance abuse do not count toward these limits and you must
continue to make these payments
Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that

circumstances beyond your control prevented you from filing on time
Who provides PacifiCare of Oklahoma operates as a mixed model plan MMP This means that doctors provide my health care either in contracted medical centers or in their own offices
care
What do I do if Call us We will help you select a new one my primary
care physician leaves the Plan

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PacifiCare of Oklahoma 2000
Section 3 How to get benefits continued
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or need to go into the specialist will make the necessary hospital arrangements and supervise your care
hospital
What do I do if First call our customer service department at 1 800 825 9355 If you are new to the FEHB I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and
hospital when are switching to us your former plan will pay for the hospital stay until I join this
Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist Referral to a participating specialty care specialist is given at the primary care doctor's discretion

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 may have to get an authorization or approval beforehand when creating your treatment plan

What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a if I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you I enroll to see a specialist who does not participate with our Plan

What do I do Call your primary care physician who will arrange for you to see another specialist You may if my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the Program

Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your provider for up to 90 days after we notify you that we are terminating our
contract with the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist authorize medical or recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows general accepted medical practice
How do you The Plan accepts the determination of PacifiCare's National and Regional Medical Committees as decide if a service to whether treatments procedures and drugs are accepted as no longer experimental or
is experimental investigational The determinations are based on the safety and effectiveness of new medical or investigational procedures technologies devices and drugs

Plan providers will follow generally accepted medical practice in prescribing any course of treatment Before you enroll in this Plan you should determine whether you will be able to accept
treatment or procedures which may be recommended by Plan providers

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PacifiCare of Oklahoma 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal ask OPM to OPM will determine if we correctly applied the terms of our contract when we denied your claim
review a denial or request for service
What if I Call us at 1 800 825 9355 and we will expedite the review have a serious
or life threatening condition and you
haven't responded to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contracts Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We did not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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PacifiCare of Oklahoma 2000
Section 4 What to do if we deny your claim or request for service continued
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 Send your request for review to Office of Personnel Management Office of Insurance Programs I mail my Contracts Division IV P O Box 436 Washington D C 20044
disputed claim to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the decision your only 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 if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and the and us to determine if our denial of your claim is correct The information OPM collects during
Privacy Act the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this

information to support the disputed claim decision If you file a lawsuit this information will become part of the court record

Section 5 Medical and Surgical Benefits
What is A comprehensive range of preventive diagnostic and treatment services is provided by Plan covered physicians and other Plan providers This includes all necessary office visits you pay a 10 office
visit copayment but no additional copayment for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan physician such care is necessary
and appropriate you pay a 10 copayment for a physician's house call There is no cost to you for home visits by nurses and health aides

The following services are included
Preventive care including well baby care and periodic checkups Hearing Screenings you pay a 10 copayment
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 to two years for
women age 50 through 64 one mammogram every year for women age 65 and above one mammogram every two years In addition to routine screening mammograms are covered
when prescribed by the physician 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

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PacifiCare of Oklahoma 2000
Section 5 Medical and Surgical Benefits continued
What is Complete obstetrical maternity care for all covered females including prenatal delivery and covered postnatal care by a Plan physician You pay a 10 copayment for the 1st pre natal visit all
continued subsequent pre natal visit copayments are waived for the remainder of the pregnancy The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after
coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be covered under
either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family
enrollment Women may self refer to a gynecologist within their medical group for one pap smear pelvic
exam and breast exam per calendar year Voluntary family planning services
Sterilization you pay a 50 copayment for a vasectomy you pay a 100 copayment for a tubal ligation
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including testing and treatment materials subject to 10
copayment allergy serum is covered in full The insertion of internal prosthetic devices such as pacemakers and artificial joints
Kidney cornea heart heart lung lung single or double pancreas and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's
lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer Related medical
and hospital expenses of the donor are covered when the recipient is covered by this Plan Women who undergo mastectomies or lymph node dissections related to the treatment of
breast cancer and other breast conditions may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours and 24 hours respectively after the
procedure Dialysis
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need Chiropractic services
Disposable needles and syringes needed for injecting covered prescribed medication Depo Provera subject to a 25 copayment per injection
Implantable drugs except Zoledex 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 Outpatient surgery is covered in full
Stop Smoking comprehensive self paced program which includes telephone case management video tape urge tamer bag and quit booklets you pay a 20 copayment
Healthy Pregnancy Program Includes pregnancy risk screening education and case management for women with special needs Staff nurses are available by calling a toll free
hotline you pay nothing Orthopedic devices such as custom made foot orthotics prosthetic devices such as artificial
limbs lenses following cataract removal and breast prosthesis and surgical bras as well as their replacement following a mastectomy and durable medical equipment such as wheelchairs
and hospital beds limited to the initial placement of the device or equipment are covered in full Repair or adjustment required because of a change in your condition as determined by
your Plan physician is provided

