Pages 1--32 from Untitled

A Health Maintenance Organization
For changesin 4 benefitssee
page Serving Western Massachusetts and Northern Connecticut

Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
DJ1 Self Only
DJ2 Self and Family

10 98 5 00
This service area has commendable
accreditation from the NCQA
See the 2000 Guide for more
information on NCQA

Visit the OPM website at http www opm gov insure
Authorized for distribution by the

RI 73 437 1
1 Page 2 3
Health New England 2000
Table of Contents
Page

Introduction 3

Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5 8
Section 4 What to do if we deny your claim or request for service 8 10
Section 5 Benefits 10 20
Section 6 General exclusions Things we don't cover 21
Section 7 Limitations Rules that affect your benefits 21 22
Section 8 FEHB FACTS 23 27
Inspector General Advisory Stop Healthcare Fraud 28
Summary of benefits 31
Premiums 32

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Health New England 2000
Introduction
Health New England Inc One Monarch Place Suite 1500 Springfield MA 01144
This brochure describes the benefits you can receive from Health New England under its contract CS 2329 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 4 of this brochure Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences

We refer to Health New England 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 rewritten 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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Health New England 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 Plan providers you will not have to submit claim forms or pay bills However you must pay copayments listed in this brochure When you receive emergency services out of plan you may have to submit claim forms There
are no claim forms when Plan doctors are used
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 Plan providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care management our network
changes 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 with 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

To keep premiums as low as possible OPM has set a minimum copay of 10 for all primary care office visits

Changes to Your share of the non postal premium will decrease by 4.9 for Self Only or 6 for Self this Plan and Family
Scalp hair prostheses wigs are covered by the Plan up to 350 per year for those members undergoing treatment for any form of cancer or leukemia See page 12
Copayments for prescription drugs increased from 5 10 15 to 7 15 30 per 30 day supply or refill See page 17
Members must use the mail order program for 90 day supplies of medication See page 17
Copayments for emergency room treatment increased from 25 to 50 per visit See page 15

Under this Plan doctor office visits and house calls oral and maxillofacial services and accidental injury benefits will increase from 5 to 10 per visit

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Health New England 2000
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 The Massachusetts counties of Berkshire Franklin Hampden and Hampshire The Worcester County towns of Athol Barre Brookfield East Brookfield Gardner Hardwick New Braintree North Brookfield Oakham Petersham Royalston Spencer Sturbridge Warren

and West Brookfield The northern Connecticut towns of East Granby East Windsor Enfield Granby Somers South Windsor Suffield Warehouse Point West Suffield Windsor and
Windsor Locks
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 for the
Open Season to change plans Contact your employing or retirement office
How much do You must share the cost of some services This is called a copayment a set dollar amount
I pay for services Please remember you must pay this amount when you receive services After you pay 2,375 in copayments for one family member or 5,250 for two or more family

members you do not have to make any further copayments for certain services for the rest of the calendar year This is called a catastrophic limit However copayments for your prescription
drugs do not count towards these limits and you must continue to make these copayments
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 Health New England is a Federally Qualified Independent Practice Association IPA Health
my health care Maintenance Organization HMO We not only pay for health care services we coordinate them through a network of highly skilled doctors and medical facilities We have contracts with Baystate Medical Center Cooley Dickinson Hospital Holyoke Hospital Noble Hospital

Hillcrest Hospital Berkshire Medical Center Fairview Hospital North Adams Regional Hospital Franklin Medical Center and Mary Lane Hospital as well as over 300 established
primary care doctors and 1,000 specialists In addition HNE has contracts with various hospitals in Worcester and Boston including University of Massachusetts Medical Center Beth Israel
Hospital and New England Medical Center which provide with prior approval from the Plan specialty services that are not performed locally

You will need to let us know which primary care physician you select for each member of the family If you need help in choosing a physician please call us at 413 787 4004 You may
change your choice by calling us Changes will be effective on the first day of the month following the date your request is received

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Health New England 2000
Section 3 How to get benefits continued

What do I do Call us We will help you select a new one
if my primary care
physician leaves
the Plan

What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or
need to go into the specialist will make the necessary hospital arrangements and supervise your care
hospital

What do I do if I'm First call our customer service department at 413 787 4004 If you are new to the FEHB
in the hospital when program we will arrange for you to receive care If you are currently in the FEHB program and are switching to us your former plan will pay for the hospital stay until
I join this Plan You are discharged not merely moved to an alternative care center or

