Pages 1--24 from fed-2000

A Health Maintenance Organization
Serving For benefits changes
in page 4
Enrollment in this Plan is limited see page 18 for requirements see

Enrollment code
C81 Self Only
C82 Self and Family

Visit the OPM Website at http www opm gov insure and this Plan's Website at http www bcnepa com
Authorized for distribution by the
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1 Page 2 3
Table of Contents
Page

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organization 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 7 9
Section 5 Benefits 9 17
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18 19
Section 8 FEHB Facts 20 23
Inspector General Advisory Stop Healthcare Fraud 23
Premiums 24

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First Priority Health
First Priority Health 70 North Main Street Wilkes Barre Pennsylvania 18711
This brochure describes the benefits you can receive from First Priority Health HMO under its contract CS2327 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 First Priority Health 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

Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

How we change for 2000 If you are a current member and want to see how we have changed read this section
How to get benefits Make sure you read this section it tells you how to get services and how we operate
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

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
General exclusions Things we don't cover Look here to see benefits that we will not provide
Limitations Rules that affect your benefits This section describes limits that can affect your benefits
FEHB Facts Read this for information about the Federal Employees Health Benefits FEHB Program
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Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure

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

Section 2 How we change for 2000
Program wide 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

You may review and obtain copies of your medical records on request If you need 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 relevant or complete 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 13.1 for Self Only or 22.1 for Self and Family
Diabetic supplies and outpatient self management training and education are covered

The cost of diabetic equipment and supplies including blood glucose monitors monitor supplies insulin injection aids syringes insulin infusion devices
pharmacological agents for controlling blood sugar and orthotics with a 8 member copay

60 outpatient mental health visits are now covered Inpatient days may be converted to outpatient days on a one 1 for two 2 basis
Mail Order Prescription Drug Program offers a 90 day supply of medication for 16 member copayment
Prescription drug Zyban for smoking cessation
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Section 3 How to get benefits
What is this Plan's service To enroll with us you must live or work in First Priority Health's service area This
area is where our providers practice Our service area is In Pennsylvania all of Bradford Carbon Clinton Lackawanna Luzerne Lycoming Monroe Pike

Sullivan Susquehanna Tioga Wayne and Wyoming counties

You may also enroll with us if you live or work in the following places In Pennsylvania all of Bradford Carbon Clinton Lackawanna Luzerne Lycoming
Monroe Pike Sullivan Susquehanna Tioga Wayne and Wyoming counties

Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will
not pay for any other health care services

If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child
goes to college in another state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family
member move you do not have to wait until Open Season to change plans Contact your employing or retirement office

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

Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few benefits

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 The Plan is an individual practice prepayment plan It offers medical care for both the prevention of disease and the treatment of serious illnesses The Plan has over
550 participating primary care doctors and over 1615 participating specialist physicians representing a wide range of areas of medicine All participating
doctors practice in their own offices in the community

You must select a participating primary care doctor for each covered family member Covered benefits are available only when rendered by or coordinated through
your primary care doctor Always receive a referral from your primary care doctor before obtaining covered services from another doctor or obtaining specialty
services In a life threatening emergency seek treatment immediately and then contact your primary care doctor Services not authorized by your primary care
doctor are not covered

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

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

What do I do if I'm in the hospital First call our customer service department at 800 822 8753 If you are new to the
when I join this Plan FEHB 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 A women may see her plan gynecologist for her annual routine exam without a referral

If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your
treatment plan The physician will have to get an authorization or approval beforehand from First Priority Health's Medical Director

What do I do if I am seeing a Your primary care physician will decide what treatment you need If they decide to
specialist when I enroll refer you 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
leaves the Plan You 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 illness and my provider leaves the Plan or this Plan leaves the Program

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

How do you authorize medical Your physician must get our approval before sending you to a hospital referring you
services to a 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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Section 3 How to get benefits continued
How do you decide if a service is The following describes this Plan's criteria for determining when a medical treatment
experimental or investigational or procedure or a drug device or biological product is experimental or investigational

The First Priority Health Medical Director determines if a treatment procedure facility equipment drug device or supply is Experimental or investigative by
whether it is

The subject of written investigational or research protocol The subject of written informed consent
The subject of an on going phase I II or III clinical trial or

Evidence exists as reflected in at least two published Peer reviewed Medical Literature Publications

That the service is recognized by a majority of these practicing the appropriate medical specialty as being safe and effective for use in the treatment of the
particular condition in question and That the service has a definite positive effect on health outcomes
That over time the service leads to improvement in health outcomes That the service is at least effective in improving health outcomes as established
technology or is not employable and That improvement in health outcomes is possible in standard conditions of
medical practice outside clinical investigatory settings