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PacifiCare of Oklahoma 2000
Section 5 Medical and Surgical Benefits continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or areas
surrounding the teeth are not covered including shortening of the mandible or maxillae for cosmetic purposes correction of malocclusion and any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 treatment days per medical episode if significant improvement can
be expected within the 60 treatment days per medical episode you pay 10 per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for up to 60 treatment days per disability you pay a 10 copayment per visit
Diagnosis and treatment of infertility is covered including but not limited to sperm count hysterosalpingography endometrial biopsy or clomid therapy you pay 50 of charges The
following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay 50 of the charges cost of donor
sperm is not covered Oral fertility drugs are covered subject to a member copayment of 50 The member must purchase the medication at the pharmacy and submit the receipt for the full cost to
PacifiCare for 50 reimbursement Other fertility drugs are not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not
covered
What is not Physical examinations that are not necessary for medical reasons such as those required for covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Hearing aids Long term rehabilitative therapy
Homemaker services Transplants not listed as covered

Section 5 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 physician You pay nothing per inpatient admission All
necessary services are covered including
Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units Blood and blood derivatives

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PacifiCare of Oklahoma 2000
Section 5 Hospital Extended Care Benefits continued
Extended care The Plan provides a comprehensive range of benefits up to 100 consecutive calendar days from first treatment per disability when skilled nursing care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a Plan physician and approved by the Plan You pay nothing per inpatient admission 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 physician
Hospice care Supportive and palliative care for a terminally ill member are 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 6 months or less

Ambulance care Benefits are provided for ambulance transportation ordered or authorized by a Plan physician
Limited benefits
Inpatient dental Hospitalization for certain dental procedures are covered when a Plan physician determines there is procedures a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition unless the member is age 8 or younger or severely disabled
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 12 for nonmedical substance abuse benefits

What is not Personal comfort items such as telephone and television covered Custodial care rest cures domiciliary or convalescent care

Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical believe endangers your life or could result in serious injury or disability and requires immediate
emergency medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include uncontrolled bleeding loss of consciousness broken
bones or severe chest pain 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 physician In extreme within the emergencies if you are unable to contact your physician contact the local emergency system e g
service area the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family
member should notify your primary care physician within 48 hours unless it is not reasonably possible to do so It is your responsibility to ensure that your primary care physician has been
timely notified
If you need to be hospitalized your primary care physician must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the
Plan within that time If you are hospitalized in non Plan facilities and Plan physicians believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any
ambulance charges covered in full

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PacifiCare of Oklahoma 2000
Section 5 Emergency Benefits continued
Emergencies Benefits are available for care from non Plan providers in a medical emergency only if delay in within the reaching a Plan provider would result in death disability or significant jeopardy to your condition
service area continued 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 10 copayment per visit for emergency and urgent care services provided in an urgent care center or a plan physician's office after normal business hours This service is not available at all centers
or Plan physician's offices To determine if your center or Plan doctor's office provides after hours care you must contact them directly you pay a 50 copayment for each hospital emergency room
visit If the emergency results in admission to a hospital the emergency care copayment is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the because of injury or unforeseen illness
service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred
when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 copayment per visit for emergency room or urgent care center visit for emergency care services which are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copayment is waived

What is Emergency care at a physician's office or an urgent care center covered 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 nonemergency 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 for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
providers 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 6

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
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PacifiCare of Oklahoma 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Mental conditions

What is To the extent shown below this Plan provides the following services necessary for the diagnosis and covered 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 Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar care year you pay a 20 copayment per visit for visits 1 through 20 within the first 20 visits group
sessions are covered subject to a 10 copayment per visit and 50 of cost for each visit for visits 21 40 all charges thereafter

Inpatient Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all care
charges thereafter