The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

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Health New England 2000
Section 3 How to get benefits continued
How do I get Your primary care physician will arrange your referral to a specialist You must receive a written
specialty care referral from your physician before getting care If the specialist suggests services or visits beyond those authorized on the referral you must first check with your primary care physician

If you need a specialist who does not participate with us your primary care physician must
request our approval Do not go to the specialist unless your primary care physician has arranged
for and we have approved the referral in advance We will send our decision on the request to
both you and your primary care physician

You may see your participating obstetrician or gynecologist or obtain one eye exam each year
without a referral from your primary care physician

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

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to
seeing a specialist a 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 the receive services from your current specialist until we can make arrangements for you to see
Plan someone else

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 seeing your provider for up to 90 days after we notify you that we are terminating our contract
my provider leaves with the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Plan or this Plan 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 Your physician must get approval before sending you to a hospital referring you to an out ofplan
authorize medical specialist or recommending out of plan follow up care Before giving approval we consider
services if the service is medically necessary and if it follows generally accepted medical practice

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Health New England 2000
Section 3 How to get benefits continued
How do you decide Experimental means any medical procedure equipment treatment or course of treatment or
if a service is drugs or medicines that are considered to be unsafe experimental or investigational according to among other sources formal or informal studies opinions and references to or by the American
experimental or Medical Association the Food and Drug Administration the Department of Health and Human
investigational Services the National Institutes of Health the Council of Medical Specialty Societies experts in the field and any other association or federal program or agency that has the authority to approve

medical testing or treatment

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
OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service

What if I have Call us at 413 787 4004 and we will expedite our review
a serious or life
threatening
condition and
you haven't
responded to
my request for
service

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Health New England 2000
Section 4 What to do if we deny your claim or request for service continued
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious
for care and my or life threatening conditions are ones that may cause permanent loss of bodily functions or death
condition is serious if they are not treated as soon as possible
or life threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time 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
to OPM information 1 A statement about why you believe our decision is wrong based on specific benefit

provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the request

1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the
enrolled person's representative They must send a copy of the person's specific
written consent with the review request

Where should I Send your request for review to Office of Personnel Management Office of Insurance
mail my disputed Programs Contract Division III PO Box 436 Washington DC 20044
claim to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our
upholds the decision your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
I file a lawsuit its 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

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Health New England 2000
Section 4 What to do if we deny your claim or request for service continued
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

provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become
part of the court record

Section 5 Benefits
Medical and surgical benefits

What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office
visit copay but no additional copay for laboratory tests and X rays Within the service area
house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate You pay a 10 copay for a doctor's house call nothing for home visits by nurses
and home health aides

The following services are included and are subject to the office visit copay unless stated otherwise

Preventive care including well baby care and periodic check ups
Sigmoidoscopy screening for colorectal cancer every five years for those age 50 and above
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years and for women age 40 and above one mammogram every year In
addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness

Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor office visit copays are waived for obstetrical care 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

Voluntary sterilization and family planning services
Infertility services diagnosis and treatment including fertility drugs unless either spouse has
previously undergone a voluntary sterilization

Artificial insemination The following types are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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Health New England 2000
Section 5 Benefits continued
In vitro fertilization if the donor is the spouse and medical eligibility criteria are met
Embryo transfers
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung single and double kidney and liver transplants allogeneic
donor bone marrow transplants autologous bone marrow transplants autologous stem cell
and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma 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 if the
expenses are not covered by the donor's insurance

Patients 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
Medical formulas for certain inherited diseases
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

What benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures
are limited 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 You pay a 10 copayment per service
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 Breast prosthesis and surgical bras including replacements following a mastectomy
are covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 11
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Health New England 2000
Section 5 Benefits continued
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient
or outpatient basis for up to two months or 25 visits whichever is greater per condition
per calendar year if significant improvement can be expected within this period You pay a 10
copay 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

Durable medical equipment DME such as glucometers ostomy supplies wheelchairs and
hospital beds orthopedic devices such as braces prosthetic devices such as artificial limbs
and lenses following cataract removal are covered up to a maximum Plan payment of 2,000
per year DME requires a written order from a Plan doctor and repair and replacements not
provided for under a manufacturer's warranty or purchase agreement are covered when noted
on the order Certain items require authorization of HNE's Health Services Department
You pay all charges in excess of 2,000

