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KEYSTONEBLUE 2000

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Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
EF1 Self Only
EF2 Self and Family

This Plan has a commendable status
from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure and
This Plan's website at http www highmark com

Authorized for Distribution by the
United States Office of Personnel Management

Federal Employees Health Benefits Program

RI 73 484 1
1 Page 2 3

KeystoneBlue 2000
Table of Contents
Page

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 20
Section 8 FEHB facts 21
Inspector General Advisory Stop Healthcare Fraud 25
Summary of benefits Inside back cover
Premiums Back cover

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Return to Table of Contents KeystoneBlue 2000
Introduction Keystone Health Plan West Inc d b a KeystoneBlue Fifth Avenue Place 120 Fifth Avenue Pittsburgh PA 15222

This brochure describes the benefits you can receive from KeystoneBlue under its contract CS2340 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 KeystoneBlue as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How to use this This brochure has eight sections Each section has important information you should read If you brochure 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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KeystoneBlue 2000 Return to Table of Contents
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate
your health care services The care you receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

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

Section 2 How we change for 2000
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 KeystoneBlue's non postal premium will increase by 38.5 for Self Only or 113.1 for Self and Family
If you or your dependents have a serious mental illnesses as defined by the American Psychiatric Association including schizophrenia bipolar disorder obsessive compulsive disorder major depressive
disorder panic disorder anorexia nervosa bulimia nervosa schizo affective disorder delusional disorder you are now entitled to coverage for at least 30 days of inpatient care and 60 days of outpatient
care annually Inpatient days can be converted to outpatient days on a one for two basis
This brochure now states that coverage is provided for breast reconstruction following a mastectomy that includes reconstruction of the unaffected breast for symmetry Previously this was

covered through interpretation of the reconstructive surgery benefit
Coverage is provided certain prescription drugs when related to diabetes The following supplies among others are covered when related to the treatment of diabetes injection aids syringes blood

glucose monitors test strips and orthotics

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Return to Table of Contents KeystoneBlue 2000
Emergency care services are covered without prior approval or referral Emergency service is defined as any health care service provided to a member after the sudden onset of a medical condition
that manifests itself by acute symptoms of sufficient severity or severe pain such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect
the absence of immediate medical attention to result in 1 placing the health of the member or with respect to a pregnant woman the health of the woman or her unborn child in serious jeopardy
2 serious impairment to bodily functions or 3 serious dysfunction of any bodily organ or part

Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is Western Pennsylvania which includes the following areas

Greater Pittsburgh The Pennsylvania counties of Allegheny Armstrong Beaver Butler Fayette Greene Lawrence Washington and Westmoreland

Erie The Pennsylvania counties of Clarion Crawford Erie Forest McKean Mercer and Venango
Altoona The Pennsylvania counties of Bedford Blair Cambria Clearfield Elk Huntingdon Indiana Jefferson Somerset and Warren

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 you or a family member move you do not have to wait until Open Season to change plans Contact
your employing or retirement office

Reciprocity Away from Home Care The Away from Home Care program HMO Blue USA is the Blue Cross and Blue Shield Association's basic reciprocity program The HMO Blue USA program offers Plan
members urgent care and guest membership at participating Blue Cross and Blue Shield HMOs throughout the United States The participating HMO will bill the Plan for urgent care charges or

guest membership services You will be responsible for paying non covered benefits The Plan will pay all other charges at 100 for outpatient treatment and inpatient admissions minus any applicable
copayments or deductibles A toll free number 1 800 4HMO USA is available for contacting a participating HMO when you are outside the Plan Service Area and need urgent care treatment

Your Away From Home Care also includes a guest membership feature This feature is for members who will be living outside western Pennsylvania for an extended period of time for example a
child away at school or when business takes you temporarily to another location Through the Away From Home Care program you can apply for a guest membership in another area of the
country that has a Blue Cross and Blue Shield HMO plan The guest membership is designed to serve members who plan to be out of the KeystoneBlue area for 90 to 180 days The temporary
residence can be for either work related or personal reasons Your dependents covered by KeystoneBlue can also apply for an unlimited length of time as long as the application is renewed
yearly As a guest member of another Blue HMO plan you or your dependents would choose a primary care doctor at that plan and have the benefits offered by that HMO For care coordinated by
that plan's PCP you would be responsible only for any applicable copayments or deductibles for that HMO You need to apply for a guest membership at least 30 days before you would like the
guest membership to become effective