What is not Care for psychiatric conditions which in the professional judgment of PacifiCare Behavioral covered Health are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by PacifiCare Behavioral Health to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is This Plan provides medical and hospital services such as acute detoxification services for the covered medical non psychiatric aspects of substance abuse including alchoholism and drug addiction the
same as for any other illness or condition Services for the psychiatric aspects are provided in conjunction with the Mental Conditions Benefits shown above Outpatient visits to Plan mental
health providers for follow up care and counseling are covered as well as inpatient services necessary for diagnosis and treatment The Mental Conditions Benefits visit day limitations and
copays apply to any covered substance abuse care
What is not Treatment that is not authorized by PacifiCare Behavioral Health covered Educational programs to which drinking drivers are referred by a court
Codependency sexual addictions and compulsive disorders Care when there is no reasonable expectation of short term improvement
Leaving treatment against medical advice Halfway house and court ordered treatment

All Mental Health and Substance Abuse treatment must be pre authorized by PacifiCare Behavioral Health at 1 800 524 4574

Section 5 Prescription Drug Benefits
What is Prescription drugs prescribed by a Plan or referral physician and obtained at a Plan pharmacy will covered be dispensed for up to a 30 day supply or one commercially prepared unit such as inhalers or tubes
drugs are prescribed by Plan physicians and dispensed in accordance with the Plan's drug formulary you pay a 5 copayment for generic drugs a 10 copayment for name brand formulary

drugs per prescription unit or refill Nonformulary drugs will be covered when prescribed by a Plan physician you pay a 10 copayment per prescription unit or refill

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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PacifiCare of Oklahoma 2000
Section 5 Prescription Drug Benefits continued
What is The PacifiCare Formulary is a list of over 1600 prescription drugs that Physicians use as a guide covered when prescribing medications for patients The Formulary plays an important role in providing
continued safe effective and affordable prescription drugs to PacifiCare members It also allows us to work together with physicians and pharmacies to ensure that our members are getting the drug therapy

they need A Pharmacy and Therapeutics Committee consisting of physicians and pharmacists evaluate prescription drugs based on safety effectiveness quality treatment and overall value The
committee considers first and foremost the safety and effectiveness of a medication before reviewing the cost PacifiCare's physicians will request preauthorization for non formulary drugs
A participating physician may initiate the pre authorization request simply by phoning or faxing in the request Requests are generally processed within ten minutes although a few require up to 2
working days when additional information is needed from the physician
Non Formulary drugs will be covered in the following instances No Formulary alternative is appropriate

You have tried the Formulary drugs and they have not been effective or you have been experiencing side effects or interactions with other drugs The physician is asked to provide a
copy of the medical chart notes specifically stating treatment failure with the Formulary alternatives
You have been under treatment and remain stable on a non Formulary prescription drug and conversion to a Formulary drug would be medically inappropriate
Your physician provides evidence to PacifiCare in the form of documents records or clinical trials which establishes that use of the requested non Formulary drug over the Formulary drug
is medically necessary as determined by PacifiCare
The formulary is a list of outpatient medications covered by PacifiCare The formulary is regularly updated If the retail cost of the prescription drug is less than the copayment you will pay the

retail cost Unless a brand name is medically indicated prescriptions will be filled with generic drugs

Maintenance drugs up to a 90 day supply may be obtained through a Mail Order Prescription Drug program the member pays 2 copayments per 90 day supply Please call the Plan's Customer
Service Department at 1 800 825 9355 for information
Covered medications and accessories include Drugs for which a prescription is required by law

Oral contraceptive drugs prescription diaphragms and IUD's Implanted contraceptive devices such as Norplant
Insulin Diabetic supplies including Insulin syringes blood glucose test strips urine test strips
glucagon emergency kits injectable glucagon and lancets Inhaler extender devices epipens and Anakits
Intravenous fluids and injectable medication for home use covered under Medical and Surgical Benefits as a home health service see page 8

Limited benefits Drugs to treat sexual dysfunction are covered when the Plan's medical criteria is met Contact the plan for dose limits You pay 50 of the cost of the medication per prescription unit or
refill up to the dosage limits and all charges above that Prescription smoking cessation medications upon proof of completion of a smoking cessation
program Reimbursement is limited to a 90 day supply for one time per calendar year with a three time lifetime maximum

What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered available
Drugs obtained at a non Plan pharmacy except for out of area emergencies Vitamins and nutritional substances which can be purchased without a prescription
Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes
Drugs to enhance athletic performance Fertility drugs oral fertility drugs are covered under the Medical and Surgical Benefits section
for the diagnosis and treatment of infertility Lifestyle enhancing drugs

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PacifiCare of Oklahoma 2000
Section 5 Other Benefits
Dental care
What is Inpatient dental care provided under Hospital Extended Care Benefits see page 10 covered Ambulatory surgical center expenses and general anesthesia associated with certain dental

procedures are covered for members age 8 and younger or severely disabled
The following dental services are covered when provided by participating Plan dentists You pay nothing