Insulin pumps will be covered when determined by the Plan to be medically necessary and
when precertified by the Plan

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
is provided at a Plan facility You pay a 10 copayment

Scalp hair prostheses wigs will be covered by the Plan for hair loss suffered due to the
treatment of any form of cancer or leukemia You will be reimbursed by the Plan up to
350 towards the cost of the scalp hair prosthesis Benefit is limited to 350 per calendar
year Requests for reimbursement must be sent to the HNE Customer Service
Department The request must include proof of payment and a written statement from
your doctor that the scalp hair prosthesis is medically necessary

Low protein foods are covered for members with inherited diseases of amino acids and organic
acids up to 2500 per member per year

What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance attending school or camp or travel
Blood and blood derivatives not replaced by the member

Cost of donor sperm
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services
Routine foot care
Foot orthotics

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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Health New England 2000
Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered 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

Hospital care 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 100 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 The Plan provides coverage for licensed hospice services to terminally ill patients with a life expectancy of six months or less Services must be authorized by a Plan doctor and approved by
the Plan You pay nothing
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a 25 copayment per trip

Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there procedures is a need for hospitalization for reasons totally unrelated to the dental procedure The Plan will
cover the hospitalization but not the cost of any professional 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 pages 16 17 for nonmedical Substance Abuse Benefits

What is not Personal comfort items such as telephone and television
covered Blood and blood derivatives not replaced by the member

Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 13
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Health New England 2000
Section 5 Benefits continued

Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you
medical believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
emergency 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

What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services

Ambulance service approved by the Plan

What is not Elective care or nonemergency care
covered Emergency care provided outside the service area if the need for care could have been foreseen

before leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area

What should I do If you are in an emergency situation please call your primary care doctor In extreme emergencies
if an emergency 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
occurs within the room personnel that you are a Plan member so they can notify the Plan You or a family member
service area must 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 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 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

What does the Plan The Plan pays reasonable charges for emergency services to the extent the services would have
pay if an emergency been covered if received from Plan providers
occurs within the
service area

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Health New England 2000
Section 5 Benefits continued
What do I pay if an You pay 50 per hospital emergency room visit or 50 per urgent care center visit for emergency
emergency occurs care that are covered benefits of this Plan If the emergency results in admission to a
within the service hospital the emergency care copay is waived
area

What should I do Benefits are available for any medically necessary health service that is immediately required
if an emergency because of injury or unforeseen illness
occurs outside the If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
service area 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

What does the The Plan pays reasonable charges for emergency services to the extent the services would have
Plan pay if an been covered if received from Plan providers
emergency occurs
outside the service
area

What do I pay You pay 50 per hospital emergency room visit or 50 per urgent care center visit for emergency
if an emergency care that are covered benefits of this Plan If the emergency results in admission to a
occurs outside hospital the emergency care copay is waived
the service area

Filing claims for The Plan will pay benefits directly to the providers of your emergency care upon receipt of their
non Plan providers 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 the 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 8 9

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Health New England 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits All services must be approved in advance by us Please call 413 787 4000 before getting care

Mental conditions
What is covered To the extent shown below our Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including treatment of mental illness or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay a 5 copay for each covered visit all charges thereafter

Inpatient care Up to 60 days of hospitalization each calendar year You pay nothing for the first 60 days all charges thereafter Two days of partial hospitalization day treatment may be substituted for each
day of inpatient care There are no copayments for partial hospitalization

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject
covered 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 20 outpatient visits per calendar year to Plan providers for treatment each calendar year You pay a 5 copay for each covered visit all charges thereafter

The substance abuse benefit may be combined with the outpatient mental conditions benefit
shown above provided such treatment is a necessary service and is approved by the Plan to
permit an additional 20 outpatient visits per calendar year with the applicable mental conditions
benefits copayments

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Health New England 2000
Section 5 Benefits continued
Inpatient care Up to 30 days in substance abuse rehabilitation intermediate care programs per calendar year in an alcohol detoxification or rehabilitation center approved by the Plan You pay nothing during
the benefit period all charges thereafter Two days of partial hospitalization day treatment may
be substituted for each day of inpatient care There are no copayments for partial hospitalization

