Pages 1--25 from FEHB 2000 Brochure

2000 An Independent Licensee of the Blue Cross and Blue Shield Association
AHealth Maintenance Organization
For changes in
Serving Central New York benefits please
see page 4
Enrollment in this Plan is limited see page 4 for requirements

Enrollment Code
EB1 Self only
EB2 Self and family

This Plan has full accrediation from the
NCQA See the 2000 Guidefor
more information on NCQA

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www bcbscny org

United States
Office of
Personnel
Management RI 73 461 1
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HMO CNY 2000
Table of Contents
I n t ro d u c t i o n .3

Plain language .3
How to use this bro c h u re .3
Section 1 Health Maintenance Organizations .4
Section 2 How we change for 2 0 0 0 .4
Section 3 How to get benefits .4
Section 4 What to do if we deny your claim or request for s e r v i c e .7
Section 5 Benefits .9
Section 6 General exclusions Things we don't cover .1 7
Section 7 Limitations Rules that affect your b e n e f i t s .1 7
Section 8 FEHB FA C T S .1 8
I n s p e c t o r General A d v i s o ry Stop Healthcare Fraud .2 2
S u m m a ry of benefits Inside back cover
P remiums Back cover

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HMO CNY 2000
Introduction
HMO CNY Inc P O Box 4712 344 South Warren Street Syracuse N Y 13221 4712

This brochure describes the benefits you can receive from HMO CNY under its contract CS2318 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 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 HMO CNY 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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HMO CNY 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

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 or group of physicians 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
P ro g r a m w i d e To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
c h a n g e s 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 Plan Your share of the HMO CNY non postal premium will increase by 2.9 for Self Only and decrease by
11.7 for Self and Family

The prescription drug program is changing to a 3 three tier benefit Generic drugs will remain at a 5 copayment per 30 day supply Brand name drugs on our preferred drug list will remain at 20
per 30 day supply Brand name drugs not on our preferred list will require a 35 copayment per 30
day supply This applies to both retail and mail order pharmacies See pages 14 15

Section 3 How to get benefits

What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our
service are a service area is

The New York counties of Broome Cayuga Chemung Cortland Onondaga Oswego Schuyler
Steuben Tioga and Tompkins and the zip codes listed in the following counties Madison County
NY 13030 13032 13035 13037 13038 13043 13051 13052 Chenango County NY 13730
13733 13830 13778 Delaware County NY 13742 13755 13756 13783 13804 13838 13839
Bradford County PA 18810 18840 18851 Susquehanna County PA 18801 18812 18813
18821 18822 18823 18826 18827 18830 18834 18843 18847

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HMO CNY 2000
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
unless we have given prior approval for those 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 contact our customer service department about an
HMO USAGuest Membership application at 315 448 6820 or 1 800 447 6269 HMO USA guest
membership benefits are available to subscribers and their dependents when out of this Plan's service
area for an extended period of time This benefit includes access to primary care doctors in the out ofarea
location i e an eligible student dependent attending college outside this Plan's service area
HMO USAis a network of Blue Cross and Blue Shield HMOs that can coordinate your medical care If
you need more information the Plan can tell you more about its reciprocity benefits If you or a family
member move you do not have to wait until Open Season to change plans Contact your employing or
retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount or
f o r s e r v i c e s coinsurance a set percentage of charges Please remember you must pay the applicable amount when you receive services

Your out of pocket expenses for benefits under this Plan are limited to the copayments or coinsurance
stated in this brochure Copayments are due when service is rendered except for medical emergency
care

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider
c l a i m s 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 my A primary care physician you choose from the Provider Directory will provide or arrange your health
health care care services In addition participating specialists cover a wide range of professional specialty care

If you have a question about choosing a personal physician from the Directory or have a question
regarding the Plan a customer service representative will gladly assist you Please call us at 315
448 6820 or 1 800 447 6269 Please note that during physician vacations urgent visits etc
appropriate coverage will be available