How much do I pay for You must share the cost of some services This is called either a copayment a set dollar amount or services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services except for a referred specialist's office visit Your out of pocket expenses for benefits under this Plan are limited to the copayments stated in this brochure

Do I have to submit No We do not require you to submit claim forms claims

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KeystoneBlue 2000 Return to Table of Contents
Who provides my health KeystoneBlue is an Individual Practice Prepayment IPP model HMO offering you a choice of care more than 1,500 primary care doctors Federal employees annuitants and their dependents enrolled
in this Plan will need to select a personal doctor from a list of our participating primary care doctors A primary care doctor is a doctor who has been specially trained in the areas of Family Practice

Internal Medicine or Pediatrics In fact we require our doctors to be specialty board certified

Role of a primary care The first and most important decision you and your family members must make is the selection of a doctor primary care doctor The decision is important since it is through this doctor that all other health
services particularly those of specialists are obtained It is your primary care doctor's responsibility to obtain any necessary authorizations from us before referring you to a specialist or making

arrangements for hospitalization Services of other providers are covered only when there has been a referral by the appropriate primary care doctor with the following exception a woman may see
her Plan obstetrician gynecologist without a referral A woman may self refer to any KeystoneBlue network OB GYN directly for any gynecological services without a referral from her primary care
doctor and may receive medically necessary and appropriate follow up care and referrals for diagnostic testing without prior approval of PCP The OB GYN will manage the care of the member for
any gynecological services and establish the treatment plan for the member All female members are encouraged to receive an annual routine exam including a pelvic exam and clinical breast exam and
one Papanicolaous PAP smear per calendar year

Choosing your doctor Our provider directory lists primary care doctors generally family practitioners pediatricians and internists with their locations and phone numbers and notes whether or not the doctor is accepting
new patients Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Service Department at 1 800 421 0959 you can also find

out if your doctor participates with this Plan by calling this number If you are interested in receiving care from a specific provider who is listed in the directory call the provider to verify that he or
she still participates with the Plan and is accepting new patients Important note When you enroll in this Plan services except for emergency benefits are provided through the Plan's delivery system
the continued availability and or participation of any one doctor hospital or other provider cannot be guaranteed

If you enroll we will ask you to complete a primary care doctor selection form and send it directly to us You will need to indicate the name of the primary care doctor s and the doctor's number as
indicated in the directory that you have selected for you and each member of your family You may change all doctor selections by notifying our Member Service Department If you contact
Member Service before the 15th of the month the change will be effective the first day of the following month If you contact Member Service after the 15th of the month the change will be effective
the first day of the second following month

What do I do if my We will notify you of the doctor's departure from our network and ask you to select a new primary primary care physician care doctor
leaves the Plan

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

What do I do if I'm in First call our customer service department at 1 800 421 0959 If you are new to the FEHB Program the hospital when I join we will arrange for you to receive care If you are currently in the FEHB Program and are
this Plan 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

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How do I get specialty Your primary care physician will arrange your referral to a specialist Except in a medical emergency care or when a primary care doctor has designated another doctor to see his or her patients you
must receive a referral from your primary care doctor or Blues On Call SM before seeing any other doctor or obtaining special services Blues On Call is a toll free 24 hour health care advice and

assistance number 1 888 BLUE 428 that connects you to a specially trained registered nurse who provides care assistance including referrals to network specialists when appropriate Referrals to a
participating specialist are given at the primary care doctor's discretion if non Plan specialists or consultants are required the primary care doctor will arrange appropriate referrals

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 You may also be entitled to receive a 60 day standing
referral to your specialist if certain criteria are met Your PCP can coordinate this for you
When you receive a referral from your primary care doctor or Blues On Call you may be treated by the consultant doctor up to 60 days from the time of issuance of the referral All diagnostic testing
and follow up care can be provided or arranged by the consulting doctor If additional services or visits are suggested by the consultant beyond the 60 day limit you must first check with your primary
care doctor and obtain an additional referral Do not go to the specialist unless your primary care doctor or Blues On Call has arranged for and the Plan has issued an authorization for the referral
in advance

