CIGNA HealthCare HealthCare of California Inc 2000
A Health Maintenance Organization
For changes
in benefits page 2 Serving Greater California
see
Enrollment in this Plan is limited see pages 2 3 for requirements
Enrollment code
9T1 Self Only
9T2 Self and Family
CIGNA HealthCare of Northern California Inc CIGNA HealthCare of Southern
California Inc and CIGNA HealthCare of San Diego Inc each previously earned Commendable accreditation from the National Committee for Quality Assurance
NCQA However as a result of the 1998 consolidation of the three plans into
CIGNA HealthCare of California Inc the merged plan is now listed as Commendable Merger Consolidation Review Pending The plan
underwent the merger consolidation acquisition MAC review in
June 1999 to determine accreditation status as one entity
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www cigna com healthcare
Authorized for distribution by the
LOGO United States LOGO Office of
Personnel Federal Employees Health Benefits Program
Management RI 73 402
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CIGNA HealthCare of California Inc 2000
Table of Contents
Page
Introduction 1
Plain Language 1
How to Use This Brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How We Change for 2000 2
Section 3 How to Get Benefits 2 5
Section 4 What to Do if We Deny Your Claim or Request for Service 5 6
Section 5 Benefits 6 12
Section 6 General Exclusions Things We Don t Cover 13
Section 7 Limitations Rules That Affect Your Benefits 13 14
Section 8 FEHB Facts 14 16
Department of Defense FEHB Demonstration Project 17
Inspector General Advisory Stop Healthcare Fraud 18
Summary of Benefits Inside back cover
Premiums Back cover
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CIGNA HealthCare of California Inc 2000
Introduction
CIGNA HealthCare of California Inc 400 North Brand Boulevard Glendale California 91203 This brochure describes the benefits
you can receive from CIGNA HealthCare of California Inc under its contract CS 2841 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 2 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 efer to CIGNA HealthCare of California Inc as this Plan throughout this brochure even though in other legal documents you will
see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not ewritten the Benefits section of this brochure You will find new benefits language next year
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 compari
sons 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 ead 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 equest 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 informa
tion 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 hat 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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CIGNA HealthCare of California Inc 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that equire 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 p eventative
care such as outine office visits physical exams well baby care and immunizations as well as treatment for illness and injury When
you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and
coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan s benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our equest 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 ecords on request If you want copies of your
medical ecords ask your health care provider for them Your may ask that a physician amend a
record that is not accurate not elevant 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 ecords 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 premium will decrease by 1.4 for Self Only and increase 1.2 for Self and
this Plan Family
Section 3 How to Get Benefits
What is this Plan s To enroll with us you must live in our service area This is where our providers practice Our
service area service area is
CIGNA HealthCare of Northern California
Enrollment Code 9T1 Self Only
9T2 Self and Family
Service area Services from Plan providers are available only in the following areas Alameda
Butte Contra Costa El Dorado Fresno Glenn King Marin Merced Monterey Placer Sacra
mento San Francisco San Joaquin San Mateo Santa Clara Santa Cruz Solano Sonoma
Stanislaus Tulare and Yolo counties See attached zip code list for partially covered counties as
indicated above in italics
The counties of Merced and Monterey are partially covered The following zip codes are within
CIGNA s service area
Merced Monterey
95315 93901 2 93942 4
95324 93905 8 93950
93911 2 93953 93915 93955
93921 4 93962
93933 95012
2 93940
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CIGNA HealthCare of California Inc 2000
Section 3 How to Get Benefits continued
CIGNA HealthCare of Southern California
Enrollment Code 9T1 Self Only
9T2 Self and Family
Service area Services from Plan providers are available only in the following areas Ker n Los
Angeles Orange Riverside San Bernardino San Luis Obispo Santa Barbara and Ventura coun
ties See attached zip code list for partially covered counties as indicated above in italics
The counties of Kern Riverside and San Bernardino are partially covered The following zip codes
are within CIGNA s service area
Kern Riverside San Bernardino
93203 93276 93516 91718 20 92551 7 91701 92334 7 93205 93280 93518 91752 92562 4 91708 10 92340
93206 93283 93519 91760 92567 91729 30 92342
93215 93285 93523 92220 92570 2 91737 92345 6 93216 93287 93524 92223 92589 93 91739 92350
93217 93300 93527 92230 92595 91743 92354
93220 93301 93528 92282 92599 91758 92356 9 93222 93302 93531 92320 91760 4 92368 9
93224 93303 93554 92379 91784 6 92372 7
93225 93304 93555 92500 9 91798 92392 4 93226 93305 93556 92513 23 92301 92397
93238 93306 93560 92530 2 92307 9 92399
93240 93307 93561 92311 3 92400 16 93241 93308 93570 92316 92418
93243 93309 93581 92317 92420
93249 93311 93582 92324 92423 4 93250 93312 93596 92329 92427
93251 93313
93252 93380 9 93255 93390
93263 93399
93268 93501 5
CIGNA HealthCare of San Diego
Enrollment Code 9T1 Self Only
9T2 Self and Family
Service area Services from Plan providers are available only in the following area San Diego
County
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 etirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount or
pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for certain benefits
After you pay 1,000 in copayments or coinsurance for one family member or 3,000 per 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 or coinsurance for your prescription drugs dental