Oral Exam Prophylaxis cleaning once every 6 months
Topical application of fluoride once every 6 months Sealants
Oral hygiene instructions X rays for members over age 15 full mouth series limited to once every 24 to 36 months and
bitewings limited to once every 12 months Vitality tests
Oral cancer exam
There will be a 10 charge for broken appointments without 24 hours prior notice
Accidental Dental emergencies are covered for cases when immediate stabilization of sound natural teeth is injury benefit required due to accident or injury Stabilization is defined as the splinting cementing or wiring of
the teeth in an emergency room provided as a temporary and precautionary measure until follow up care may be obtained from a dentist or oral surgeon All follow up care is not provided even if the
teeth are not saved by emergency stabilization you pay a 50 copayment at the hospital
What is not Other dental services not shown as covered covered

Vision care
What is In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of covered the eye this Plan provides the following vision care benefits from Plan providers You pay a 10

copayment per visit
One eye refraction every 12 month period including the written lens prescription for eyeglasses
Initial placement of post cataract extraction contact lens in surgically affected eye
What is not Corrective eyeglasses and frames or contact lenses including the fitting of the lenses for covered eyeglasses
Eye exercises Replacement of initial lens following cataract surgery

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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PacifiCare of Oklahoma 2000
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor Prosthetics
guaranteed under the contract with FEHB Program but are Complete Maxillary Denture 230.00 made available to all enrollees and family members of the Plan Complete Mandibular Denture 230.00
The cost of the benefits described on this page is not included in Crown and Bridge the FEHB premium any charges for these services do not count Porcelain with Metal Crown 240.00
toward any FEHB deductibles out of pocket maximum Cast Metal Crown 200.00 copayment charges etc These benefits are not subject to the 3 4 Crown 150.00
FEHB disputed claims procedures Acrylic Crown 45.00
Expanded dental benefits Eligibility The United Dental Care Life Health Insurance Co UDC As a Federal Member of PacifiCare you are eligible to join this

provides you with a direct pay dental care plan which allows Dental Plan you to obtain dental services with greatly reduced fees no
deductibles and no annual maximum You can budget your costs Enrollment in the UDC Dental Plan is separate from your and coordinate your dental and medical care PacifiCare FEHB enrollment and it is your personal choice You
do not have to enroll in the Dental Plan if you take PacifiCare In order to join UDC Direct Pay Dental Plan you must be a However you must enroll in PacifiCare to take the Dental Plan
member of PacifiCare of Oklahoma as of January 2000
UDC will provide you through its participating dentists the Monthly Premium Premiums are paid directly to UDC following care with copayments due at the time of service
Member Only 11.50 per month

Coverage Member Plus One 16.00 per month Please obtain a Schedule C of Services and Copayments for a Member Plus Family 18.50 per month

complete listing of services and Exclusions and Limitations of Orthodontic Rider Additional 5.00 per month Benefits For a copy of the schedule please call UDC at 1 800
How to enroll 443 0225 The mailing address is UDC P O Box 844747 Contact UDC membership services at 1 800 443 0225 for an

Dallas Texas 75248 4747 This is a lock box used for application for direct pay enrollments premiums etc

Enrollment into this Dental Plan may be done anytime during Restorative Initial the year however premiums must be received in the UDC
Consultation No Charge Administrative Office prior to the 10th of the month to ensure Sedative Base under filling 10.00
eligibility on the 1st of the following month Oral Examination No Cost

X Ray Single film No Cost What is not covered Amalgam Restoration per surface 15.00 Prescription for dental care

Composite Restoration 25.00 Endodontics Root Canal Medicare Choice Prepaid Plan Enrollment This Plan offers
Initial Consultation No Charge Medicare recipients the opportunity to enroll in the Plan through Pulp Capping 20.00 Medicare As indicted on page 4 annuitants and former spouses
Vitalometer No Charge with FEHB coverage entitlement to Part A and Medicare Part Pulpectomy 38.00 B may elect to drop their FEHB coverage and enroll in a
Root canal therapy Medicare Choice prepaid plan when one is available in their One Canal per tooth 130.00 area They may then later reenroll in the FEHB Program Most
Two Canals per tooth 175.00 Federal Annuitants have Medicare You must be entitled to Part Oral Surgery A and enrolled in Part B Medicare to enroll in this
Initial Consultation No Charge Medicare Choice prepaid plan Contact your retirement system Simple Extraction single 24.00 for information on dropping your FEHB enrollment and
Multiple Extraction per tooth 15.00 changing to a Medicare Choice prepaid plan Contact us at Surgical Extraction Impacted Tooth 1 800 322 8877 for information on the Medicare Choice
soft tissue 55.00 prepaid plan and the cost of that enrollment Partial Bone Impaction 65.00
If you are Medicare eligible and are interested in enrolling in a Space Maintainers Medicare Choice HMO sponsored by this Plan without

