Pages 1--28 from RI 73-467 PDF 2b

Preferred Care HMO 2000 Preferred Care 2000
A Health Maintenance Organization

Serving Greater Rochester and Surrounding Counties
Enrollment in this Plan is limited see page 6
for requirements

Enrollment code
GV1 Self Only
GV2 Self and Family

This Plan has excellent accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure
and
our website at http www preferredcare org

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service

RI 73 467
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Preferred Care HMO 2000
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Preferred Care HMO 2000
Table of Contents Page
Introduction 4
Plain language 4
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6 8
Section 4 What to do if we deny your claim or request for service 8 9
Section 5 Benefits 10 18
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19 20
Section 8 FEHB facts 20 23
Inspector General Advisory Stop Healthcare Fraud 25
Summary of benefits 27
Premiums 28

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Preferred Care HMO 2000
Introduction
Preferred Care
259 Monroe Avenue
Rochester New York 14607

This brochure describes the benefits you can receive from Preferred Care HMO under its contract CS2371 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 5 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 Preferred Care HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not 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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Preferred Care HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive urgent or emergency care when out of the Plan's service area
you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and
or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our
networks facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request
you may continue to see your specialist for up to 90 days If your provider leaves the Plan
and you are in the second or third trimester of pregnancy you may be able to continue seeing
your OB GYN until the end of your postpartum care You have similar rights if this Plan
leaves the FEHB program See Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not
amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five
years This screening is for colorectal cancer

Changes to this Plan Your share of the non postal premium will increase by 6.5 for Self Only or 6.5 for Self and Family

Prescription drugs are now covered with a 5 copayment per generic prescription or refill
and a 10 copayment per brand name prescription or refill

When an A rated generic drug can be substituted for a brand name drug the patient's drug
benefit will be based on the cost of the generic drug If the brand name drug is dispensed
the patient will pay the brand copayment plus the difference between the lower priced generic
drug and the higher priced brand name drug If there is no A rated generic substitute the
Generic MAC program will not apply See page 16

Insulin and diabetic supplies are now covered with a brand name prescription copayment of
10 See page 16

Acupuncture is now covered for up to 10 visits per member per calendar year with a 50
copayment required See page 11

Hearing aids for children through age 18 are now covered for up to 600 every three years
See page 12

Routine eye exams are now covered annually See page 17
Copayments for medically necessary pregnancy related radiological procedures are now
waived See page 10

Pre and post operative copayments are now waived See page 10 5 5
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Preferred Care HMO 2000
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
service area practice Our service area is Monroe Genesee Livingston Ontario Orleans Seneca Wayne Wyoming and Yates Counties in New York State

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 urgent or emergency care except for students
attending school or college outside of the service area With prior authorization from the
Plan follow up care for students is covered

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 you should consider enrolling in a feefor
service plan or an HMO that has agreements with affiliates in other areas If you or a
family member move you do not have to wait until Open Season to change plans Contact
your employing or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar
for services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for some preventive services which are covered in

full

After you pay 3,300 in copayments or coinsurance for one family member or 8,400 for
two or more family members you do not have to make any further payments for certain
services for the rest of the year This is called a catastrophic limit However copayments or
coinsurance for your prescription drugs do not count toward these limits and you must
continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are
responsible for informing us when you reach the limits

Do I have to submit claims You normally won't have to submit claims to us unless you receive emergency services from a 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 my health care More than 2,600 doctors and area health centers participate with Preferred Care to provide primary care as well as specialty services to the membership In addition to doctors the Plan
has arranged for hospital skilled nursing facility home health and other covered health
services

All members must choose a primary care doctor who will provide arrange and coordinate all
medically necessary services All female members are strongly encouraged to select an
obstetrician gynecologist in addition to a primary care doctor The OB GYN will treat for
any gynecological or obstetrical condition Members do not need a referral from their
primary care doctor to see their OB GYN A women's OB GYN is considered an additional
primary care doctor New York State law does provide coverage with Nurse Midwives and
the Plan maintains Nurse Midwives on the provider panel Plan members may elect a Nurse
Midwife instead of an OB GYN

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

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Preferred Care HMO 2000
Section 3 How to get benefits continued
What do I do if I need to go Talk to your Plan physician If you need to be hospitalized your primary care physician or
into the hospital specialist will make the necessary hospital arrangements and supervise your care

What do I do if I'm in the First call our customer service department at 800 950 3224 If you are new to the FEHB
hospital when I join this Plan 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