What is the role of The first and most important decision you and each family member must make is the selection of a primary
a primary care care doctor The decision is important since it is through this doctor that all other health services
d o c t o r particularly those of specialists are obtained It is your primary care doctor's responsibility to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements

for hospitalization Services of other providers are covered only when there has been a referral by your
primary care doctor with the following exceptions a woman may see her Plan gynecologist directly or
you and your family members may see a plan ophthalmologist or optometrist for a routine eye exam
with no need to be referred by a primary care doctor

What do I do if Call us We will help you select a new one If you are receiving services from a doctor who leaves the
my primary care Plan the Plan will pay for covered services until the Plan can arrange with you to be seen by another
physician leaves participating doctor
the Plan

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist
I need to go into the will make the necessary hospital arrangements and supervise your care
h o s p i t a l

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HMO CNY 2000
What do I do First call our customer service department at 315 448 6820 or 800 447 6269 If you are new to the
if I'm in the hospital FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and
when I join this are switching to us your former plan will pay for the hospital stay until
P l a n 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 Except in a medical emergency or
specialty care when a primary care doctor has designated another doctor to see his or her patients you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services

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 Referral to a participating specialist is given at the primary care doctor's
discretion if non Plan specialist or consultants are required the primary care doctor will arrange
appropriate referrals

When you receive a referral from your primary care doctor you must return to the primary care doctor
after the consultation unless your doctor authorizes additional visits All follow up care must be provided
or authorized by the primary care doctor Do not go to the specialist for a second visit unless
your primary care doctor has arranged for and the Plan has issued an authorization for the referral in
advance

If you have a condition that requires ongoing care you and your PCP may request a standing referral to
a specialist To request a standing referral to a specialist your PCP should contact HMO CNY to discuss
the reasons why it is appropriate for you Our Medical Director will review the request

If you are a new or current member with a life threatening condition or disease or a degenerative and
disabling condition or disease requiring specialized medical care over a prolonged period of time you
and your PCP may request permission to have a specialist provide and or coordinate your care or you
may request access to a specialty care center Your PCP should contact HMO CNY to discuss the reasons
why a specialty care coordinator is appropriate for you Our Medical Director will review the
request

What do I do if I am Your primary care physician will decide what treatment you need If your PCP decides to refer you to a
seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate with
when I enro l l 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

If you are a new member with a life threatening condition or disease or a degenerative and disabling
condition or disease you may continue to receive covered services from your current health care
provider for up to 90 days after your date of enrollment even if the provider does not participate in our
network If you are a new member in the second or third trimester of pregnancy you may continue to
see your provider for covered services through the remainder of the pregnancy and during any postpartum
care directly related to a delivery performed by that provider Simply call or have your provider
call our Customer Service Department for authorization to continue receiving his her services during
the transitional period We will authorize members not affected by a pre existing condition waiting
period to continue ongoing treatment with providers who agree to the following conditions

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 the services from your current specialist until we can make arrangements for you to see someone else
P l a n But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the Program

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HMO CNY 2000
Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
your provider for up to 90 days after we notify you that we are terminating our contract with the
provider unless the termination is for cause If you are in the second or third trimester of pregnancy
you may continue to see your OB GYN until the end of your postpartum care

You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
condition or are in your second or third trimester Your new plan will pay for or provide your care for
up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in
your second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care

In order for you to obtain authorization to continue seeing your provider as described in this and the
preceding paragraph the provider must meet HMO CNY's quality management standards accept as
payment in full the reimbursement rates in effect for participating providers provide us with all the
necessary information related to your care and adhere to all HMO CNY policies and procedures applicable
to participating providers

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

How do you decide We consider any service treatment procedure facility equipment drug device or supply to be experimental
if a service is or investigational if
experimental or
i n v e s t i g a t i o n a l it is considered to be so by the BlueCross and BlueShield Association or any appropriate technical
assessment body or

it does not have the appropriate governmental or regulatory approval or
reliable evidence defined below shows that it is not generally recognized as standard medical treatment or

experts agree that it should be the subject of further study or ongoing clinical trials
Reliable evidence is the opinions and practices of medical groups throughout the country or published
reports and articles in authoritative medical journals or written procedures used by medical providers