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist when specialist ask if you can see your current specialist If your current specialist does not participate
I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan However you may be able to continue
care with a non Plan provider for up to 60 days after your effective date of coverage on this Plan Coverage may be extended beyond 60 days if clinically appropriate

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the receive services from your current specialist until we can make arrangements for you to see someone
Plan else

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

your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you
receive from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist medical services 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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How do you decide if a The use of any treatment service procedure facility equipment drug device or supply intervention service is experimental that is not determined by the Plan or its Designated Agent to be medically effective for the
or investigational condition being treated The Plan or its Designated Agent will consider an intervention to be Experimental Investigative if

The intervention does not have FDA approval to market for the specific relevant indication s or
Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes or

The intervention is not proven to be as safe or as effective in achieving an outcome equal to or exceeding the outcome of alternative therapies or
The intervention is not proven to be applicable outside the research setting If an intervention as defined above is determined to be Experimental Investigative at the time of service it will not
receive retroactive coverage if at some future date medical opinion changes

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 verbal or 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review a denial 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 Call us at 1 800 547 9378 and we will expedite our review or life threatening
condition and you haven't responded to
my request for service

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern Time or life 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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Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for additional
information

What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

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

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

Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan

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

review request

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

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

What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure

described above

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information

to support the disputed claim decision If you file a lawsuit this information will become part of the court record

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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 copay for a primary
doctor's office visit nothing for a referral specialist's office visit but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment

of the Plan doctor such care is necessary and appropriate you pay a 10 copay for a doctor's house call nothing for home visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows an initial baseline mammographic screening for all female Members between 35 and 40 years of age for women age 40 and over one annual mammogram

screening every year In addition to routine screening mammograms are covered regardless of age when prescribed by the primary care doctor or network OB GYN as medically necessary to diagnose
or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option

may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated
during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is
covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum copay is waived

The insertion of internal prosthetic devices such as pacemakers and artificial joints breast prosthesis and surgical bras as well as their replacement
Cornea heart heart lung kidney liver lung single or double pancreas kidney skin and tissue 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
medical director Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan All transplant services must be pre determined in writing by the 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 at a participating facility or in the home when authorized by the plan
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces custom molded foot orthotics requires prior authorization by the Plan

Standard durable medical equipment such as wheelchairs and hospital beds requires prior authorization by the Plan

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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What is covered Prosthetic devices such as artificial limbs and lenses following cataract removal requires prior continued authorization by the Plan

Home health services of nurses and health aides when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for 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 excision of tumors and cysts and extractions of impacted third molars when partially or

totally covered by bone 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
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 days per condition if significant improvement can be expected within 60

days you pay nothing 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
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
Diagnosis and treatment of infertility is covered you pay up to 200 or 50 of the cost of the plan of treatment whichever is less The following types of artificial insemination are covered intravaginal

insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay up to 200 or 50 of the cost of the plan of treatment whichever is less cost of donor sperm is
not covered Fertility drugs are covered with prior authorization from the plan 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 covered in full at a Plan facility for up to 12 weeks you pay nothing All services must be authorized

by your primary care doctor and KeystoneBlue
Chiropractic services are covered but coverage is limited to spinal manipulations
Enteral Formulae is covered when administered on an Outpatient basis either orally or through a feeding tube primarily for the therapeutic treatment of phenylketonuria branched chain ketonuria

galactosemia and homocystinuria and when medically necessary and appropriate for the member's medical condition when Enteral Formulae is the sole source of nutrition and utilized instead of
regular shelf food or regular infant formulae Benefits for Enteral Formulae are exempt from any applicable deductible requirements but policy limitations and maximums do apply

In order to receive Enteral Formulae the member must receive prior authorization from the Plan by meeting specific medical criteria Coverage for Enteral Formulae will continue as long as the Formulae
represent at least 50 of the member's daily caloric requirements Enteral Formulae coverage does not include normal food products used in the dietary management of rare hereditary
genetic metabolic disorders or when utilized for the sole purpose of weight loss or gain The coverage does not cover blenderized food baby food or infant formulae with intact proteins