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 specialty care Your primary care physician will arrange your referral to a specialist
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

What do I do if I am seeing a Your primary care physician will decide what treatment you need If they decide to refer you
specialist when I enroll to a specialist ask if you can see your current specialist If your current specialist does not participate 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 specialist Call your primary care physician who will arrange for you to see another specialist You
leaves the Plan may receive services from your current specialist until we can make arrangements for you to see someone else

But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to
illness and my provider leaves continue seeing your provider for up to 90 days after we notify you that we are terminating
the Plan or this Plan leaves our contract with the provider unless the termination is for cause If you are in the second
the Program or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care

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

How do you authorize medical Your physician must get our approval before sending you to a hospital referring you to a
services specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice

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Preferred Care HMO 2000
Section 3 How to get benefits continued
How do you decide if a This Plan considers a drug device treatment or procedure to be experimental or
service is experimental or investigational if it meets one or more of the following criteria
investigational 1 It cannot be lawfully marketed without the approval of the FDA and such approval has

not been granted at the time of its use

2 It is the subject of a current investigational new drug or device application on file with
the FDA

3 It is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental
or research arm of a clinical trial

4 It is being provided pursuant to a written protocol which describes among its objectives
determination of safety efficacy or efficacy in comparison to conventional alternatives

5 The predominant opinion among experts as expressed in the published peer review
literature is that further research in necessary in order to define safety compared with
conventional alternatives

6 It is not experimental or investigational in itself but is being used in conjunction with a
drug device treatment or procedure that is experimental or investigational

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 OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or
review a denial refusal OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious or life Call us at 716 325 3113 or 800 950 3224 and we will expedite our review
threatening condition and you
haven't responded to my
request for service

What if you have denied my If we expedite your review due to a serious medical condition and deny your claim we will
request for care and my inform OPM so that they can give your claim expedited treatment too Alternatively you can
condition is serious or life call OPM's health benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m
threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible

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Preferred Care HMO 2000
Section 4 What to do if we deny your claim or request for service continued
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our 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 to OPM Your request must be complete or OPM will return it to you You must send the following 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 the request Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the
enrolled person's representative They must send a copy of the person's specific written
consent with the review request

Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance
disputed claim to OPM Programs Contract Division 3 P O Box 436 Washington D C 20044

What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
Plan's denial decision your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of
the third year after the year in which you received the disputed services or supplies

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

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from
Privacy Act you 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

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Preferred Care HMO 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10
office visit copay but no additional copay for laboratory tests Primary care doctor office
visits for children ages 0 2 are covered in full you pay nothing 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 health aides

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

Preventive care including periodic check ups well baby and well child care and two
gynecological office visits per year copay waived

Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years 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 copays are waived

Routine immunizations and boosters
Consultations by specialists you pay a 10 copay per visit including OB GYN office
visits

Pre and post operative visits copay waived
Diagnostic procedures such as laboratory tests and X rays you pay a 10 copay for
X rays only Copay waived for medically necessary pregnancy related radiological
procedures

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 regular delivery
and 96 hours after 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 family planning services and sterilization
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
Non experimental transplants including cornea heart heart lung lung single and
double 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 when approved
by the Plan's Medical Director Related medical and hospital expenses of the donor are
covered when the recipient is covered by this Plan

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Preferred Care HMO 2000
Section 5 BENEFITS continued
Women who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces custom made only foot orthotics you pay 20 of
charges

External prosthetic devices such as artificial limbs you pay 20 of charges
Breast prostheses and surgical bras as well as their replacement you pay 20 of
charges

Internal prosthetic devices such as lenses following cataract removal custom made
only breast implants associated with reconstructive surgery you pay nothing

Durable medical equipment such as wheelchairs and hospital beds and glucose
monitors you pay 20 of charges

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

Ambulatory surgery you pay a 10 copay per visit
Chiropractic services for manipulation of the spinal column are covered you pay a 10
copay per visit

Acupuncture you pay 50 Coverage is limited to up to 10 visits per member per
calendar year

Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but
not limited to treatment of fractures and excision of tumors and cysts All other procedures
involving the teeth or intra oral areas surrounding the teeth are not covered including any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or from an injury or surgery that has produced a major effect on the member's
appearance and if the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have breast reconstruction
surgery following a mastectomy and whether surgery on the other breast is needed to
produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an
inpatient or outpatient basis for up to two months per condition if significant improvement
can be expected within two months you pay 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