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

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Section 4 What to do if we deny your claim or request for service continued
What if I have a serious or life Call us 1 800 822 8753 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
request for care and my condition we will inform OPM so that they can give your claim expedited treatment too
is serious or life threatening Alternatively you can call OPM's Health Benefits Division IV at 202 606 0737 between 8 a m and 5 p m 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

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

What address should I send my Send your request for review to Office of Personnel Management Office of
disputed claim Insurance Programs Contract Division IV P O Box 436 Washington D C 20044

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

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Section 4 What to do if we deny your claim or request for service continued
What laws apply if I file a lawsuit Federal law governs your lawsuit benefits and payment of benefits The Federal court will 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 Privacy Act Chapter 89 of title 5 United States Code allows OPM to use the information it collects from 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

Section 5 Benefits Medical Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits
you pay a 10 office visit copay but no additional copay for laboratory tests and Xrays 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 you pay nothing for home visits by nurses and home health
aides

Plan doctors also provide all necessary medical or surgical care in a hospital or extended care facility at no additional cost to you

The following services are included
Preventive care including well baby care and periodic check ups One Mammography screening per calendar year is covered for all members age
40 and over whether or not directed toward a definite condition of disease or injury Mammograms which are recommended by a physician are covered for
all subscribers Benefits for mammography screening are payable only if performed by a mammography service provider who is properly certified by the
Department of Health in accordance with Mammography Quality Assurance Act of 1992
Routine immunizations and boosters Consultations by specialists you pay 10
Diagnostic procedures such as laboratory tests and X rays Complete obstetrical maternity care for all covered females including
prenatal delivery and postnatal care by a Plan doctor office visit copays are waived for obstetrical care after the first visit The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean 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
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Section 5 Benefits continued
Voluntary sterilization and family planning services 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
External breast prosthesis and surgical bras Cornea heart kidney lung single lung only for primary fibrosis cystic
fibrosis primary pulmonary hypertension end stage pulmonary disease and emphysema double lung only for cystic fibrosis 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 testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer Related
medical and hospital expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after
the procedure Dialysis
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically
review the program for continuing appropriateness and need All necessary medical or surgical care in a hospital or extended care facility
from Plan doctors and other Plan providers

Limited benefits Oral and maxillofacial surgery is provided for 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 surgery for bone impacted teeth 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 malocclusions 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 The accident or surgery must occur on or after the
effective date of the member's coverage in any plan under the FEHB Program 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 occupational and cognitive is provided on an inpatient or outpatient basis for forty five 45 visits per calendar
year if significant improvement can be expected within that time you pay nothing 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Diagnosis and treatment of infertility is covered excluding dry treatment you pay 10 office visit copay Oral fertility drugs are covered see Prescription Drug
Benefits for appropriate copay Injectable fertility drugs are not covered Artificial insemination intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI is covered you pay 10 cost of donor sperm is not covered Other assisted reproductive technology ART procedures such as InVitro
fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for acute care or rehabilitation hospital programs for up to 36
sessions you pay nothing

Durable medical equipment the initial provision of prosthetic appliances such as artificial limbs and lenses following cataract removal and the initial provision of
orthopedic braces such as braces for the treatment of congenital defects and foot orthotics are covered Instruction and appropriate services required to properly use
the item such as attachment and insertion are covered The Plan pays all charges up to 2,500 per calendar year for any combination of these items You pay all charges
thereafter

Out of area care for unexpected conditions is covered if a the member is traveling in the service area of an HMO that participates in the HMO Blue USA Away From
Home Care Program and b the member contacts the HMO Blue USA Away From Home Care Coordinator at 1 800 4HMO USA and coordinates care for the unexpected
condition through the coordinator Emergencies need not be coordinated through this program

Administration and processing of whole blood blood plasma and blood derivatives are covered
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment insurance or attending
school or camp or travel Blood and blood derivatives no charge if replacement is arranged by member
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Long term rehabilitative therapy Manipulation of the spine
Homemaker services Transplants not specified as covered
Weight reduction programs

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 per inpatient admission 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled
nursing facility is in lieu of hospitalization and approved by the Plan You pay nothing per inpatient admission 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 Administration and processing of whole blood blood plasma and blood
derivatives

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

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

Limited benefits
Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there 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 such a condition

Acute inpatient detoxification Hospitalization for medical treatment of substance abuse is limited to emergency care 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 Blood and blood derivatives no charge if replacement is arranged by member
Custodial care rest cures domiciliary or convalescent care