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 11
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Medical and Surgical Benefits continued
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Storage of blood except when done in preparation for a scheduled surgical procedure
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Homemaker services
Services related to contraceptive devices including diaphragms and implanted contraceptive medications such as Norplant

Immunizations required for foreign travel
Hair growth stimulants and hair replacement
Weight reduction programs
Charges for missed appointments
Radial keratotomy

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no day limit when you are hospitalized under the care of a Plan doctor You pay a 100 copay per admission if readmitted within 60 days

of the first admission regardless of condition no additional copay is due Once inpatient hospital admission copayments incurred total 300 per individual or 500 per family in a calendar year

no further inpatient copayment is required of that individual or family in that calendar year 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 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor 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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures 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 Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate

See page 16 for nonmedical Substance Abuse Benefits

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

Custodial care rest cures domiciliary or convalescent care
Private duty nursing when provided in an inpatient setting

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 13
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Emergency Benefits
What is a medical Emergency care services are covered without prior authorization or referral Emergency service is emergency defined as any health care service provided to a member after the sudden onset of a medical condition
that manifests itself by acute symptoms of sufficient severity or severe pain such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the

absence of immediate medical attention to result in 1 placing the health of the member or with respect to a pregnant woman the health of the woman or her unborn child in serious jeopardy 2
serious impairment to bodily functions or 3 serious dysfunction of any bodily organ or part

Emergencies within the In the event that you or a covered dependent requires emergency care all charges for such covered service area services will be paid No prior authorization is required for emergency care Either the member or a
family member should if possible notify the Primary Care Physician with 48 hours of the emergency care or as soon as reasonably possible to facilitate a follow up call

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges
covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition

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

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 emergency room visit or 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 the Benefits are available for any medically necessary health service that is immediately required service area 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 services to the extent the services would have been covered if received from Plan providers

You pay 50 per emergency room visit or 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
The HMO Blue USA program offers Plan members urgent care and guest membership at participating Blue Cross and Blue Shield HMOs throughout the United States The participating HMO will

bill this Plan for urgent care charges or guest membership services You will be responsible for paying non covered benefits The Plan will pay all other charges at 100 for outpatient treatment
and inpatient admissions minus any applicable copayments or deductibles A toll free number 1 800 4HMO USA is available for contacting a participating HMO when you are outside the Plan
Service Area and need urgent care treatment

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

Ambulance service if approved by the Plan

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

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

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card Payment

will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions
of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 9

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Mental Conditions Substance Abuse Benefits
You may self refer to this Plan's mental health administrator for treatment of mental conditions and substance abuse The mental health administrator will make all subsequent determinations of appropriate

treatment and which specialists will be used Call us for the name and phone number of our mental health administrator

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 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 25 copay for each covered visit all charges thereafter
Up to 60 days of outpatient care for serious mental illness per calendar year you pay a 25 copay for each covered visit all charges thereafter Serious mental illness is defined by the American
Psychiatric Association to include schizophrenia bipolar disorder obsessive compulsive disorder major depressive disorder panic disorder anorexia nervosa bulimia nervosa schizo affective disorder
and delusional disorder

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for first 30 days all charges thereafter For serious mental illness as defined above you are covered for at least 30 days of inpatient
care same inpatient care copay applies Inpatient days can be converted to outpatient days on a one for two basis

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
covered significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless

determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same

as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Inpatient Up to seven 7 days per admission with a lifetime maximum of four admissions in a facility
detoxification care approved by the Plan

Inpatient Up to 30 days substance abuse rehabilitation program per calendar year with a lifetime maximum of
rehabilitation 120 days in a Rehabilitation Center approved by the Plan you pay nothing during the benefit
care period all charges thereafter

Outpatient care Up to 60 outpatient visits per calendar year and 120 visits per lifetime to Plan providers for treatment you pay nothing for the first course of treatment second and additional courses of treatment
will be subject to a 25 copay per visit or 50 of allowable charges whichever is less all charges thereafter

