HIP Health Plan of Florida 2000
A Health Maintenance Organization
Serving South Florida and Tampa Bay areas
Enrollment in this Plan is limited see page 3 for requirements
Enrollment code South Florida
3N 1 Self Only 3N 2 Self and Family
Tampa K7 1 Self Only
K7 2 Self and Family This Plan has commendable accreditation from the NCQA See the 2000 Guide for
more information on NCQA
Special Notice The Plan divided its service and rating areas into two separate enrollment codes K71 K72 for the Tampa area and 3N1 3N2 for South Florida
If you live or work in South Florida Broward Miami Dade and Palm Beach counties you must complete a Standard Form SF 2809 during Open Season to switch to enrollment code 3N1 3N2 If you do not you will remain enrolled with HIP
Health Plan of Florida but you will pay the higher rate for enrollment code K71 K72
If you live or work in the Tampa area Hernando Hillsborough Pasco and Pinellas counties your enrollment code will NOT change No action is required if you wish to remain enrolled with HIP Health Plan of Florida
Visit the OPM website at http www opm gov insure and
our website at http www hipusa com
Authorized for distribution by the
United States Office of Personnel Management
Retirment and Insurance Service
HIP Health Plan of Florida 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 3
Section 4 What to do if we deny your claim or request for service 5
Section 5 Benefits 7
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16
Section 8 FEHB facts 17
Inspector General Advisory Stop Healthcare Fraud 20
Summary of benefits 21
Premiums Back Cover
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HIP Health Plan of Florida 2000
Introduction
HIP Health Plan of Florida 300 South Park Road Hollywood Fl 33021
This brochure describes the benefits you can receive from HIP Health Plan of Florida under its contract CS2363 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 on the back cover
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 HIP HMO 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
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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HIP Health Plan of Florida 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care changes office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program see
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this For enrollment code K71 K72 your share of the non postal premium will increase by 134.8 for Self Plan Only or 186.1 for Self and Family See back of brochure
Plan provider office visit copayment increased from 5 to 10 See page 7
Under Prescription Drugs the copayment for brand name 0drugs increased from 5 to 10 The generic copayment remains at 5 See page 12
Under Prescription Drugs a Mail Order program is now available for maintenance medications For a 90 day supply you pay a 10 copayment for generic and 20 copayment for brand name drugs See
page 12
Under Prescription Drugs home delivery of prescriptions is now available in South Florida See page 12
Under Vision Care the single lens copayment increased from 28 to 29 the bifocal copayment increased from 40 to 48 See page 14
Simultaneous Enrollment in the FEHB and HIP VIP Medicare is no longer offered
The Plan's service area has been redefined and two enrollment codes apply See page 3
Under How much do I pay for services copayments for prescription drugs dental services and 2 eyeglasses contacts do not count toward the catastrophic limit See page 3
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HIP Health Plan of Florida 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan s service Our service areas are defined by the following counties in Florida
area South Florida enrollment code 3N
Broward Miami Dade and Palm Beach
Tampa enrollment code K7 Hernando Hillsborough Pasco and Pinellas
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 moves 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 This Plan has an affiliate in New York which serves the greater New York metropolitan
area If you move to that area you may enroll in the FEHB program offered by that plan If you or a family member moves you do not have to wait until Open Season to change plans Contact your
employing or retirement office
How much do You must share the cost of some services This is called either a copayment a set dollar amount or I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services except for well child care and pre natal care
After you pay 1,500 in copayments for one family member or 3,000 for two or more family members you do not have to make any further payments for certain services for the rest of the year
This is called a catastrophic limit However copayments for your prescription drugs dental services and eyeglasses contacts 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 of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides HIP Health Plan of Florida contracts with over 1200 primary care doctors and 2200 specialist doctors my health care to provide care to its members When a family joins the Plan each family member may select a
different doctor The primary care doctor usually a family practitioner internist or pediatrician provides primary medical care arranges lab tests x rays referrals to specialists and hospitalization
for you as medically necessary
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist to go into the hospital will make the necessary hospital arrangements and supervise your care
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HIP Health Plan of Florida 2000
Section 3 How to get benefits continued
What do I do if First call our Customer Service Department at 1 800 HIP TALK TTY 1 888 444 7352 for the I'm in the hearing impaired If you are new to the FEHB Program we will arrange for you to receive care If
hospital when you are currently in the FEHB Program and are switching to us your former plan will pay for the I join this Plan 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 referral to a specialist The following services do not specialty care require a referral from your primary care physician
The annual well woman examination Podiatry
Chiropractic care First 5 visits per year to a dermatologist
Inpatient and outpatient mental health and substance abuse treatment call 1 800 221 5487 to arrange an appointment
Preventive dental services call 1 800 432 3376 to select a participating dentist
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan The physician may have to get an authorization or approval from
us beforehand
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a 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 receive specialist leaves services from your current specialist until we can make arrangements for you to see someone else
the Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
provider leaves the the provider unless the termination is for cause If you are in the second or third trimester of Plan or this Plan pregnancy you may continue to see your OB GYN until the end of your postpartum care