Emergency Benefits
What is a medical emergency A medical emergency is the sudden and unexpected onset of a condition or an injury that you as a prudent layperson 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 Other 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Emergencies within the service If you are in an emergency situation please call your primary care physician In
area extreme 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 so they can notify the Plan You or a family member should notify the Plan

within 48 hours It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full Benefits are available for care from non Plan providers in a medical emergency only
if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition To be covered by this Plan any follow up care recommended
by non Plan providers must be approved by the Plan or provided by the 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 10 per visit at a doctor's office a 25 copayment per visit at a hospital emergency
room or outpatient department for emergency services which are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care

copay is waived If you are referred to the emergency room by your primary care doctor or the Plan and services could have been provided in the primary care
doctor's office you pay only the 10 office visit copay For reimbursement you must submit the appropriate referrals from your primary care doctor to the Plan
within five business days

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

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any
ambulance charges covered in full To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by
Plan providers

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

You pay 10 per visit at a doctor's office a 25 copayment per visit at a hospital emergency room or outpatient department for emergency services which 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

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Section 5 Benefits continued
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 7

Mental Conditions Substance Abuse Benefits
Mental conditions To the extent shown below this Plan provides the following services necessary for
What is covered the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders These services are covered only when a member
family member or member's primary care doctor contacts the Regional Referral Center RRC at 1 800 599 2428 and coordinates the member's care before services

are rendered

Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services

Outpatient care Up to 60 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay a 10 copayment per visit

Out of area students can receive outpatient mental health services out of the area if a the primary care doctor and RRC coordinate the care and b the member
maintains full time student status and attends classes Member must return to the Plan's service area if inpatient treatment is required

Inpatient care Up to 35 days of hospitalization each calendar year you pay nothing for the first 35 days all charges thereafter You may convert all inpatient days for partial hospitalization
to outpatient days on a 1 for 2 basis

What is not covered Care for psychiatric conditions which 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 Non emergency mental health care services not coordinated through the
Regional Referral Center

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Section 5 Benefits continued
Substance abuse This Plan provides medical and hospital services such as acute detoxification
What is covered 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 These services are covered only when a member family member or member's primary

care doctor contacts the Regional Referral Center RRC at 1 800 599 2428 and coordinates the member's care before services are rendered

Outpatient care Up to 60 outpatient visits for substance abuse per calendar year You pay nothing
up to 30 visits may be exchanged on a 2 for 1 basis for an additional 15 days of nonhospital residential facility inpatient care there is a 120 visit lifetime maximum

Out of area students can receive outpatient out of area treatment for substance abuse if a the primary care doctor and RRC coordinate the care and b the
member maintains full time student status and attends classes Member must return to the Plan's service area if inpatient treatment is required

Inpatient care Inpatient treatment for substance abuse is provided for up to 30 days of treatment per calendar year in a non hospital residential facility subject to a 90 day lifetime
maximum No copayment will be required for the first course of treatment A copay of 50 of charges will be required for the second and subsequent courses of
non hospital residential facility treatment until the lifetime maximum is reached

What is not covered Non emergency substance abuse services not coordinated through the Regional Referral Center

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 34 day supply You pay an 8 copay per
prescription unit or refill Unexpected prescriptions obtained beyond a reasonable distance of the member's Plan pharmacy will be reimbursed at 75 of the cost less

the 8 copayment Generic drugs will be substituted where legally possible for brand name drugs unless the member elects to receive the brand name drug and
pays the cost above the cost of the generic drug plus the generic copayment Payment is to the pharmacy

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The Plan selects formulary drugs on the basis of effectiveness and
cost Non formulary drugs will be covered when prescribed by a Plan doctor

Prescription drug mail order service through Advance Paradigm Mail Services Inc This service will provide significant cost savings when obtaining prescription
medication Through the mail order drug program you can receive a 90 day supply of medication for twice your monthly copayment You pay a 16 copay per prescription
unit The mail order service should only be utilized for medication when supplied in 90 day increments so please do not send a 30 day supply prescription
You will need to complete a prescription drug order form provided by member services

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Covered medications and accessories include
Drugs for which a prescription is required by Federal law Insulin Disposable needles and syringes needed for injecting prescribed
medication Urine test or reagent strips tablets or tape blood glucose test or reagent strips for home blood glucose monitor calibrated solution high low
control lancets Insulin pen pen needles humulin insulin vials cartridges oral diabetic drugs and spring powdered device for lancets
Intravenous fluids and medication for home use implantable drugs and some Injectable drugs are covered under Medical and Surgical Benefits

Oral fertility drugs Contraceptives Options such as oral contraceptives contraceptive devices and related services

Limited Benefits Drugs to treat sexual dysfunction are limited Contact Plan for dose limits You pay an 8 copay for up to the dosage limit and all charges above that
Zyban a smoking cessation drug Coverage for up to 12 weeks
What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies see above

Vitamins and nutritional substances which can be purchased without a prescription
Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes
Drugs to enhance athletic performance Injectable fertility drugs are not covered