Initial Consultation No Charge dropping your enrollment in this Plan's FEHB plan call 1 800 Unilateral 42.00
322 8877 for information on the benefits available under the Bilateral 63.00 Medicare Choice HMO

Orthodontics Optional rider Adults 1,800.00
Benefits on this page are not part of the FEHB contract Children 1,700.00

Initial Diagnostic Workup and X rays 85.00 Periodontics

Initial Consultation No Charge Gingivectomy Per tooth less than six 60.00

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PacifiCare of Oklahoma 2000
Section 6 General Exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent

diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric
practice Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits or eligible self referred services Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We can't 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 For information on the Medicare Choice
plan offered by this Plan see page 15
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage You must tell us if you or a family member has double coverage You must also send us
coverage 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 plans 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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PacifiCare of Oklahoma 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 beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care

control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another persons caused you must reimburse us for whatever services we paid for We will cover
for injuries the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are
the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for

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 to information right to information about your health plan its networks providers and facilities You can also find

about your HMO 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 1 800 825 9355 or write to 84 NE Loop 410 Suite 100 San Antonio Texas 78216 5884 You may also contact us by fax at 210 474 5048 or visit
our website at www pacificare com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the an informed decision about FEHB Program
When you may change your enrollment How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office

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PacifiCare of Oklahoma 2000
Section 8 FEHB FACTS continued
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1

premiums effective Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorized coverage for Under certain circumstances you may also get family and me coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a self only enrollment you may change to a self and family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical We will keep your medical and claims information confidential Only the following will have and claims access to it
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 bonafide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also
use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled

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PacifiCare of Oklahoma 2000
Section 8 FEHB FACTS continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible to 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 RI79 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 You can pick a new plan about TCC
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 32nd 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 If you leave Federal service your employing office will notify you of your right to enroll under enroll in TCC 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

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PacifiCare of Oklahoma 2000
Section 8 FEHB FACTS continued
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
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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 1 800 932 3004 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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PacifiCare of Oklahoma 2000
Summary of Benefits for PacifiCare of Oklahoma 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pay provides Page
Inpatient Hospital Comprehensive range of medical and surgical services with no dollar or day limit Includes
Care 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 9

Extended Care All necessary services up to 100 consecutive days per disability You pay nothing 10
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care Conditions per year You pay nothing 12

Substance Covered under Mental Conditions 12 Abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
Care 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 10

per office visit 10 per house call by a physician 7

Home Health All necessary visits by nurses and home health aides You pay nothing per visit 8 Care

Mental Up to 40 outpatient visits per year You pay 20 copayment per outpatient visit for visits Conditions
1 through 20 and 50 of cost for each visit for visits 21 40 12

Substance Covered under Mental Conditions 12 Abuse

Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay a 10 per visit copayment for emergency and urgent care services provided in a
Plan physician's office after normal business hours 50 copay for each emergency room or urgent care center and any charges for services that are not covered benefits of this Plan 11

Prescription Drugs Drugs prescribed by a Plan physician and obtained at a participating pharmacy You pay 5 for generic 10 for name brand formulary and 10 for non formulary per prescription unit
or refill 13

Dental Care Preventive dental benefit You pay nothing Accidental injury You pay a 50 copayment 14
Vision Care One refraction annually You pay 10 a copayment per visit 14
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses
Maximum reach a maximum of 600 per Self Only or 1,800 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copayment maximum does

not include prescription drugs dental services inpatient mental health and rehabilitation for substance abuse 4

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PacifiCare of Oklahoma 2000
2000 Rate Information for
PacifiCare of Oklahoma

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 postal employees If you are a
career employee but not a member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which
rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

Okla Cty and Tulsa area

Self Only 2N1 55.11 18.37 119.41 39.80 65.21 8.27 65.21 8.27
Self and Family 2N2 143.29 47.76 310.46 103.48 169.56 21.49 169.56 21.49

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