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

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HMO CNY 2000
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
OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request
d e n i a l for service

What if I have a Call us at 315 448 6820 or 1 800 447 6269 and we will expedite our review
serious orlife thre a tening
condition and
you haven't re s p o n d e d
to my request for
s e r v i c e

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my re q u e s t OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health
f o r c a re and my condition benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern Time Serious or
is serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they
life thre a t e n i n g are not treated as soon as possible

A re there other t i m e You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
limits 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 to Your request must be complete or OPM will return it to you You must send the following information
O P M 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
re q u e s t 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

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HMO CNY 2000
W h e re should I mail by Send your request for review to U S Office of Personnel Management Office of Insurance Programs
disputed claim to OPM Contract Division III P O Box 436 Washington DC 20044

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the Plan's your only recourse is to sue
d e n i a l 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 I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
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

Yo u r records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
the Privacy A c t 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 covere d 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 copay per office visit but

no additional copay for laboratory tests X rays and normal follow up care resulting from a surgical
procedure Within the service area house calls will be provided if in the judgment of the Plan doctor
such care is necessary and appropriate you pay nothing for a doctor's house call or for home visits by
nurses and health aides

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

Preventive care including well baby care and periodic check ups You pay nothing through age 18
Mammograms are covered in full as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for

women age 50 and over 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 You pay nothing
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays You pay nothing
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option may

remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarian delivery
Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during
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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 9
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HMO CNY 2000
Voluntary sterilization and family planning services contraceptive surgical procedures e g Norplant
Diagnosis and treatment of diseases of the eye
Hearing examinations for children through the age of 18 You pay nothing
Allergy testing and treatment including treatment materials such as allergy serum You pay the office visit copayment for allergy testing and materials but nothing for allergy treatment

The insertion of internal prosthetic devices such as pacemakers and artificial joints breast prosthesis and surgical bras as well as their replacement
Non experimental transplants including cornea heart heart lung lung single and double kidney pancreas kidney pancreas and liver transplants allogeneic donor bone marrow transplants autologous
bone marrow transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or 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 Transplants are covered when approved by the Plan Medical Director Related medical and
hospital expenses of the donor are covered when the recipient is covered by this Plan

Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy You pay nothing
Surgical treatment of morbid obesity
Prosthetic devices such as artificial limbs and lenses following cataract removal You pay nothing
Standard durable medical equipment such as wheelchairs and hospital beds and orthopedic devices such as braces You pay 20 of covered charges

Home health services of nurses and health aides services including intravenous fluids and medication 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

Insulin diabetic supplies disposable needles and syringes You pay a 10 copay per item
Chiropractic services limited to spinal manipulation

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 areas surrounding the teeth are not covered
including shortening of the mandible or maxillae for cosmetic purposes correction of malocclusion and any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the condition
can reasonably be expected to be corrected by such surgery

A patient and her attending physician may decide whether to have breast reconstruction surgery following
a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Your provider will obtain the authorization for these services

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient basis
for up to 60 days or outpatient basis for up to six months per condition if significant improvement can
be expected within this period you pay a 10 copay per session for outpatient therapy and no copay for
inpatient care 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

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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HMO CNY 2000
Diagnosis and treatment of infertility is covered you pay a 10 copay per office visit for the initial
diagnosis and 50 of the maximum amount payable per treatment The following types of artificial
insemination are covered if medically necessary Intravaginal Insemination IVI Intracervical
Insemination ICI and intrauterine insemination IUI you pay 50 of the maximum amount payable
per treatment The cost of donor sperm is not covered Fertility drugs are not covered Diagnostics or
services to monitor the effectiveness of fertility drugs are not covered Other assisted reproductive technology
ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided
when approved by the Plan in advance of service you pay a 10 copay per visit

What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining
c o v e re d or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Blood and blood derivatives no charge if replacement is arranged by the member
Hearing aids
Homemaker services
Foot Orthotics
Travel costs related to health services

