Serving Eastern Ohio and Northern and Central West Virginia
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
U41 Self Only
U42 Self and Family
This Plan has a comendable 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 healthplan org
Authorized for distribution by the
Un U ni i t te ed d S St ta at te es s Of O ff fi i e e o of f Pe P er rs so on nn ne el l Ma M an na ag ge em me en nt t
Federal Employees
re r et ti i r re em me en nt t an a nd d I I n ns su ur ra an n e e se s er rv vi i e e Health Benefits Program
RI 73 553
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THE HEALTH PLAN HMO 2000
Table of Contents Page
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
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 7
Section 5 Benefits 9
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 25
Summary of benefits Inside back cover
Premiums Back cover
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THE HEALTH PLAN HMO 2000
Introduction
The Health Plan of the Upper Ohio Valley Inc The Health Plan HMO
52160 National Road East
St Clairsville OH 43950
This brochure describes the benefits you can receive from The Health Plan HMO under its contract CS2616 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 The Health Plan HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it
more understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year
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THE HEALTH PLAN HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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THE HEALTH PLAN HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals
and other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness
and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive 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
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THE HEALTH PLAN HMO 2000
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes 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 Your share of the non postal premium will increase by 19 for Self Only or 19 for Self and Family
Plan We have added an urgent care benefit to this plan There is a 25 copay per visit See page 13
We have added a limited TMJ benefit to this plan There is a 30 copay See page 10
We have expanded this Plan's service area to include the additional West Virginia counties of Barbour
Pleasants Ritchie Wirt and Wood and the additional Ohio county of Washington See page 5 for
complete service area listing
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THE HEALTH PLAN HMO 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our
Plan's service service area is Ohio counties of Belmont Guernsey Harrison Jefferson Monroe Muskingum Noble and
area Washington Also the West Virginia counties of Barbour Brooke Doddridge Gilmer Hancock Harrison Lewis Marion Marshall Monongalia Ohio Pleasants Preston Ritchie Taylor Tyler Upshur Wetzel
Wirt and Wood
Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If
your dependents live out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other
areas If you or a family member move you do not have to wait until Open Season to change plans
Contact your employing or retirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount or
pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs
and dental services do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims 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 The Health Plan is an Individual Practice Plan IPP servicing the residents of Eastern Ohio and Northern
my health care West Virginia As an IPP we provide medical services to our members by contracting with local physicians We contract with over 1,000 doctors from the primary and specialty fields of medicine
What do I do if Call us We will help you select a new one
my primary care
physician leaves
the Plan
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will
need to go into make the necessary hospital arrangements and supervise your care
the hospital
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THE HEALTH PLAN HMO 2000
Section 3 How to get benefits continued
What do I do if First call our member relations department at 800 624 6961 If you are new to the FEHB Program we
I'm in the hospital will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
when I join your former plan will pay for the hospital stay until
this Plan You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist Referrals are not required for
specialty care OB GYN visits if you select one as your secondary care physician
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 have to get an
authorization or approval from us beforehand
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a
am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us
specialist when you must receive treatment from a specialist who does Generally we will not pay for you to see a
I enroll specialist who does not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive
my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
have a serious your provider for up to 90 days after we notify you that we are terminating our contract with the provider
illness and my unless the termination is for cause If you are in the second or third trimester of pregnancy you may
provider leaves continue to see your OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
Plan leaves the you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
Program 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 Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize recommending follow up care Before giving approval we consider if the service is medically necessary
medical and if it follows generally accepted medical practice
services
How do you This Plan uses nationally accredited specialty consultants appropriate government agencies and other
decide if a service regulatory agencies to decide if a service or item is experimental or investigational This Plan does not
is experimental or cover experimental or investigational services or items
investigational
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THE HEALTH PLAN HMO 2000
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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
OPM to review OPM will determine if we correctly applied the terms of our contract when we denied your claim
a denial or request for services
What if I have a Call us 800 624 6961 and we will expedite our review
serious or life
threatening
condition and
you haven't
responded to my
request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health
request for care benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening
and my conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
condition is soon as possible
serious or life
threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time 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
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THE HEALTH PLAN HMO 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send Your request must be complete or OPM will return it to you You must send the following information
to OPM 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 Those who have a legal right to file a disputed claim with OPM are
the 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 Send your request for review to Office of Personnel Management Office of Insurance Programs Contract
mail my Division 3 P O Box 436 Washington D C 20044
disputed claim
to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the your only recourse is to sue
Plan's denial 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
if I 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
the 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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THE HEALTH PLAN HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
WHAT IS COVERED
A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers
This includes all necessary office visits you pay a 10.00 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 10.00 copay for a doctor's house call nothing for home visits by nurses