services mental health substance abuse services durable medical equipment and external prosthetic
appliances do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
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CIGNA HealthCare of California Inc 2000
Section 3 How to Get Benefits continued
Do I have to You normally won t have to submit claims to us unless you receive emergency services from a
submit provider who doesn t contract with us If you file a claim please send us all of the documents for
claims 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 circum
stances beyond your control prevented you from filing on time
Who provides my Your care is provided by over 28,000 doctors who practice either in medical groups or independent
health care private offices As a member of this Plan you and each of your family members will choose a
primary care physician to coordinate all your health care needs A woman may see her Plan
gynecologist for her annual outine examination without a eferral
What do I do if my Call us We will help you select a new one
primary care physician
leaves he Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or special
to go into he hospital ist will make the necessary hospital arrangements and supervise your care
What do I do if I m First call our customer service department at 800 832 3211 If you are new to the FEHB Program
in he hospital when we will arrange for you to eceive care If you are currently in the FEHB Program and are switching
I join his Plan to us your former plan will pay for the hospital stay until
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 eferral to a specialist except for well woman care
specialty care from an ob gyn
If you need to see a specialist frequently because of a chronic complex or serious medical condi
tion your primary care physician will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional eferrals Your primary care physician in consulta
tion with the Plan 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 efer you to a
am seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you
to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves receive services from your current specialist until we can make arrangements for you to see
the Plan someone else
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue
a serious illness and seeing your provider for up to 90 days after we notify you that we are terminating our contract with
my provider leaves the provider unless the termination is for cause If you are in the second or third trimester of
the Plan or this Plan pregnancy you may continue to see your OB GYN until the end of your postpartum care
leaves he Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious o
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
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CIGNA HealthCare of California Inc 2000
Section 3 How to Get Benefits continued
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or ecommending follow up care Before giving approval we consider if the service is medically
necessary and if it follows generally accepted medical practice
How do you decide The Plan evaluates equests for new and emerging treatments experimental and investigational
if a service is treatment on a case by case basis The Plan review process uses a Medical Technology Assess
experimental or ment Council peer reviewed medical literature and independent medical experts to assist the
investigational Medical Director in reaching determinations
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 equest 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 easons beyond your control
We have 30 days from the date we receive your econsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service o
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our equest We must make a decision within 30 days
after we receive the additional information If we do not eceive 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 eview the denial after you ask us to reconsider our initial denial or refusal
OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim o
denial request for service
What if I have a serious If we expedite your eview due to a serious medical condition and deny your claim we will inform
or life hreatening OPM so that they can give your claim expedited treatment too Alternatively you can call OPM s
condition and you have health benefits Contracts Division IV at 202 606 0737 between 8 am and 5 pm Serious or life
not responded to my threatening conditions are ones that may cause permanent loss of bodily functions or death if they
request for service are not treated as soon as possible
What if you have denied Call us at 1 800 832 3211 and we will expedite our eview
my request for care and
my condition is serious
or life hreatening
Are there other You must write to OPM and ask them to eview our decision within 90 days after we uphold our
time limits initial denial or refusal of service You may also ask OPM to eview your claim if
1 We do not answer your equest within 30 days In this case OPM must receive your equest
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 equest within 120 days of the date we asked you
for additional information
What do I send Your equest 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
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CIGNA HealthCare of California Inc 2000
Section 4 What to Do If We Deny Your Claim or Request for Service continued
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical ecords 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 eview 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
What address should Send your equest for review to Office of Personnel Management Office of Insurance Programs
I send my disputed Contracts Division IV P O Box 436 Washington D C 20044
claim to
What if OPM upholds OPM s decision is final There are no other administrative appeals If OPM agrees with our
the Plan s denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply 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 ecover 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
the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claims file and is subject to the provi
sions of the Freedom of Information Act and the Privacy Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become part of
the court record
Section 5 Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors
and other Plan providers This includes all necessary office visits you pay a 10 office visit copay
but no additional copay for lab tests and X rays Within the Service Area you pay nothing 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 through 64 one mammogram every year and for women age 65 and
above one mammogram every two years In addition to outine 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
6 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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CIGNA HealthCare of California Inc 2000
Section 5 Benefits continued
Diagnostic procedures such as laboratory tests and X rays Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor Pre and post natal maternity care office visit copays are waived
after initial visit determining pregnancy The mother at her option may remain in the hospital
up to 48 hours after a regular delivery and 96 hours after a caesarian delivery Inpatient stays
will be extended if medically necessary If enrollment in the Plan is terminated during preg
nancy 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 Cornea heart heart lung lung liver kidney pancreas 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 neuroblas
toma breast cancer multiple myeloma and epithelial ovarian cancer and testicular mediasti
nal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by
the Medical Director Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
Initial rental or purchase of durable medical equipment such as wheelchairs and hospital beds initial purchase and fitting as well as medically necessary replacement of external prosthetic
appliances such as artificial limbs
External lenses following cataract surgery Implanted time release medications such as Norplant
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures
for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of
fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral
areas surrounding the teeth are not covered including any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the member s appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstructive 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 as medically necessary if significant improvement can be expected within two
months you pay a 10 copay per outpatient session Speech therapy is limited to treatment of
certain speech impairments of o ganic origin Occupational therapy is limited to services that assist
the member to achieve and maintain self care and improved functioning in other activities of daily
living
Diagnosis and treatment of infertility is covered you pay a 20 copay per office visit The
following types of artificial insemination are covered intravaginal insemination IV intracervical
insemination ICI and intrauterine insemination IUI you pay 50 per treatment or surgery cost
of donor sperm is not covered Oral fertility drugs are covered under the Prescription Drug benefit
Injectable infertility drugs are covered as part of a plan approved infertility treatment program
under the Medical Benefit Injectable fertility drugs are not covered under the Prescription Drug
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 7
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CIGNA HealthCare of California Inc 2000
Section 5 Benefits continued
benefit Other assisted reproductive technology ART procedures that enable a woman with
otherwise untreatable infertility to become pregnant through other artificial conception procedures
such as in vitro fertilization and embryo transfer are not covered
Prosthetic devices are covered such as artificial limbs external lenses following cataract emoval
the initial device only external breast prostheses and bras including replacements
What is not covered Physical examinations that are not necessary for medical reasons such as those required for
obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Homemaker or custodial services Hearing aids
Transplants not listed as covered Cardiac rehabilitation
Orthopedic devices such as braces and foot orthotics
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 60 days per calendar year when full
time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All
necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness
with a life expectancy of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
hospitalizations but not the cost of the professional dental services Conditions for which hospital
ization would be covered include hemophilia and heart disease the need for anesthesia by itself is
not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxifi
cation if the Plan doctor determines that outpatient management is not medically appropriate See
page 10 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care est cures domiciliary or convalescent care
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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CIGNA HealthCare of California Inc 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies
the service area 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 should notify the
Plan within 48 hours It is your esponsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours
following your admission unless it was not easonably possible to notify the Plan within that time
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in
a Plan hospital you will be transferred when medically feasible with any ambulance charges
covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 50 per hospital emergency room visit or per non Plan urgent care center visit for emergency
services that are covered benefits of this Plan If the emergency results in admission to a hospital
the emergency room copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours following your admission
unless it was not easonably 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 per hospital emergency room visit or per u gent care center visit for emergency services that are
covered benefits of this Plan If the emergency results in admission 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 covered Elective care or non emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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CIGNA HealthCare of California Inc 2000
Section 5 Benefits continued
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care
non Plan providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
