For changes
in benefits
page 5 Serving West Michigan see
Enrollment in this Plan is limited See page 6 for requirements
Enrollment code
BQ1 Self Only
BQ2 Self and Family
For HMO Product
This Plan has commendable accreditation from the NCQA
See the 2000 Guide for more information on NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www priority health com
Authorized for distribution by the
United States Office of Personnel Management Federal Employees
Retirement and Insurance service Health Benefits Program RI 73 550
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Priority Health 2000
Table of Contents
Page
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB facts 21
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits Inside Back Cover
Premiums Back Cover
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Priority Health 2000
Introduction
Priority Health 1231 East Beltline NE Grand Rapids MI 49525 4501
This brochure describes the benefits you can receive from Priority Health under its contract CS 2613 with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of
benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled
for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page
5 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to Priority Health 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
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How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
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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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 This year you have a right to more information about this Plan care management our networks
changes facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until
the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record
you may add a brief statement to it If they do not provide you 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 Your share of the non postal premium will increase by 29.6 for Self Only or 71.3 for Self and
Plan Family
Benefit changes For dependent college students residing outside the service area all out of area routine services office exams from your primary care doctor etc are covered at 70 You pay 30 of charges
Routine services do not require authorization However emergency care can be sought when
needed and your primary care doctor's office must be notified for follow up care
Clarifications The brochure has been clarified to show that a primary care doctor referral is not needed to access Mental Conditions Substance Abuse Benefits However all Mental Health Services Substance
Abuse Services must be authorized by the plan's Behavioral Health Department which can be
reached at 616 975 8500 or 800 673 8043
Other Changes The Plan has expanded its service and enrollment area by adding all or a portion of 14 counties in Northern Michigan see page 6
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Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our
service area service area is
Antrim Benzie Charlevoix Grand Traverse Kent Leelenau Manistee Montcalm Muskegon Otsego
and Ottawa Counties and portions of the following counties as defined by these zip codes
Allegan 49010 49070 49078 49080 49311 49314 15 49323 49328 49335 49344 49348 49406
49408 49416 49419 49422 24 49447 49453
Barry 48897 49035 49046 49050 49058 49073 49325 49333 49344
Cheboygan 49705 49799 49717
Clinton 48833 48835 48845 48853 48873 48879
Crawford 49733
Eaton 48849 48890 49096
Emmet 49706 49716 49722 49740 49764 49769 49770 49711 49723 49737
Gratiot 48806 48807 48811 48856 48862 48871 48879 49430
Ionia 48809 48815 48846 48849 48851 48860 48865 48870 48875 48881 48887 48890
Kalkaska 49646 49676,49680
Mason 49410 49411
Mecosta 48850 49307 49334 49336 49338 49342 49346
Montmorency 49709,49756
Newaygo 49309 49327 49337 49343 49347 49349 49412 49421
Oceana 48006
Wexford 49620 49668
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 or authorized urgent 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 lives with a parent in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates
in other areas We provide limited coverage for dependent college students residing outside our service
area See Other benefits on page 17 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 dollar amount or
services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for services that do not require a copayment or coinsurance
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Copayments for pregnancy are limited to 60 per pregnancy Copayments for Physical Speech
Occupational Pulmonary and Cardiac Therapy Short Term Rehabilitative Services are limited to
200
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a
claims provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you
received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides my Priority Health an independent provider association model HMO contracts with approximately 719
health care primary care physicians 889 specialists and 17 hospitals
The first and most important decision each member must make is the selection of a 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 the responsibility of your primary care doctor to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization See How do I get specialty care below for services that you can
receive without a referral from your primary care doctor
The Plan's provider directory lists primary care doctors generally family practitioners OB GYNs
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 Customer Service Department at 616 942 1221 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 you should 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 other
provider cannot be guaranteed
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care doctor or specialist will
to go to the hospital make the necessary hospital arrangements and supervise your care
What do I do if I'm in First call our Customer Service Department at 616 942 1224 or 800 446 5674 If you are new to the
the hospital when I FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and
join this Plan 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 Except in a medical emergency services of other providers are covered only when your primary care
care doctor refers you except 1 a female enrollee may seek the services of an in plan obstetrician gynecologist without a referral from her PCP for routine obstetrical services and an annual
well woman examination and 2 mental health or substance abuse services can be obtained by
contacting the Priority Health Behavioral Health Department at 616 975 8500 or 800 673 8043
When your primary care doctor designates another doctor to see patients when he or she is unavailable
you must receive a referral from your primary care doctor before seeing any other doctor or obtaining
special services Referral to a participating specialist is given at the primary care doctor's discretion if
specialists or consultants are required beyond those participating in the Plan the Plan must issue a
written authorization for the referral in advance
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When you receive a referral from your primary care doctor you must return to the primary care doctor
after the consultation All follow up care must be provided or arranged by the primary care doctor
Your primary care doctor will give specific instructions to the consultant as to what services are
authorized If additional services or visits are suggested by the consultant you must first check with
your primary care doctor Do not go to the specialist unless your primary care doctor has arranged for
and the Plan has issued an authorization for the referral in advance
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care doctor will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your PCP will use our criteria when creating your
treatment plan PCP may have to get an authorization or approval beforehand
What do I do if I am Your primary care doctor will decide what treatment you need If your primary care doctor decides to
seeing a specialist refer you to a specialist ask if you can see your current specialist If your current specialist does not
when I enroll 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 Call your PCP who will arrange for you to see another specialist You may receive services from your
specialist leaves the current specialist until we can make arrangements for you to see someone else
Plan
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 the