Other Benefits
Vision care In addition to the medical and surgical benefits provided for diagnosis and treatment
What is covered of diseases of the eye this Plan provides the following vision care benefits from Plan providers

One routine annual eye examination by a participating ophthalmologist once per calendar year You pay an office visit copayment of 10

Reimbursement up to 35 toward the purchase of prescription lenses and frames including contact lenses once in a 24 month period For reimbursement
send your paid in full receipt with your First Priority Health Identification Number to First Priority Health Claims Department 70 North Main
Street Wilkes Barre PA 18711 We must receive your receipt within one year of the date of service You pay all charges in excess of 35

What is not covered Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is
not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedures

Exercise Program
Members can enroll in programs which focus on exercise and fitness

Nutrition Program
Members can enroll in programs regarding a safe effective healthy approach to eating

Prenatal Program
Members can enroll in health education programs concerning such topics as pregnancy planning and prepared childbirth

Smoking Cessation Program
Members can enroll in programs to quit smoking

For further information on these programs members may call 1 800 258 4080

Benefits on this page are not part of the FEHB contract 17 17
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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

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Section 7 Limitations Rules that affect your benefits continued
Other group insurance coverage When anyone has coverage with us and with another group health plan it is called double coverage You must tell us if you or a family member has double coverage
You must also send us documents about other insurance if we ask for them

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

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

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

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

When others are responsible for When you receive money to compensate you for medical or hospital care for injuries
injuries or 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

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Section 8 FEHB FACTS
You have a right to information OPM requires that all FEHB plans comply with the Patients Bill of Rights which
about your HMO gives you the right to information about your health plan its networks providers and facilities You can also find out about care management which includes

medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov

lists the specific types of information that we must make available to you

If you want specific information about us call 800 822 8753 or write to 70 North Main Street Wilkes Barre PA 18711 You may also contact us by fax at 570 831
2240 or visit our website at HYPERLINK http www bcnepa com

Where do I get information about Your employing or retirement office can answer your questions and give you a
enrolling in the FEHB Program Guide to Federal Employees Health Benefits Plans brochures for other plans and other materials you 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
premiums effective your 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
available for me and my family spouse and your unmarried dependent children under age 22 including any foster or step children your 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 self support

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

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

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

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Section 8 FEHB FACTS continued
Are my medical and claims records We will keep your medical and claims information confidential Only the following
confidential will have 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 Worker's Compensation Programs OWCP when coordinating benefit payment and
subrogating claims Law enforcement officials when investigating and or prosecuting alleged civil
or criminal actions OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members Identification cards
We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive
your ID card You can also use an Employee Express confirmation letter
What if I paid a deductible under Your old plan's deductible continues until our coverage begins
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

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

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
If you are divorced from a Federal employee or annuitant you may not continue to get 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

What is former spouse coverage office to get more information about your coverage choices
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

What is TCC 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

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Section 8 FEHB FACTS continued
Key points about TCC You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you
separate If you no longer qualify as a family member you can receive TCC for up to 36

months Your TCC enrollment starts after regular coverage ends

If you or your employing office delay processing your 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 TCC If you leave 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 individual You may convert to an individual policy if
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

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Section 8 FEHB FACTS continued
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

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 800 822 2753 and explain the situation

If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
1 202 418 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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23 Page 24
Authorized for Distribution by the
United United United United United Sta Sta States Sta Sta tes tes tes tes Of Of Off Of Of ffice ff ice ice ice ice of of of of of

PP PPer P er er ersonnel er sonnel sonnel sonnel sonnel Mana Mana Manag Mana Mana gg ggement ement ement ement ement

2000 Rate Information for
First Priority Health of Northeastern Pennsylvania

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 employee who is 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 Self Self Self Self Only Only Only Only Only C81 C81 C81 C81 C81 72.20 72.20 72.20 72.20 72.20 24.06 24.06 24.06 24.06 24.06 156.42 156.42 156.42 156.42 156.42 52.14 52.14 52.14 52.14 52.14 85.43 85.43 85.43 85.43 85.43 10.83 10.83 10.83 10.83 10.83 85.43 85.43 85.43 85.43 85.43 10.83 10.83 10.83 10.83 10.83
Self Self Self Self Self and and and and and F F Famil F F amil amil amily amil yy yy C82 C82 C82 C82 C82 175.97 175.97 175.97 175.97 175.97 72.17 72.17 72.17 72.17 72.17 381.27 381.27 381.27 381.27 381.27 156.37 156.37 156.37 156.37 156.37 207.74 207.74 207.74 207.74 207.74 40.40 40.40 40.40 40.40 40.40 201.02 201.02 201.02 201.02 201.02 47.12 47.12 47.12 47.12 47.12

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