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

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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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 maximum 34 day supply Generic drugs may be dispensed when substitution
is permissible you pay an 8 copayment per prescription or refill When generic drugs are available and the prescribing doctor requires the use of a name brand drug you pay a 14 copayment per

prescription or refill When generic drugs are available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay a 14 copayment per
prescription or refill plus the price difference between the generic and name brand drug
MAIL ORDER A mail order program is available to provide up to a 90 day supply of maintenance drugs You pay a single copay for each 90 day supply

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
All FDA approved contraceptive drugs and devices Up to a three cycle supply of oral and injectable contraceptive drugs may be obtained for a single copay charge through the mail order program

Insulin
Insulin syringes needles and or disposable diabetic testing materials supplies will be included under the same copayment as the insulin

Disposable needles and syringes needed to inject covered prescribed medication
Implanted time release medications provided at no charge
Prenatal vitamins
Fluoride vitamins
Fertility drugs requires prior authorization by the Plan
Intravenous fluids and medications for home use provided under home health services at no charge and some covered injectable drugs are covered under Medical and Surgical Benefits

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

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
Drugs or other devices to aid in smoking cessation
Weight loss drugs

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 17
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Other Benefits
Dental care

Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth
benefit The need for these services must result from an accidental injury you pay nothing

What is not Treatment for accidental dental injury caused by chewing
covered

Vision OptiChoice is our Preferred Provider Vision Care Program The OptiChoice In Network Annual Vision Benefits Program offers affordability and paid in full vision benefits on standard eligible
services It also offers a quality network of statewide and national vision care providers who agree to accept program allowances as payment in full in accordance with the OptiChoice benefit design

Members are required to select an optometrist ophthalmologist or optical supplier from the Preferred Provider Network Payment for services is limited to in network only and services are eligible
once a year It also provides discounts on additional examinations frames lenses contacts optical accessories and supplies There is no pre authorization or deductible required OptiChoice
Preferred Providers submit claims for members and receive direct reimbursement completely removing members from the paperwork process Following is a summary of benefits and out ofpocket
expenses

What is covered Benefit You pay
Eye Examination and Refractive Service Nothing

Contact Lens Prescription and Fitting Nothing
Post Refractive Services
Frames All charges in excess of 60
Single Vision Lenses Standard Nothing
Bifocal Vision Lenses Standard Nothing
Trifocal Vision Lenses Standard Nothing
Aphakic Vision Lenses Standard Nothing

Single Vision Lenses Non standard 90 of the difference
Bifocal Vision Lenses Non standard betweeen the normal charge and the non standard
Trifocal Vision Lenses Non standard charge for the same type of
Aphakic Lenticular Vision Lenses Non standard Standard lenses

Hard Contact Lenses Standard Nothing
Soft Contact Lenses Standard Nothing
Specialty Contact Lenses Standard All charges in excess of 75
Vision Care Options tints contact lens solutions etc The cost of the items less a 10 discount

Additional Post Refractive Services All charges in excess of the Program's Allowance

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
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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 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

KeystoneBlue also offers members these Distinct Health Enhancement Opportunities
Dental coverage All KeystoneBlue members may take advantage of special discounts through our Healthy Lifestyle Program By simply presenting your Plan ID card at participating
Healthy Lifestyle providers you will receive a 10 to 30 discount off the cost of most dental services Some dental providers also offer KeystoneBlue members free
or discounted initial exams x rays and cleanings
Healthy Lifestyle All KeystoneBlue members may take advantage of discounts available at more than Programs
500 area establishments which promote healthy lifestyle choices By simply presenting your KeystoneBlue membership card at the time of purchase at participating

establishments you may take advantage of discounts on health club memberships sporting goods fitness equipment and nutritional items

Also KeystoneBlue members may take advantage of free lifestyle improvement classes on such topics as nutrition and weight loss smoking cessation stress management
and prepared childbirth These classes are offered at least three times a year at various locations in the Western Pennsylvania area