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Preferred Care HMO 2000
Section 5 BENEFITS continued
Hearing aid coverage for children through age 18 will be provided for up to 600 every
three calendar years

Diagnosis and treatment of infertility is covered you pay 10 copay in primary care
physician's office or 10 copay in specialist's office The following types of artificial
insemination are covered intravaginal insemination IVI intracervical insemination ICI
and intrauterine insemination IUI you pay 10 copay in primary care physician's office or
10 copay in specialist's office cost of donor sperm is not covered Fertility drugs are
covered under the Prescription Drug Benefit Other assisted reproductive technology ART
procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction is provided when specific criteria are met at a Plan facility for up to 36 visits you
pay 10 copay per visit

What is not covered Physical examinations and immunizations that are not necessary for medical reasons
such as those required for obtaining or continuing employment or insurance attending
school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids for adults over age 18
Homemaker services
Long term rehabilitative therapy

Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations when a Plan doctor determines it is medically
necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for up to 120 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility
is medically appropriate as determined by a Plan doctor and approved by the Plan You pay
nothing All necessary services are covered including

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

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

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Preferred Care HMO 2000
Section 5 BENEFITS continued
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor and approved by the Plan

Limited benefits
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 the professional dental services Conditions

for which hospitalization would be covered include hemophilia and heart disease the need
for anesthesia by itself is not a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is

not medically appropriate See page 15 for nonmedical substance abuse benefits

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

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires
immediate medical or surgical care Some problems are emergencies because if not treated
promptly they might become more serious examples include deep cuts and broken bones
Others are emergencies because they are potentially life threatening such as heart attacks
strokes poisonings gunshot wounds or sudden inability to breathe There are many other
acute conditions that the Plan may determine are medical emergencies what they all have
in common is the need for quick action

Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme
service area emergencies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to

tell the emergency room personnel that you are a Plan member You or a family member
must notify the primary care doctor within 48 hours unless it was not reasonably possible to
do so It is your responsibility to ensure that the primary care doctor has been timely
notified

If you need to be hospitalized your primary care doctor must be notified within 48 hours
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

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Preferred Care HMO 2000
Section 5 BENEFITS continued
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers

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

You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency
services that are covered benefits of this Plan If the emergency results in admission to a
hospital the emergency care copay is waived

Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area because of injury or unforeseen illness

If you need to be hospitalized your primary care doctor must be notified within 48 hours
unless it was not reasonably possible to notify the Plan within that time If a Plan doctor
believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers

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

You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital the emergency care copay is waived
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
Follow up care for students who attend school or college outside of the service area is
covered you pay a 10 copay in a primary care physician's office or a 10 copay in a
specialist's office Prior authorization is required

What is not covered Elective care or nonemergency 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 non Plan With your authorization the Plan will pay benefits directly to the providers of your
providers emergency care 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

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Preferred Care HMO 2000
Section 5 BENEFITS continued
Mental Conditions Substance
Abuse Benefits

Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental
illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 5 copay for initial evaluation visit 50 of charges per visit for
visits 2 40 all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for first 30 days all
charges thereafter In lieu of hospitalization a member may substitute up to 15 inpatient
mental health days for services in a mental health day treatment program One inpatient
mental health day may be used to cover two days of outpatient mental health day treatment

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

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

Psychological testing that is 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 on an outpatient basis Inpatient services
necessary for diagnosis and treatment of substance abuse are provided in conjunction with
the mental conditions benefit shown above The mental conditions benefit visit day
limitations apply to these inpatient benefits

Outpatient care Up to 60 outpatient visits for diagnosis and rehabilitation for substance abuse a covered family member may use up to 20 of 60 visits for family therapy related to a member's alcohol
abuse or substance abuse You pay a 5 copay per visit
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay
nothing during the benefit period all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 15
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Preferred Care HMO 2000
Section 5 BENEFITS continued
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 one commercially prepared unit i e one
inhaler one vial ophthalmologic medication or insulin You pay a 5 copay per generic
prescription or refill and a 10 copay per brand name prescription or refill When an A rated
generic drug can be substituted for a brand name drug the patient's drug benefit will be
based on the cost of the generic drug If the brand name drug is dispensed the patient will
pay the brand copay plus the difference between the lower priced generic drug and the higher
priced brand name drug If there is no A rated generic substitute the Generic MAC program
will not apply

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles blood chem strips lancets and
monolets you pay a 10 copay

Smoking cessation drugs and medication including nicotine patches
Oral contraceptive drugs
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use and some injectable drugs such as
Depo Provera are covered under Medical and Surgical Benefits