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 your 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 240 days per admission 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 This benefit renews after 90 days only if the
member has received no hospital care home health care or skilled nursing care within that time You
pay nothing All necessary services are covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling These services are provided under
the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life
expectancy of approximately six months or less A maximum of 210 hospice days is covered

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
Inpatient dental hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization
p ro c e d u re s 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 11
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HMO CNY 2000
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment
d e t o x i f i c a t i o n 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 14 for

non medical substance abuse benefits

What is not covere d Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
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
e m e r g e n c y 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 poisoning 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 are a 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 or medical facility Be sure to tell the emergency

room personnel that you are a Plan member You or someone on your behalf must notify your primary
care physician within 2 business days of the emergency or as soon as is reasonably possible It is your
responsibility to ensure that the Plan has been timely notified

If your emergency situation is not urgent please call your primary care doctor before obtaining care
Your primary care doctor will advise you of the most appropriate action

If you need to be hospitalized in a non Plan facility your primary care doctor must be notified within
two business days or on the first working day following your admission If you are hospitalized in nonPlan
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 must be approved by the Plan Contact your primary
care physician if the emergency room or medical facility recommends additional care outside of the
visit

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

You pay 50 per hospital emergency room visit or urgent care center visit for emergency care services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care
copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because
the service are a of injury or unforeseen illness If an emergency situation occurs call the local emergency system e g the 911 telephone system or go immediately to the nearest hospital emergency room or medical facility

You or someone on your behalf must notify your primary care physician within 2 business days of

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HMO CNY 2000
the emergency or as soon as is reasonably possible It is your responsibility to ensure that the Plan has
been timely notified Claims for care in non life threatening emergency medical situations which are not
authorized by your primary care physician will be denied

If you need to be hospitalized the Plan must be notified within 48 hours Your primary care doctor must
be notified within two business days 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

If you require emergency treatment when traveling overseas you must contact your primary care physician
within two business days of your return to obtain authorization of the overseas services and to
arrange any follow up care All services for unauthorized non life threatening emergency medical treatment
will be your financial responsibility For reimbursement send a receipt with English translation
that includes the U S dollar amount services rendered date of service and diagnosis plus proof of payment
to our Member Services Department upon your return

To be covered by this Plan any follow up care must be approved by the Plan Contact your primary care
physician if the emergency room or medical facility recommends additional care outside of the visit

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 50 per hospital emergency room visit for emergency care services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency copay is waived
What is covere d 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 covere d 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 pro v i d e r s 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 8

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 13
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HMO CNY 2000
Mental Conditions Substance Abuse Benefits

Mental conditions 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

What is covere d 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 15 copay per visit for all covered visits all charges thereafter

Inpatient care The combined benefit for the treatment of an acute mental health condition or the treatment or rehabilitation of acute alcoholism or substance abuse is limited to 60 days per contract year You pay nothing
during the benefit period all charges thereafter

Outpatient A member may use up to 60 inpatient days or up to 180 day or night visits or a combination inpatient
psychiatric days and day or night visits at an inpatient psychiatric facility The Plan will only pay for day night care
f a c i l i t y if a member remains in the center for at least 3 hours You pay nothing for up to 180 days all charges thereafter

What is not covere d Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate

Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the medical
What is covere d non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other illn for the diagnosis and treatment

Outpatient care Outpatient visits for the diagnosis treatment referral and medical care of substance abuse including alcoholism and drug abuse are provided in full for up to 60 visits per calendar year You pay a 5 copay
for each covered visit and all charges thereafter

Inpatient care The combined benefit for the treatment or rehabilitation of acute alcoholism or substance abuse or the treatment of an acute mental health condition is limited to 60 days per contract year You pay nothing
during the benefit period all charges thereafter

What is not covere d Treatment that is not authorized by a Plan doctor
Methadone maintenance services or programs

Prescription Drug Benefits
What is covere d 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 copay per prescription unit or refill for generic drugs a
20 copay per prescription unit or refill for brand name drugs on our preferred drug list or a 35 copay
per prescription unit or refill for brand name drugs not on our preferred drug list