If you are required to pay for the services submit itemized bills and your eceipts 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 pages 5 6
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services
Outpatient care Up to 30 combined individual and group therapy outpatient visits to Plan doctors consultants or
other psychiatric personnel each calendar year Individual sessions you pay a 10 copay for each
covered visit all charges thereafter Group therapy sessions you pay a 5 copay for each covered
visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay 25 for the first 30 days all charges
thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the
medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness or condition and to the extent shown below the services necessary for
diagnosis and treatment
Outpatient care Up to 60 combined individual and group therapy sessions each calendar year All necessary
treatment equired for follow up care and counseling Individual sessions you pay a 10 copay for
each covered session Group therapy sessions you pay a 5 copay for each covered session all
charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year All necessary inpatient services equired for the
diagnosis and treatment of abuse of or addiction to alcohol or drugs you pay a 25 copay for first
30 days all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs present on the Plan formulary prescribed by a Plan or eferral doctor and
obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay a 5 copay for
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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CIGNA HealthCare of California Inc 2000
Section 5 Benefits continued
generic drugs and a 10 copay for name brand drugs per prescription unit or refill for up to a 30
day supply or 100 unit supply whichever is less When generic substitution is permissible i e a
generic drug is available and the prescribing doctor does not equire the use of a name brand drug
but you request the name brand drug you pay the price difference between the generic and name
brand drug as well as the 10 copay per prescription unit or efill Limited to generic drugs unless a
Plan doctor determines that a name brand drug is medically necessary
Maintenance Prescription Drugs are available through Participating Mail Order Pharmacies You
pay a 10 copay for generic drugs and a 20 copay for name brand drugs per prescription up to a
90 day supply
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan s drug formulary
Medically necessary nonformulary drugs will be covered when prescribed by a Plan doctor and
approved by the Plan s medical director
The Plan s drug formulary is updated regularly by the Pharmacy and Therapeutics Committee The
Committee consists of providers pharmacists medical directors and pharmacy directors They
review medications for safety therapeutic value and cost effectiveness Based on this review
medications are added or deleted from the formulary
Covered medications and accessories include
Drugs for which a prescription is required by Federal law Oral and injectable contraceptives drugs contraceptive devices contraceptive diaphragms
Implanted time release medications such as Norplant You pay a one time copay of 10 per prescription Norplant is covered under Medical and Surgical Benefits
For other internally implanted time release medications you pay 5 for generic and 10 for name brand There is no charge when the device is implanted during a covered hospitalization
Insulin Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use Oral fertility drugs are covered as part of a plan approved infertility treatment program
Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan for the dose limit You pay a 10
copayment up to the dosage limits and charges above that
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Smoking cessation drugs and medication including nicotine patches 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
Drugs for cosmetic purposes Drugs to enhance athletic performance
Diabetic supplies except for needles and syringes
Other Benefits
Dental care
Accidental Restorative services and supplies necessary to promptly epair but not eplace sound natural teeth
injury benefit The need for these services must result from an accidental injury You pay a 5 copay per visit
What is not covered Other dental services not shown as 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 refractions to provide a written lens prescription for eyeglasses may be
obtained from Plan providers Eye exercises are also covered You pay a 5 copay per visit
What is not covered Eyeglasses contact lenses or the fitting of contact lenses except after cataract emoval
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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CIGNA HealthCare of California Inc 2000
Section 5 Benefits continued
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedure
Medicare prepaid This plan offers Medicare recipients who live within the Southern California service area of Los
plan enrollment Angeles Orange Riverside and San Bernardino counties the opportunity to enroll in the Plan
through Medicare As indicated on page 13 annuitants and former spouses with FEHB coverage
and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan
when one is available in their area They may then later reenroll in the FEHB Program Most
Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare
prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium
Before you join the plan ask whether the plan covers hospital benefits and if so what you will
have to pay Contact your etirement system for information on dropping your FEHB enrollment
and changing to a Medicare prepaid plan Contact us at 1 800 747 8686
CIGNA HealthCare for A plan providing affordable health care benefits quality care and a choice of physicians It s a plan
Seniors that offers convenience and is easy to use Anyone with Medicare can apply including those under
age 65 entitled to Medicare on the basis of Social Security Disability Benefits
We give you personal one on one service You ll be in touch with a member of our staff who will
guide you through your first few months with CIGNA We ll make sure you know how to use your
plan access your physician get a special eferral what to do in an emergency and more If you
need to call us we re always here with CIGNA s 24 Hour Helpline 1 800.472.4462
CIGNA Dental Health care for your teeth available for FEHB program members separate from the CIGNA Medical