leaves the 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 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 authorize Your physician must get our approval before sending you to a hospital referring you to a specialist or medical services recommending follow up care Before giving approval we consider if the service is medically
necessary and if it follows generally accepted medical practice
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HIP Health Plan of Florida 2000
Section 3 How to get benefits continued
How do you decide A service supply drug device procedure or treatment is considered experimental or investigational if a service is if any of the following applies
experimental or There is insufficient outcomes data available from controlled clinical trials published in the peerreviewed investigational
literature to substantiate its safety and effectiveness for the disease or injury involved The Food and Drug Administration FDA has not granted the required approval for general use
A recognized national medical or dental society or regulatory agency has determined in writing that it is experimental investigational or for research purposes
The written protocols or informed consent used by the treating facility or any other facility studying substantially the same drug device procedure or treatment state that it is experimental
investigational or for research purposes
However coverage will not be excluded for any drug prescribed for the treatment of cancer on the grounds that the drug is not approved by the FDA for a particular indication if that drug is recognized
for treatment of that indication in a standard reference compendium or recommended in the medical literature Coverage also includes medically necessary services associated with the administration of
the drug
Also coverage will not be excluded for bone marrow transplant procedures recommended by the referring physician and treating physician if the particular use of the bone marrow transplant
procedure is determined to be accepted within the appropriate oncological specialty and not experimental pursuant to FAC Rule 10D 127.001
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review OPM will determine if we correctly applied the terms of our contract when we denied your claim or
a denial request for service
What if I have a serious or life threatening condition and you haven't responded to my request for service Call us at 1 800 HIP TALK and we will expedite our review
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious health benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or lifethreatening or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are
not treated as soon as possible 5
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HIP Health Plan of Florida 2000
Section 4 What to do if we deny your claim or request for service continued
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for
additional information
What do I send Your request must be complete or OPM will return it to you You must send the following information to OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with the
review request
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs disputed claim Contract Division III P O Box 436 Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision the Plan s denial 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 if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and Privacy Act 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 provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the court record
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HIP Health Plan of Florida 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay 10 per visit however
well child care and pre natal care are not subject to the copayment Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate
you pay 10 for a doctor's house call or for home visits by nurses 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 routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after a 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
Annual routine gynecological exam
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers cochlear implants and artificial joints
Cornea heart heart lung kidney liver lung single or double and pancreas kidney transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem
cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical and hospital
expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure In addition coverage for
breast cancer treatment includes reconstruction of the breast on which the mastectomy was performed surgery and reconstruction of the other breast to produce a symmetrical appearance prostheses and
treatment of physical complications at all stages of the mastectomy including lymph edemas
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 7
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics
Prosthetic devices such as artificial limbs breast prostheses or surgical bras and their replacements and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds when part of home health service treatment plan
Chiropractic services
Blood and blood derivatives
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
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 the treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected within
two months you pay 10 copayment per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the
member to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered Artificial insemination is covered you pay 10 copayment per visit cost of donor sperm is not covered Fertility drugs used in connection with
artificial insemination services are covered under the Prescription Drug Benefit Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not
covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction you pay 10 copayment per session
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
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
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids however cochlear implants will be covered
Transplants not listed as covered
Long term rehabilitative therapy
Radial keratotomy lasik or laser surgery to correct eyesight
Reversal of voluntary sterilization
Acupuncture
Immunizations required for travel
Biofeedback services and other forms of self care or self help training and any related diagnostic testing hypnosis meditation and pain control
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
Semi private room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 30 days per calendar year when fulltime skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need procedures for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 12 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency 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 if the service area 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 responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the