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
14 Page 15 16
HMO CNY 2000
MAIL ORDER Prescription drugs prescribed by a Plan or referral doctor and obtained via mail order
will be dispensed for up to a 90 day supply You pay a 5 copay per prescription unit or refill for
generic drugs per each 30 day supply a 20 copay per prescription unit or refill for brand name drugs
on our preferred drug list per each 30 day supply or a 35 copay per prescription unit or refill for
brand name drugs not on our preferred list per each 30 day supply

NON PLAN PHARMACIES Drugs purchased at a non Plan pharmacy will be reimbursed at the same
rate as a Plan pharmacy You must first pay for the entire prescription and then file a claim with us for
reimbursement You pay the applicable copay plus any amount in excess of our usual allowance for
each drug Call us for instructions on reimbursement

Covered medications and accessories include

Drugs for which a prescription is required by law
Oral and injectable drugs including contraceptive devices
Implanted time release contraceptive medications such as Norplant
Smoking cessation drugs and medication including nicotine patches
Enteral formulas for home use when prescribed in writing by a Plan doctor for malnourishment or a disorder which would cause chronic physical disability mental retardation or death

Medically necessary modified solid food products with low or modified protein for treatment of inherited diseases of amino acids and organic acid metabolism

Insulin diabetic supplies and disposable needles and syringes needed to inject covered prescribed medication
are available through the Plan's medical and surgical benefits and are subject to the doctor's
office visit copayment see page10

Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered
under Medical and Surgical Benefits

What is not covere d Drugs available without a prescription or for which there is a nonprescription equivalent available
Vitamins and nutritional substances that can be purchased without a prescription except as stated above

Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs

Other Benefits
Dental Care Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are
Accidental injury covered within one year of the accident unless medical necessity dictates otherwise The need for these services must result from an accidental injury You pay a 10 copay per visit
b e n e f i t

What is not covere d Other dental services not shown as covered
Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the
What is covere d eye annual eye refractions which include the written lens prescription for eyeglasses for children through age 18 and once every 2 years for members over age 18 may be obtained from Plan providers

You pay nothing

What is not covere d Corrective lenses or frames including the fitting of the lenses
Vision therapy and eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 15
15 Page 16 17
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan These benefits are not subject to the FEHB disputed
claims procedures

Health Education As prescribed by your primary care physician Charges may apply to classroom materials Topics
C l a s s e s include weight control childbirth education and smoking cessation Services must be provided by a participating provider Call our customer service department for a list of participating providers in

your area

C h i l d b i rth Classes Charges may apply to classroom materials

16 Benefits on this page are not part of the FEHB contract 16
16 Page 17 18
HMO CNY 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
M e d i c a re 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

HMO CNY does not offer a Medicare Choice option For information on Medicare Choice plans contact
your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833

O t h e r g roup When anyone has coverage with us and with another group health plan it is called double coverage
insurance coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the first
plan pays we will pay either what is left of the reasonable charge or our 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 17 17
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HMO CNY 2000
C i rc u m s t a n c e s Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our c o n t ro l 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 cost
i n j u r i e s 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
T R I C A R E TRICARE is the health care program for members eligible dependents and retirees of the military T R ICARE
includes the CHAMPUS program If both TRICARE and this Plan cover you we are the primary
p a y e r See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Wo r k e r s We do not cover services that
c o m p e n s a t i o n 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 M e d i c a i d

We pay first if both Medicaid and this Plan cover you O t h e r G o v e r n m e n t
A g e n c i e s We do not cover services and supplies that a local State or Federal Government agency directly or
indirectly pays for
Section 8 FEHB FACTS

You have a right to
information about OPM requires that all FEHB plans comply with the Patients'Bill of Rights which gives you the right to
y o u r H M O 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 315 448 6820 or 800 447 6269 or write to HMOCNY
Inc P O Box 4712 344 South Warren St Syracuse N Y 13221 4712 You may also contact us
by fax at 315 448 4922 or visit our website at www bcbscny org