What is not Treatment that is not authorized by a Plan doctor
covered

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 or a 100 unit supply whichever is less You pay a 7
copay per prescription or refill for generic drugs a 15 copay per prescription or refill for brand
name formulary drugs or a 30 copay per prescription or refill for brand name non formulary
drugs However in no event will the copay exceed the cost of the drug

Generic drugs will be dispensed unless specified otherwise by the Plan doctor When there is no
generic drug available there may be more than one brand name drug available to treat a condition
The formulary is a list of preferred brand name drugs offered to members for a somewhat
higher copayment than the generic Non formulary drugs are brand name drugs not on the
formulary that are available at the highest of the three copayment levels

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Nonformulary drugs will be covered when prescribed by a Plan doctor

A mail order pharmacy service is available for most maintenance medications through
PharmaCare Direct Mail order is a convenient and less costly method to order and refill up to a
90 day supply of maintenance drugs 90 day supplies are only available through mail order
You may contact PharmaCare Direct at 1 800 346 9113 for information You pay a 14 copay
per prescription or refill for a 90 day supply of generic drugs a 30 copay per prescription or
refill for a 90 day supply of brand name formulary drugs or a 90 copay per prescription or
refill for a 90 day supply of brand name non formulary drugs

What is a The Health New England HNE Formulary is developed and maintained by a joint Pharmacy
Formulary and Therapeutics Committee The Committee consists of physicians and pharmacists who review all therapeutic drug classes annually The review includes evaluation of new medications
and review of new data on existing medications Both formulary and nonformulary medications
are covered by HNE the difference being the amount of the copayment you will have to pay

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 17
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Health New England 2000
Section 5 Benefits continued
What medications Drugs for which a prescription is required by federal law
and accessories FDA approved drugs prescriptions and devices for birth control
are covered Insulin

Insulin syringes and needles
Blood glucose monitoring strips for insulin dependent diabetics only
Disposable needles and syringes needed to inject covered prescribed medication
Prenatal vitamins
Vitamins with fluoride for infants up to one year of age
Non injectable fertility drugs injectable fertility drugs are covered under Medical and Surgical
Benefit

NOTE Intravenous fluids and medication for home use are covered under Medical and Surgical
Benefits

What medications Sexual dysfunction or erectile dysfunction drugs have dispensing limitations and require documentation
and accessories of medical necessity from the prescribing doctor
have limited Smoking cessation drugs and medication including nicotine patches have certain limitations
coverage and coverage requirements contact the Plan for details

What medications Drugs available without a prescription or for which there is a nonprescription equivalent
and accessories available
are not covered Drugs obtained at a non Plan pharmacy except for out of area emergencies

Vitamins other than those listed above and nutritional substances that can be purchased without
a prescription

Medical supplies such as dressings and antiseptics
Diabetic supplies other than syringes needles and blood glucose monitoring strips for noninsulin
dependent diabetics only

Drugs for cosmetic purposes
Drugs to enhance athletic performance
Implanted time release medications other than Norplant

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
18 Page 19 20
Health New England 2000
Section 5 Benefits continued

Pediatric Dental Benefits
What is covered You pay a 25 deductible per child per calendar year Children under the age of 12 receive the following benefits

Initial oral examination periodic exam up to once every six months
X rays of entire mouth up to once every 60 months
Bitewing X rays up to once every six months when oral conditions indicate need
Single tooth X ray as needed
Routine cleaning scaling and polishing of teeth up to once every six months
Fluoride treatments up to once every six months
What if I have Initial services and supplies necessary to stabilize injury to sound natural teeth are covered The
an accident need for these services must result from an accidental injury You pay a 10 copayment for the initial treatment

What is not Other dental services not shown as covered
covered

Vision Care Benefits
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions which include the written lens prescription may be obtained from
Plan providers once every year without a referral Coverage for more frequent eye refractions
will be provided with a referral from your primary care doctor You pay a 10 copay per visit

What is not Corrective lenses or frames
covered Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19 19
19 Page 20 21
Health New England 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are
made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included
in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket
maximums These benefits are not subject to the FEHB disputed claims procedure

Vision Benefit
HEALTH NEW ENGLAND MEMBERS CAN GET A 15 DISCOUNT OFF THE LOWEST PRICE OF PRESCRIPTION
EYEGLASSES AND CONTACT LENSES AT PARTICIPATING EYEWEAR PROVIDERS