Plan within that time If you are hospitalized in non Plan facilities and 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 Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or
significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is waived
Emergencies outside the Benefits are available for any medically necessary health service that is immediately required because service area of injury or unforeseen illness
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
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is waived
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 if 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
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan 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 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 5
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 40 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay a 25 copayment for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
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 medically necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
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 40 outpatient visits to Plan providers for treatment each calendar year you pay a 25 copayment for each covered visit all charges thereafter
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing for the 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 prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be
dispensed for up to a 30 day supply You pay a 5 generic or 10 brand name copayment per prescription unit or refill up to a 30 day supply For maintenance medications a 90 day mail order
supply is available for a copayment of 10 generic or 20 brand name drugs
When generic substitution is available the Plan doctor must obtain prior authorization from the Plan in order to prescribe a name brand drug When generic substitution is permissible i e a generic
drug is available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay the price difference between the generic and name brand drug
as well as the 10 copayment per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor
The Drug Formulary is a list of drugs both brand name and generic approved by the Plan as covered medications To be included in the Formulary the drug is evaluated by HIP's Pharmacy and
Therapeutics Committee for a multitude of factors including effectiveness safety and cost with the effectiveness and safety components being of utmost importance The Pharmacy and Therapeutics
Committee is comprised of doctors pharmacists and other health care professionals Exceptions to the Formulary may be requested by any Plan provider and will be considered by the Pharmacy and
Therapeutics Committee
At no time will the copayment exceed the Plan's cost for the prescription
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin a copayment applies to each vial
Implanted time release medications such as Norplant For Norplant you pay 10 of the cost per prescription For other internally implanted time release medications you pay 10 of the cost
per prescription There is no charge when the device is implanted during a covered hospitalization There will be no refund of any portion of these copayments if the implanted timerelease
medication is removed before the end of its expected life
Disposable needles and syringes needed to inject covered prescribed medication
Non barbiturate hypnotics i e tranquilizing drugs including sleeping pills
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
Contraceptive drugs and devices
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
Limited Benefits Sexual dysfunction drugs have dispensing limitations you pay a 15 copayment per prescription or refill for generic or name brand drugs formulary or non formulary when prescribed by your Plan
doctor Contact the Plan for details
In South Florida enrollment code 3N home delivery of prescriptions is available from one of the participating pharmacies Contact the Plan for details
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
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
Fertility drugs except those prescribed in connection with artificial insemination services
Smoking cessation drugs and medication including nicotine patches unless in conjunction with participation in the Plan's approved behavioral modification program
Dietary supplements
Refills in excess of the number specified by the physician
Drugs that are to be taken by or administered to you in whole or in part while you are a patient in a hospital sanitarium skilled nursing facility convalescent hospital inpatient hospice facility or
other facility where drugs are ordinarily provided by the facility on an inpatient basis
Vitamins except Legend prenatal vitamins Legend vitamins used for the treatment of renal disease hypoparathyroidism or other medically necessary conditions when prescribed by a Plan
physician and approved by the Plan may be covered
Drugs which were provided to you by this Plan but which were lost stolen or destroyed
Other Benefits Dental Care
What is covered The following preventive and diagnostic services are covered when provided by Plan dentists you pay a 5 copayment per year for preventive services a 5 copayment per for visit for diagnostic
services with a maximum copayment of 10 per visit
Preventive Services Prophylaxis or cleaning two per year
Application of topical fluoride for children up to and including the age of fifteen two per year
Diagnostic Services Oral exam two per year
Bitewing X rays 2 every six months
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth benefit are covered The need for these services must result from an accidental injury you pay nothing
What is not covered Other dental services not shown as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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HIP Health Plan of Florida 2000
Section 5 Benefits continued
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this plan provides certain vision care benefits from Plan providers
Annual eye refraction to provide a written lens prescription for eyeglasses you pay 15 per visit
One pair of corrective eyeglasses per year from selected collection you pay a 29 copayment for single vision eyeglasses or a 49 copayment for bifocals
One pair of Daily Wear contact lenses per year in lieu of eyeglasses You pay 100 59 for contact lens eye examination 41 for the lenses and kit or one pair of Extended Wear contact lenses per
year You pay 140 79 for contact lens eye examination and fitting 61 for the lenses and kit
What is not covered Eye exercises
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HIP Health Plan of Florida 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered not guaranteed under the contract with the FEHBP but are made available to all enrollees and family members of this Plan The cost of the benefits described on this
page is not included in the FEHB premium and any charges for these services do no count toward any FEHB deductibles or out of pocket maximums The benefits are not subject to the FEHBP disputed claims procedures