Prescription Drug Mail Order Maintenance Program
Members are eligible for a 90 day supply of maintenance prescription drugs when
purchased for future use through Preferred Care's Mail Order Maintenance Drug
Program Members pay a 5 copay per generic prescription or refill and a 10 copay
per brand name prescription or refill

The Maintenance Drug Program is designed to provide maintenance prescription drugs
to individuals who require long term therapy Maintenance drugs must meet certain
clinical criteria the drug is being used to treat a chronic disease where a therapeutic
endpoint cannot be determined the drug is not expected to cure the disease the drug is
taken continuously for 90 days and it is not probable that the drug will need to be
changed due to monitoring over the course of therapy Only drugs considered to be
maintenance will be dispensed in quantities greater than a one month supply The Plan
recognizes that a physician may prescribe a non maintenance drug under circumstances
that are consistent with the definition of a maintenance drug Under these conditions
the physician may contact the Plan to request an exception

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Preferred Care HMO 2000
Section 5 BENEFITS continued
Limited benefits Drugs for infertility treatment after a medical condition has been corrected are limited to
4 cycles per pregnancy Pergonal Metrodin and other FDA approved drugs only after
unsuccessful treatment with Clomifen and only when very specific clinical indications
are met The coverage is limited to Pergonal Metrodin or other FDA approved drugs
administered up to but not exceeding four 4 treatment cycles per pregnancy This
benefit requires an approved referral for each cycle If no pregnancy has occurred after
completion of four cycles of Pergonal or Metrodin all fertility drug benefits are
exhausted

Sexual dysfunction drugs have dispensing limitations Contact the Plan for details

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance

Other Benefits
Dental care accidental injury Coverage is provided for dental services required for treatment of sound natural teeth due to
benefit an accidental injury Benefits are provided only for services rendered within 12 months of the injury You pay a 10 copay per visit

What is not covered Restoration of injured teeth

Vision care
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 calendar year per member
Eye exercises You pay a 10 copay
Yearly eye refractions including lens prescriptions You pay a 10 copay
An allowance up to 60 toward the purchase of one pair of prescription eyeglasses
frames and lenses or prescription daily wear contact lenses per member once every
year at participating providers Additional 20 discount applies as well Children under
12 may obtain eye wear as required by prescription change of at least .5 diopter

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 17
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Preferred Care HMO 2000
Section 5 BENEFITS continued
Non FEHB Benefits Available The benefits described on this page are neither offered nor guaranteed under the contract
to Plan Members with the FEHB 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

HealthPerks from Preferred Care are courses resources and discounts available to all
members of the Plan HealthPerks provides connections to traditional and complimentary
providers all geared to giving Plan members tools to make appropriate health and wellness
decisions for themselves and their families Preferred Care has developed our HealthPerks
program to encourage appropriate participation in healthful activities focusing on preventive
care to aid in improving the health status of our members Courses programs and workshops
cover areas such as CPR First Aid Diet Nutrition Smoking Cessation Women's Issues
and Childbirth Parenting Discounts are provided for purchasing health related recreation
or leisure merchandise or services from Weight Watchers Play It Again Sports
Muxworthy's G G Fitness Lori's Natural Foods and Rock Ventures to name a few Over
twenty health clubs provide Plan members discounted arrangements HealthPerks also
maintains a massage therapy panel that provides discounts to Plan members Discounts and
schedules vary by participating vendor To receive a HealthPerks catalog contact Preferred
Care at 716 325 3113 or toll free at 800 950 3224 Members with a speech or hearing
impairment and access to TTY TDD equipment may call 716 325 2629

Well Informed SM provides answers from health professionals 24 hours a day Well
Informed SM is a health support system that connects you by phone to registered nurses and
pharmacist who provide you with accurate up to date information and answers to your health
care questions It is easy to use and confidential This program is not a substitute for
medical care Members should consult their healthcare professional for diagnosis and
treatment To access Well Informed SM call 1 800 903 4679

www preferredcare org Preferred Care's website provides valuable health information
frequently asked questions HealthPerks offerings physicians listings and important links
to other sites that can provide you with the most up to date information on health and
wellness

Medicare Choice Enrollment This plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on Page 19 annuitants and former spouses with FEHB coverage and Medicare
Part B may elect to drop their FEHB coverage and enroll in a Medicare Choice plan when
one is available in their area They may then later reenroll in the FEHB Program Most
Federal annuitants have Medicare Part A Contact your retirement system for information on
dropping your FEHB enrollment and changing to a Medicare Choice plan Contact us at
716 327 5760 for information on the Medicare Choice plan and the cost of that enrollment