provider leaves the provider unless the termination is for cause If you are in the second or third trimester of pregnancy
Plan or this Plan leaves you may continue to see your OB GYN until the end of your postpartum care
the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you
are in your second or third trimester your new plan will pay for the OB GYN care you receive from
your current provider until the end of your postpartum care
How do you authorize The Plan will provide benefits for covered services only when the services are medically necessary to
medical services prevent diagnose or treat your illness or condition Your Plan doctor must obtain the Plan's determination of medical necessity before you may be hospitalized
Sometimes your Plan doctor may refer you for or suggest a service that the Plan does not cover Just
because your Plan doctor refers you or suggests the service does not mean you will have coverage for
that service Remember if the Plan does not authorize a service that requires Plan authorization you
must pay for the services
How do you decide if a The Plan's experimental investigational determination process is based on authoritative information
service is experimental from medical literature clinical trials prevailing opinion among experts with specialty expertise in the
or investigational subject and evidence from State and Federal government agencies and research organizations
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Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM 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 616 942 1221 or 1 800 446 5674 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 Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening
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 You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days
In this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
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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 Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contract Division IV P O Box 436 Washington D C 20044
OPM
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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
Privacy Act 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 are provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but
no additional copay for laboratory tests and X rays Within the service area house calls will be
provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a 10
copay for a doctor's house call and nothing for home visits by nurses and health aides The following
services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for
women age 50 through 64 one mammogram every year and for women age 65 and above one
mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor There is a 60 copay maximum for office visits per pregnancy
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
has ended under the Plan 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
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung single and double kidney liver and pancreas transplants skin and
bone grafts 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 and advanced
non Hodgkin's lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and
ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer
Treatment is provided when deemed medically necessary and appropriate by the Plan's Medical
Director Related medical and hospital expenses of the donor are covered when the recipient is
covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
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
Education to manage chronic disease states such as diabetes or asthma
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Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and
excision of tumors and cysts All other procedures involving the teeth or intro oral areas surrounding
the teeth are not covered including any dental care involved in the treatment of temporomandibular
joint TMJ pain dysfunction syndrome
Services for the treatment of temporomandibular joint syndrome TMJ are covered You pay
50 of covered charges Limitations apply
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have breast reconstruction surgery
following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis for up to two consecutive months per condition if significant improvement can be
expected within two months you pay a 10 copay per outpatient session up to a 200 per member per
calendar year maximum Speech therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 50 of covered charges The following
types of artificial insemination are covered intravaginal insemination IVI and intracervical
insemination ICI Cost of donor sperm is not covered Fertility drugs are covered under the
Prescription Drug Benefit Other assisted reproductive technology ART procedures such as in vitro
fertilization and embryo transfer are not covered
Sterilizations are covered A vasectomy is covered in full when performed in the physician's office or
when in connection with other covered inpatient or outpatient services A tubal ligation is covered in
full for both physician services and facility charges when the procedure is performed on an outpatient
basis Inpatient facility charges are covered in full only when the procedure is performed in connection
with delivery or other covered inpatient surgery
Durable medical equipment such as wheelchairs and hospital beds orthopedic devices and
prosthetic devices such as artificial limbs external lenses following cataract removal breast prostheses
and surgical bras are covered You pay 50 of covered charges
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided for up to 60 days if significant improvement can be expected you pay a 10 copay per visit
up to a 200 per member maximum per calendar year
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Laser therapy for port wine stains when treatment is certified in advance by the Plan's Medical
Director in consultation with the PCP as medically necessary You pay 250 per treatment
What is not covered Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Foot orthotics
Homemaker services
Health promotion classes such as stress management parenting and lifestyle changes
Hospital Extended Care Benefits
What is covered Hospital care The plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care
The Plan provides a comprehensive range of benefits for up to 45 days per calendar year when fulltime
skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary
services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness
with a life expectancy of approximately six months or less
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a
50 copay
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
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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 Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if
the service area you are unable to contact your doctor contact the local emergency system e g call 911 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 your primary care doctor You or a family member should notify your
primary care doctor 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 of significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers will be limited to
one primary care doctor approved visit for each medical emergency or urgent care situation unless
there is prior authorization by the Plan and the primary care doctor for additional visits
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 10 per Plan urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to the hospital the
emergency room copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because
the service area 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
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Priority Health 2000
To be covered by this Plan any follow up care recommended by non Plan providers will be limited to
one primary care doctor approved visit for each medical emergency or urgent care situation unless
there is prior authorization by the Plan and the primary care doctor for additional visits
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 10 per Plan urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to the hospital the
emergency room 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 you pay a 50 copay
What is not covered Elective care or non emergency care Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service
area
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency care