Enrollment in HIP VIP Medicare
Who may enroll You may enroll if you live in Broward Miami Dade and Palm Beach counties you are entitled to Medicare Part A and enrolled in Medicare Part B HIP VIP
Medicare is our Medicare Choice program for persons who are eligible for Medicare
You may enroll at any time during the year You must make a positive enrollment into the HIP VIP Medicare plan Contact the Plan at 1 800 826 1013
TTY 1 888 444 7352 for the hearing impaired to obtain an enrollment form
What is covered In Miami Dade and Broward counties HIP VIP Medicare covers all physician and hospital care in full and prescription drugs subject to a 5 copayment and an
annual limit of 1,200 for brand name drugs generic drugs are not subject to any copayment or limit In addition HIP VIP Medicare covers routine foot care
preventive dental services in full and a full range of other dental services with copayments 600 every 3 years for a hearing aid over the counter vitamins
fitness club incentive and personal home care
In Palm Beach county copayments are required for all physician and hospital care and prescription drugs are subject to a 5 generic 10 brand copayment and
an annual limit of 1,200 for brand name drugs generic drugs are not subject to any limit In addition HIP VIP Medicare covers routine foot care preventive
dental services in full over the counter vitamins and a fitness club incentive
What is not covered Routine care by non Plan providers Except for emergency and urgentlyneeded care and renal dialysis while out of the service area HIP VIP Medicare
members must use the Plan's contracted providers for all of their health care needs
Services not shown as covered
Benefits on this page are not part of the FEHB contract
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HIP Health Plan of Florida 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 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 cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan
offered by this Plan see page 15
When anyone has coverage with us and with another group health plan it is called double coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
Other group When you have double coverage one plan is the primary payer it pays benefits first The other plan insurance coverage is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
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HIP Health Plan of Florida 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to 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 another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
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 to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out about care management which includes medical practice
guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 1 800 HIP TALK or write to HIP Health Plan of Florida 300 South Park Road Hollywood Fl 33021 You may also contact us by fax at 954 893 6482 or visit our website at www HIPUSA com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about FEHB Program
When you may change your enrollment How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
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HIP Health Plan of Florida 2000
Section 8 FEHB FACTS continued
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled I retire 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 or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage for family and me 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 and We will keep your medical and claims information confidential Only the following will have access claims records to it
confidential OPM this Plan and subcontractors when they administer this contract
This Plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification 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 conditions We will not refuse 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
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HIP Health Plan of Florida 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 spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits under coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI 79 27 which describes
TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
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HIP Health Plan of Florida 2000
Section 8 FEHB FACTS continued
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 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 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 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 1 800 877 TELL HIP 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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HIP Health Plan of Florida 2000
Summary of Benefits for HIP Health Plan of Florida 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care
private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care
and complete maternity care You pay nothing 9
Extended care All necessary services up to 30 days per calendar year You pay nothing 9
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days conditions of inpatient care per year You pay nothing 11
Substance Up to 30 days per year in a substance abuse treatment program abuse You pay nothing 12
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 10 per office visit 10
per house call by a doctor 7
Home health All necessary visits by nurses and health aides You pay nothing 8 care
Mental Up to 40 outpatient visits per year You pay 25 per visit 11 conditions
Substance abuse Up to 40 outpatient visits per year You pay 25 per visit 12
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copayment to the hospital for each
emergency room visit and any charges for services that are not covered by this Plan 10
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy or via mail order You pay a 5 generic 10 brand copayment per 30 day
supply at a Plan pharmacy and 10 generic 20 brand per 90 day supply for mail order 12
Dental Care Accidental injury benefit You pay nothing Preventive and diagnostic care You pay a 5 copay per visit for preventive care a 5 copay per
visit for diagnostic care with a maximum copay of 10 per visit 13
Vision care One refraction annually eyeglasses contact lenses You pay various copays 14
Out of pocket maximum Copayments are required for a few benefits however after your out ofpocket expenses reach a maximum of 1,500 per Self Only or 3,000
per Self and Family enrollment per calendar year covered benefits will be provided at 100 3
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2000 Rate Information for
HIP Health Plan of Florida
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Tampa area
Self Only K71 78.83 46.13 170.80 99.95 93.06 31.90 93.26 31.70
Self and Family K72 175.97 169.49 381.27 367.23 207.74 137.72 201.02 144.44
South Florida
Self Only 3N1 77.19 25.73 167.24 55.75 91.34 11.58 91.34 11.58
Self and Family 3N2 175.97 108.56 381.27 235.21 207.74 76.79 201.02 83.51
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