Health Education Benefit
HEALTH NEW ENGLAND MEMBERS CAN GET A 10 DISCOUNT OFF THE COST OF HEALTH EDUCATION
CLASSES OFFERED AT PARTICIPATING PLAN HOSPITALS

A list of participating eyewear facilities will be given to each member

Benefits on this page are not part of the FEHB Contract
20 BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 20
20 Page 21 22
Health New England 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
Expenses you incurred while you were not enrolled in this Plan

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

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

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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833

21 21
21 Page 22 23
Health New England 2000
Section 7 Limitations Rules that affect your benefits continued
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance You must tell us if you or a family member has double coverage You must also send us
coverage documents about other insurance if we ask for them When you have double coverage one plan is the primary payer it pays benefits first The other

plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care
control

When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible for that another person caused you must reimburse us for whatever services we paid for We will
your injuries 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

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 determines 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 as long as you use our providers

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
Agencies or indirectly pays for

22 22
22 Page 23 24
Health New England 2000
Section 8 FEHB FACTS

You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO 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 413 787 4004 or 800 310 2835 or write to Health
New England One Monarch Place Suite 1500 Springfield MA 01144 1500 You may also
contact us by fax at 413 731 7498 or 413 736 1850

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 informed decision about
enrolling in the
FEHB Program When you may change your enrollment

How you can cover your family members

What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire

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

When are my The benefits in this brochure are effective 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 Annuitants premiums begin January 1
effective

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

23 23
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Health New England 2000
Section 8 FEHB FACTS continued
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office 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
family and me If you have a Self Only enrollment you may change to a Self and Family enrollment if you

marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

Are my medical We will keep your medical and claims information confidential Only the following will have
and claims 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 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

24 24
24 Page 25 26
Health New England 2000
Section 8 FEHB FACTS continued
Information for New Members

Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled

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

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

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible 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 32nd day after your regular coverage ends even if several months have passed

25 25
25 Page 26 27
Health New England 2000
Section 8 FEHB FACTS continued 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 retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline

How can I You may convert to an individual policy if
convert to Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
individual did not pay your premium you cannot convert
coverage 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

26 26
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Health New England 2000
Section 8 FEHB FACTS continued
How can I If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
get a Certificate that indicates how long you have been enrolled with us You can use this certificate when getting health insurance or other health care coverage You must arrange for the other coverage
of Group Health within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
Plan Coverage 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

27 27
27 Page 28 29
Health New England 2000
Inspector General Advisory
Stop Health Care Fraud

Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or
hospital has charged you for services you did not receive billed you twice for the same service or
misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 413 787 4004 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

28 28
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Health New England 2000
NOTES

29 29
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Health New England 2000
NOTES

30 30
30 Page 31 32
Health New England 2000
Summary of Benefits for Health New England 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 Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes care in hospital doctor care room and board general nursing care private room and private nursing
care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care You pay nothing 13

Extended Care All necessary services for up to 100 days per year You pay nothing 13
Mental Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care Conditions per year You pay nothing 16

Substance Up to 30 days of substance abuse treatment per year You pay nothing 17 Abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care including specialists 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 10 per house call by a doctor 10 11

Home Health All necessary visits by nurses and home health aides You pay nothing 11 Care
Mental Up to 20 outpatient visits per year You pay a 5 copay per visit 16 Conditions
Substance Up to 20 outpatient visits per year You pay a 5 copay per visit 16 Abuse

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 benefits by this Plan 14 15

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a participating pharmacy You pay a 7 copay per prescription or refill for generic drugs 15 copay per prescription or refill for formulary
drugs and a 30 copay per prescription or refill for non formulary drugs 17 18

Dental care Accidental injury benefit You pay a 10 copay per visit Preventive dental care to age 12 you pay a 25 deductible per child per calendar year 19
Vision care One refraction every year You pay a 10 copay per visit 19
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 2,375.00 per Self Only or 5,250.00 per Self and Family enrollment
per calendar year covered benefits will be provided at 100 This copay maximum does not include costs of prescription drugs
5

31 31
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Health New England 2000
2000 Rate Information for
Health New England

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

Self Only DJ1 78.83 28.24 170.80 61.19 93.06 14.01 93.26 13.81
Self and Family DJ2 175.97 60.64 381.27 131.39 207.74 28.87 201.02 35.59

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