plan at a very affordable cost It is not necessary to have CIGNA Medical Care to purchase CIGNA
Dental Care for yourself and your family
no deductibles no annual maximums
no claim forms no charge for preventive services oral exams x rays cleanings fluoride treatments
low copayments required for other treatments see Patient Charge Schedule
For information call 1 800 51DENTAL CIGNA Dental is administered by Wright and Company
Insurance Administrators
To enroll in CIGNA Dental Care choose any dental care provider for yourself and each of your
covered dependents from the Directory of Dental Offices
Members Choice allows you to select a different dental office for each covered member You may
change your dental office by calling Member Services at 1 800 367 1037
Guest Privileges Program If you or a covered family member temporarily move outside of the service area for at least 90
days you may be eligible for the Plan s guest privileges program The guest privileges
program allows participants to enroll as guests in another CIGNA HealthCare site This program
is only available when you or your covered family member is temporarily elocating to an approved
CIGNA guest site Guest privileges is an ideal way to arrange for benefits in situations such as a
temporary job transfer work assignment college child attending school away from home etc You
should be aware that your FEHBP benefits will NOT follow you to the guest site You will be
covered by the CIGNA HealthCare guest privileges program plan of benefits Contact member
services at 1 800 832 3211 for more information
12 BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
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CIGNA HealthCare of California Inc 2000
Section 6 General Exclusions Things We Don t Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your
Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
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 emain
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 etirement 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
reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot equire you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our egular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer
we may be entitled to eceive 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
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover the
cost of treatment that exceeds the amount you received in the settlement If you do not seek
damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
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CIGNA HealthCare of California Inc 2000
Section 7 Limitations Rules That Affect Your Benefits continued
TRICAR 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 compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compen sation 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 o
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 Web site
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 832 3211 or write to CIGNA HealthCare of
California Inc 400 North Brand Boulevard Glendale California 91203 You may also visit our
website at www cigna com healthcare
Where do I get Your employing or etirement 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 he 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 etirement office
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 ypes of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for me unmarried dependent children under age 22 including any foster or step children your employing or
and my family retirement office authorizes coverage for Under certain circumstances you may also get coverage
for a disabled child 22 years of age or older who is incapable of self support
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CIGNA HealthCare of California Inc 2000
Section 8 FEHB Facts continued
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 etirement office will not notify you when a family member is no longer eligible
to eceive health benefits nor will we Please tell us immediately when you add or emove 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 records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payment and
subrogation 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 esearch 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
Preexisting conditions We will not efuse to cover the treatment of a condition that you or a family member had before you
enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if 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
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 etirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose
coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or etirement office
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CIGNA HealthCare of California Inc 2000
Section 8 FEHB Facts continued
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 equest you still have to pay premiums from the 32 nd day after your egular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
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 etirement 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 etirement 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 etirement 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 etirement office within the 60 day deadline
How can I convert You may convert to an individual policy if
to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law o 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 etirement 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 preexisting 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 indicates how long you have been enrolled with us You can use this certificate when getting health
Group 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 elated 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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CIGNA HealthCare of California Inc 2000
Depar ment of Defense FEHB Demonstration Project
What is the Department of Defense DoD and FEHB Program Demonstration Project
1 The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FEHBP Demonstration Project It
allows some active and retired uniformed service members and their dependents to enroll in the FEHB Program The demonstration
will last for three years beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be effective January