HMO CNY Inc is an independent corporation organized under the Public Health Law and Insurance
Law of New York State HMO CNY operates under licenses with the Blue Cross and Blue Shield
Association an association of independent Blue Cross and Blue Shield Plans which permits HMO CNY
to use the Blue Cross and Blue Shield service marks in a portion of New York State HMO CNY does
not act as an agent of the Blue Cross and Blue Shield Association HMO CNY is solely responsible for
honoring its agreements to provide or administer benefits for health care HMO CNY is an independent
practice association health plan founded in 1984
W h e re do I get
information about Your employing or retirement office can answer your questions and give you a Guide to Federal
e n rolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to make an
FEHB Pro g r a m informed decision about

18 18
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HMO CNY 2000
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

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

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
p remiums eff e c t i v e premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
I re t i re 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 unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement
available for m y office authorizes coverage for Under certain circumstances you may also get coverage for a disabled
family and me child 22 years of age or older who is incapable of self support which is also authorized by your employing or retirement office

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 No new enrollment form is required

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

A re my medical We will keep your medical and claims information confidential Only the following will have access to it
and claims re c o r d s
c o n f i d e n t i a l 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

19 19
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HMO CNY 2000
Information for new members

Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 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 m y
old plan

P re existing We will not refuse to cover the treatment of a condition that you or a family member had before you
c o n d i t i o n s enrolled in this Plan solely because you had the condition before you enrolled

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

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse 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 T C C 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

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC
T C C 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
20 whichever is later 20
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HMO CNY 2000
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

How can I convert to Your employing or retirement office will then send your former spouse information about enrolling in
individual coverage 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

You may convert to an individual policy if

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 recieve 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
C e rtificate of Gro u p indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
C o v e r a g e 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
Department of Defense FEHB Demonstration Project

21 21
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HMO CNY 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 315 448 6820 or 1 800 447 6269 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

22 22
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HMO CNY 2000
Summary of Benefits for HMO CNY 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 11

Extended All necessary services up to 240 days per admission You pay nothing 11
care

Mental Diagnosis and treatment of acute psychiatric conditions The combined benefit
conditions for the treatment of an acute mental health condition or the treatment or
Substance Abuse rehabilitation of acute alcoholism or substance abuse is limited to 60 days per
calendar year You pay nothing during the benefit period 14

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or
injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay a 10 copay per office visit nothing per
housecall by a doctor For maternity care you pay a 10 copay for the initial
office visit only Well baby care is included in well child services for children
through age 19 you pay nothing 9 1 0

Home health care All necessary visits by nurses and skilled health aides You pay nothing 10
Mental conditions Up to 20 outpatient visits per year You pay a 15 copay per visit for all
covered visits 14

Substance abuse Up to 60 visits per calendar year You pay 5 per visit 1 4
Emergency care Reasonable charges for services and supplies required because of a medical
emergency You pay a 50 copay to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan 12 13

P rescription drugs 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 copay per
prescription unit or refill for generic drugs Brand name drugs on our preferred
drug list will require a 20 copay per 30 day supply Brand name drugs not on
our preferred list will require a 35 copayment per 30 day supply This applies
to both retail and mail order pharmacies 14 15

Dental care Accidental injury benefit You pay 10 copay per visit 1 5
Vision care Routine eye examinations including refractions for children through age 18 and
one exam every two years for members over age 18 You pay nothing 1 5

Out of pocket Your out of pocket expenses for benefits covered under this Plan are limited to
m a x i m u m the stated copayments which are required for a few benefits 5

23 23
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Authorized for Distribution by the
United States Office of Personnel Management

RI 73 461

2000 Rate Information for
HMO CNY 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 tow categories of contribution rates referred
to as Category A rates and Category B rates will apply for certain employees If you are a career postal employee but
not a member of a special postal employment class refer to the category definition 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 Your Gov't Your Your USPS Your Your USPS Your Your
Enrollment Share Share Share Share Share Shar Share Share Share Share Share Share

Self Only EB1 67.88 22.62 22 147.06 47.63 49.02 80.32 10.18 10.18 80.32 10.18
Self and Family EB2 175.97 64.03 72.52 381.27 157.13 138.73 207.74 32.26 49.62 201.02 38.98

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