Benefits on this page are not part of the FEHB Contract

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Preferred Care HMO 2000
Section 6 General Exclusions Things we don't cover

The exclusions in this section apply to all benefits Although we may list a specific service as a benefit
we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

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

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the
payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also
remain enrolled with us

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

If you involuntarily lose coverage or move out of the Medicare Choice service area you
may 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 For information
on the Medicare Choice plan offered by this Plan see page 18

Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage 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

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Preferred Care HMO 2000
Section 7 Limitations Rules that affect your benefits continued
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 beyond Under certain extraordinary circumstances we may have to delay your services or be unable
our control to provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are responsible When you receive money to compensate you for medical or hospital care for injuries or
for injuries illness that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement

If you do not seek damages you must agree to let us try This is called subrogation If you
need more information contact us for our subrogation procedures

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 compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they
must provide

OWCP or a similar agency pays for through a third party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government Agencies 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 OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you
information about your HMO the right to information about your health plan its networks providers and facilities You can also find out about care management which includes medical practice guidelines

disease management programs and how we determine if procedures are experimental or
investigational OPM's website www opm gov lists the specific types of information that
we must make available to you

If you want specific information about us call 800 950 3224 or write to 259 Monroe
Avenue Rochester New York 14607 You may also contact us by fax at 716 327 2298 or
visit our website at www preferredcare org

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Preferred Care HMO 2000
Section 8 FEHB FACTS continued
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to
about enrolling in the FEHB Federal Employees Health Benefits Plans brochures for other plans and other materials you
Program need to make an informed decision about

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 benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your
premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1

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

What types of coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse and
available for my family and your unmarried dependent children under age 22 including any foster or step children your
me employing 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 selfsupport

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

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

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

Are my medical and claims We will keep your medical and claims information confidential Only the following will have
records confidential access to it

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

21 21
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Preferred Care HMO 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 deductible Your old plan's deductible continues until our coverage begins
under my old plan

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

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

You are a family member no longer eligible for coverage

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

What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get
coverage benefits 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 32 nd day after your regular coverage ends even if several months
have passed
You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends
unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

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Preferred Care HMO 2000
Section 8 FEHB FACTS continued
How do I enroll in TCC If you are leaving Federal service your employing office will notify you of your right to
enroll under 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 convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage

or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will
not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions

How can I get a Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health Plan
Group Health Plan Coverage Coverage 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 within 63 days of 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

23 23
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Preferred Care HMO 2000
Notes

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Preferred Care HMO 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 716 325 3113 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300

U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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Preferred Care HMO 2000
Notes

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Preferred Care HMO 2000
Summary of Benefits for Preferred Care 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indiated 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 inhospital 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 12

Extended care All necessary services for up to 120 days per calendar year You pay nothing 12
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of
inpatient care per year You pay nothing 15

Substance abuse Covered under mental conditions 15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialists care preventive care including wellbaby care
periodic checkups and routine immunizations laboratory tests and Xrays
complete maternity care You pay a 10 copay per primary care doctor office
visit 10 per Specialist Office visit Xrays and house calls by a doctor Well
baby and wellchild routine visits primary care doctor visits for children ages
02 periodic checkups two gynecological exams per year mammograms and
maternity care you pay nothing 10 11

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Up to 40 visits per year You pay 5 copay for initial visit 50 of charges per
visit for visits 240 15

Substance abuse Up to 60 visits per year You pay a 5 copay per visit 15
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
or 25 for each urgent care center visit and any charges for services that are not
covered by this Plan 13 14

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a
5 copay per generic prescription or refill and a 10 copay per brand name
prescription or refill 16

Dental care Accidental injury benefit you pay a 10 copay per visit 17
Vision care Annually one refraction including lens prescriptions You pay a 10 copay
per visit 17

Out of pocket Copayments are required for a few benefits however after your outofpocket
maximum expenses reach a maximum of 3300 per Self Only or 8400 per Self and
Family enrollment per calendar year covered benefits will be provided at 100
This copay maximum does not include prescription drugs or dental services 6

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Preferred Care HMO 2000
2000 Rate Information for
Preferred Care
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 GV1 60.32 20.11 130.70 43.57 71.38 9.05 71.38 9.05
Self and Family GV2 153.06 51.02 331.63 110.54 181.12 22.96 181.12 22.96

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