1 2000 DoD and OPM have set up some special procedures to successfully implement the Demonstration Project noted below
Otherwise the provisions described in this brochure apply
Who is Eligible
DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or etired uniformed service member and you have not emarried o You are a survivor dependent of a deceased active or etired uniformed service member and
You live in one of the eight geographic demonstration areas
2 If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are not eligible to enroll
under the DoD FEHBP Demonstration Project
Where are the demonstration areas
Dover AFB DE Commonwealth of Puerto Rico
Fort Knox K Greensboro Winston Salem High Point NC
Dallas TX Humboldt County CA area
Naval Hospital Camp Pendleton CA New Orleans LA
When Can I Join
Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage
will begin January 1 2000 DoD has set up an Information Processing Center IPC in Iowa to provide you with information about how
to enroll IPC staff will verify your eligibility and provide you with FEHB Program information plan brochures enrollment instructions
and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1 877 363 3342
You may select coverage for yourself self only or for you and your family self and family during the 1999 2000 and 2001 Open
Seasons Your coverage will begin January 1 of the year following the Open Season that you enrolled
If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact the IPC to find out how to enroll
and when your coverage will begin
DoD has a Web site devoted to the Demonstration Project You can view information such as their Marketing Beneficiary Education
Plan Frequently Asked Questions demonstration area locations and zip code lists at www tricare osd mil fehbp You can also view
information about the demonstration project including The 2000 Guide to Federal Employees Health Benefits Plans Participating in
the DoD FEHBP Demonstration Project on the OPM Web site at www opm gov
Am I eligible for Temporary Continuation of Coverage TCC
See Section 8 FEHB Facts for information about TCC Under this Demonstration Project the only individual eligible for TCC is one
who ceases to be eligible as a member of family under your self and family enrollment This occurs when a child turns 22 fo
example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10 United States
Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project ends TCC enroll
ment terminates after 36 months or the end of the Demonstration Project whichever occurs first You your child or another person
must notify the IPC when a family member loses eligibility for coverage under the DoD FEHBP Demonstration Project
TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your coverage or your coverage is
terminated for any reason TCC is not available when the demonstration project ends
Do I have the 31 Day Extension and Right To Convert
These provisions do not apply to the DoD FEHBP Demonstration Project
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CIGNA HealthCare of California Inc 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not eceive 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 800 832 3211 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLIN202
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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CIGNA HealthCare of California Inc 2000
Summary of Benefits for CIGNA HealthCare of California 2000
Do not ely 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 ARCOVERED
ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit
Includes in hospital doctor care oom and board general nursing care private room
and private nursing care if medically necessary diagnostic tests drugs and medical
supplies use of operating room intensive care and complete maternity care
You pay nothing 8
Extended care All necessary services for up to 60 days per calendar year You pay nothing 8
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient
conditions care per year You pay a 25 copay all charges thereafter 10
Substance All necessary care for diagnosis and treatment for up to 30 days of inpatient care
abuse per year You pay a 25 copay all charges thereafter 10
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury
including specialist s care preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays complete maternity care
You pay a 10 copay per office visit Copays are waived for maternity care 6 7
Home health All necessary visits by nurses and health aides You pay nothing 7
care
Mental Up to 30 combined individual and group therapy outpatient visits per year You pay
conditions a 10 copay per individual visit and 5 copay per group therapy visit all charges thereafter 10
Substance Up to 60 combined individual and group therapy outpatient visits per year You pay a
abuse 10 copay per individual visit and a 5 copay per group therapy visit all charges thereafter 10
Emergency care Reasonable charges for services and supplies required because of a medical emergency
You pay a 50 copay to the hospital for each emergency room visit and any charges for
services that are not covered by this Plan 9 10
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay
for generic and 10 for name brand per prescription unit or efill For limits on name
brand drugs see pages 10 11
Tel Drug Mail order drug program for drugs prescribed by a Plan doctor and obtained through
Tel drug You pay a 10 copay for generic and 20 for name brand copay per 90 day
supply For limits on name brand drugs see pages 11
Dental care Accidental injury benefit You pay a 5 copay per visit 11
Vision care One refraction annually You pay a 5 copay per visit 11
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses
reach a maximum of 1,000 per Self Only or 3,000 per Self and Family enrollment per
calendar year covered benefits will be provided at 100 This copay maximum does not
include prescription drugs 3
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CIGNA HealthCare of California Inc 2000
2000 Rate Information for
CIGNA HealthCare of California
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category efer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for
United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Gov t Your Gov t Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Northern Southern California
Self only 9T1 67.81 22.60 146.92 48.97 80.24 10.17 80.24 10.17
Self and Family 9T2 149.19 49.73 323.24 107.75 176.54 22.38 176.54 22.38
20 22