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 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 by following with the disputed claims procedure described on page 10
Mental Conditions Substance Abuse Benefits
Important Note A primary care doctor referral is not required for members to access mental
conditions substance abuse providers To make arrangements to receive these services you must
call our Behavioral Health Department at 616 975 8500 or 1 800 673 8043
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 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 20 copay 10 for a group session for each covered visit all charges thereafter
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Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter Each day of partial hospitalization counts as 1 2 of one inpatient day
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 that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for
any other illness or condition and to the extent shown below the services necessary for diagnosis and
treatment
Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay 50 of charges during
the benefit period all charges thereafter
What is not Treatment that is not authorized by a Plan doctor
covered
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply In lieu of brand name drugs generic drugs will be dispensed when
substitution is permissible You pay a 5 copay per prescription unit or refill When generic
substitution is permissible but you or your doctor request the name brand drug you pay the price
difference between the generic and name brand drug as well as the 5 copay per prescription unit or
refill unless the name brand was approved in advance by the Plan Drugs are provided based on the
Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor Nonformulary
non covered drugs will be covered based on medically necessity Medical necessity
requirements include a therapeutic trial of a clinically equal or superior formulary product The Plan's
formulary is based on effectiveness and cost
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin with a copay charge applied to a one month supply
Diabetic supplies including insulin syringes and needles
Disposable needles and syringes needed to inject covered prescribed medication
Full range of FDA approved drugs prescriptions and devices for birth control
Limited benefit Intravenous fluids and medications are covered in full for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
HGH human growth hormone is paid in full
Fertility drugs are covered you pay 50 of the charges
Contraceptive diaphragms are covered you pay 50 of the charges
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Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay 50
coinsurance up to the dosage limits and all charges above that
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies
Diabetic supplies that can be purchased without a prescription such as glucose tablets test tape
Benedict's solution or equivalent and acetone test tablets
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Injectable drugs except insulin and Imitrex
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medications including nicotine patches
Drugs used for weight control
Other Benefits
Student out of service All out of area routine services office exams form your primary care doctor etc for dependent
area benefit college students attending school outside of the Plan's service area are covered You pay 30 of charges
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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
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
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Priority Health 2000
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
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to provide
our control 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
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Priority Health 2000
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
Worke rs We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency 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
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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 right
information about to information about your health plan its networks providers and facilities You can also find out
your HMO 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 616 942 1221 or 800 446 5674 or write to Customer
Service Department 1231 East Beltline NE Grand Rapids MI 49525 You may also contact us by fax
at 616 957 3420 or visit our website at www priority health 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 an
enrolling in the FEHB 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
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
and premiums premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
effective premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been enrolled
retire 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are available unmarried dependent children under age 22 including any foster or step children your employing or
for me and my family 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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Priority Health 2000
Are my medical and We will keep your medical and claims information confidential Only the following will have access to it
claims records
confidential OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit 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 SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an
Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan
ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not
elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
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Priority Health 2000
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 the 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
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage
due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage 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
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Priority Health 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 616 942 1221 or 1 800 446 5674 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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Notes
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Summary of Benefits for Priority Health 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 with no dollar or day
care limit Includes in hospital doctor care room and board general nursing care private room and private nursing care if medically necessary diagnostic
tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing .13
Extended All necessary services for up to 45 days per year You pay nothing .13
care
Mental Diagnosis and treatment of acute psychiatric conditions for up to
conditions 30 days of inpatient care per year You pay nothing .15
Substance Up to 30 days per year in a substance treatment program
abuse You pay 50 of charges .16
Outpatient Comprehensive range of services such as diagnosis and treatment of
care illness or injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations
laboratory tests and X rays complete maternity care You pay
a 10 copay per office visit or for a house call by a Plan doctor .11
Home health All necessary visit by nurses and health aides
care You pay nothing .11
Mental Up to 20 outpatient visits per year You pay a 20 copay per visit .15
conditions
Substance Up to 20 outpatient visits per year You pay a 20 copay per visit .16
abuse
Emergency Reasonable charges for services and supplies required because of a
care medical emergency You pay a 50 copay for each emergency room visit and any charges for services that are not covered by this Plan .14
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy
drugs You pay a 5 copay per prescription unit or refill .16
Dental care No current benefit
Vision care No current benefit
Out ofpocket Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments and coinsurance that are required
maximum for a few benefits .6
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2000 Rate Information for
Priority Health
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 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 Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
West Michigan
Self Only BQ1 78.83 26.54 170.80 57.50 93.06 12.31 93.26 12.11
Self and Family BQ2 175.97 121.76 381.27 263.81 207.74 89.99 201.02 96.71 28