Blues On Call SM All KeystoneBlue members have access to Blues On Call Blues On Call is a tollfree 1 888 BLUE 428
24 hour health care advice and assistance number that connects you to a specially trained registered nurse who provides care assistance including referrals to

network specialist when appropriate You can use Blues On Call 24 hours a day to speak confidentially with a registered nurse about everyday health concerns or
major health decisions listen to up to date recorded information on more than 430 health care topics and get help locating health care resources such as support
groups and community services
Medicare prepaid plan This plan offers Medicare recipients the opportunity to enroll in the Plan through enrollment
Medicare As indicated on page 20 annuitants and former spouses with coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare

prepaid plan when one is available in their area They may then later re enroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without
Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan
ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on changing your FEHB enrollment
and changing to a Medicare prepaid plan Contact us at 1 800 576 6343 for information on Plan benefits under the Medicare plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call
800 576 6343 for information on the benefits available under the Medicare HMO

Benefits on this page are not part of the FEHB Contract

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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 Services drugs or supplies that are not medically necessary following
Services not required according to accepted standards of medical dental or psychiatric practice

Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act

of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

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

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

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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833
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

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

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

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for injuries 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 We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for

Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about your right to information about your health plan its networks providers and facilities You can also find
HMO out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you

If you want specific information about us call 1 800 547 9378 or write to Keystone Health Plan West Inc Claims P O Box 898819 Camp Hill PA 17089 8819 Or visit our website at
www highmark com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the FEHB an informed decision about Program When you may change your enrollment

How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

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

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When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums effective 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 When you retire you can usually stay in the FEHB Program Generally you must have been retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

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

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce No new enrollment form is necessary
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim

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

What if I paid a Your old plan's deductible continues until our coverage begins deductible under my old
plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

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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
Your enrollment ends unless you cancel your enrollment or ends

You are a family member no longer eligible for coverage

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

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI 79 27 which

describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or retirement office

Key points about You can pick a new plan
TCC If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in TCC

You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

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

You are not eligible for coverage under TCC or the spouse equity law

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

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

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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Inspector General Advisory
Stop Health Care Fraud

Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information
do the following Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 421 0959 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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Notes

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Summary of Benefits for KeystoneBlue 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change
your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page

Inpatient Hospital Comprehensive range of medical and surgical services without day limit Includes care in hospital doctor care room and board general nursing care private room and private
nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care You pay 100 per admission 12

Extended care All necessary services for up to 100 days per year You pay nothing 12
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient conditions care per year You pay nothing 16

Substance For treatment of substance abuse other than alcoholism one 30 day program per year for abuse alcoholism one 30 day program per year benefits subject to lifetime maximum
You pay nothing 16
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care including specialist's care preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per visit for an office visit or house call by a primary care doctor nothing for
referral care to specialists 10
Home health All necessary visits by nurses and health aides You pay nothing 11 Care

Mental Up to 20 outpatient visits per year You pay a 25 copay per visit 16 conditions
Substance For treatment of substance abuse other than alcohol up to 30 outpatient visits per year abuse
120 visits per lifetime maximum you pay nothing For alcoholism up to 60 outpatient visits per year you pay nothing for the first course of treatment 25 copay per visit or

50 of charges whichever is less for additional courses up to visit limit 16
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 per visit for emergency room visits waived if you are admitted and any
charges for services that are not covered by this Plan 14

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay an 8 copay per prescription unit or refill for generic drugs When generic drugs are available and the
prescribing doctor requires the use of a name brand drug you pay the 14 copayment per prescription or refill If you request a name brand drug you pay a 14 copay per
prescription unit or refill plus the difference in cost between the generic and name brand drug A mail order service is available for maintenance medication you pay a single
copay for each 90 day supply 17

Dental care Accidental injury benefit you pay nothing 18
Vision care Paid in full benefits are available on standard services through the OptiChoice In Network Annual Benefits Program 18

Out of pocket limit Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits 5

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Authorized for Distribution by the
United States Office of Personnel Management

Federal Employees Health Benefits Program

2000 Rate Information for
KeystoneBlue

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 EF1 72.29 24.09 156.62 52.20 85.54 10.84 85.54 10.84
Self and Family EF2 175.97 109.96 381.27 238.25 207.74 78.19 201.02 84.91

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