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 excluding those required for travel and sports
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 You pay 10.00 for initial visit 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 cesarean delivery Inpatient stays will be extended
if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage
under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and Family enrollment
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 provided in the office
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver lung single and double bowel and pancreas transplants allogeneic donor
bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support
for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced
non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and
testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Plan
Medical Director Related medical and hospital expenses of the donor are covered when the recipient is covered by 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
External breast prostheses and surgical bras as well as their replacement you pay 20 of charges
Breast implants associated with reconstructive surgery
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Orthopedic devices such as braces foot orthotics you pay 20 of charges
Durable medical equipment such as wheelchairs and hospital beds you pay 20 of charges
Blood administration and services blood derivatives
Surgical treatment of morbid obesity
Depo Provera you pay a 15 copay per injection
Home health services of nurses including intravenous fluids and medications when prescribed by your Plan doctor
who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
at no additional cost to you
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
Limited Benefits
Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such
as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses
including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth
or intra oral areas surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular
joint TMJ pain dysfunction syndrome
Temporomandibular Joint TMJ Pain Dysfunction coverage is provided for non experimental medical services for the
treatment of TMJ if medically necessary as determined by this Plan You pay 30 of charges Non medical services related
to the treatment of TMJ are not covered
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 basis for up to 60 days per
calendar year and on an outpatient basis for up to two months per condition if significant improvement can be expected within
two months you pay nothing for inpatient sessions and a 15 copay per outpatient session Speech therapy is limited to
treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member
to achieve and maintain self care and improved functioning in other activities of daily living
Specialized rehabilitative therapy is provided on an inpatient or intensive outpatient basis as part of a specialized
multi disciplinary therapy physical occupational and speech program for up to two months of treatment days per calendar
year Outpatient therapy is limited to 60 days per discipline per calendar year You pay nothing for days 1 30 20 of
charges for days 31 60
Hearing aids are provided as needed for children The initial hearing aid is provided for adults
Diagnosis and treatment of infertility is covered you pay a 10.00 office visit copay cost of donor sperm is not covered
Fertility drugs are not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and
embryo transfer are not covered
Prosthetic devices such as artificial limbs and lenses following cataract removal are limited to one device every three years
you pay 20 of charges
Chiropractic services are provided for up to 20 visits per calendar year you pay a 15 copay per visit
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a
Plan approved facility for up to 12 weeks or 36 visits you pay nothing
Pulmonary rehabilitation is provided at a Plan approved facility for up to 12 weeks or 36 visits per calendar year
You pay nothing
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
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Long term rehabilitative therapy
Homemaker services
Replacement or repair of hearing aids
Batteries for DME items such as batteries required for hearing aids tens unit wheelchairs and glucometers
Replacement of orthopedic devices prosthetic devices or durable medical equipment prior to end of expected
life of the device except for replacement due to growth or development in children up to age 18
Corrective eyeglasses frames and contact lenses
Refractions including lens prescriptions
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
Hospital Extended Care Benefits
WHAT IS COVERED
Hospital care
The Plan provides a comprehensive range of medical and surgical benefits without dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including
Semi private room accommodations when a Plan doctor determines it is medically necessary the doctor
may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care
The Plan provides a comprehensive range of benefits for up to 120 days per calendar year when full time 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 25 per day 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 Services include home care and family
counseling these services are provided under the direction of a Plan doctor who certifies that the person is in the terminal
stages of illness with a life expectancy of approximately six months or less
Ambulance service
The Plan provides benefits for emergency ambulance transportation ordered or authorized by a Plan doctor
Limited Benefits
Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there
is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but
not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia
and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient detoxification Hospitalization for medical treatment of substance abuse is limited to emergency care
diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the
Plan doctor determines that outpatient management is not medically appropriate See page 15 for nonmedical substance
abuse benefits
WHAT IS NOT COVERED
Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical emergency
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies
because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all
have in common is the need for quick action
Emergencies within the service area
If you are in an emergency situation please call your primary care doctor If your primary care doctor can not be reached call
The Health Plan 24 hour emergency number 740 695 3585 or 1 800 624 6961 In extreme emergencies if you are unable to
contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency
room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family
member must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure
that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any
ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would
result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided
by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from
Plan providers
You pay 50 per hospital emergency room visit 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 If the emergency results in an observation
bed the copay is not waived
Emergencies outside the service area
Benefits are available for any medically necessary health service that is immediately required because of injury or
unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided
in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided
by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from
Plan providers
You pay 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the
emergency results in admission to a hospital the emergency care copay is waived If the emergency results in an observation
bed the copay is not waived
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
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
WHAT IS NOT COVERED
Emergency care provided outside the service area if the need for care could have been foreseen before leaving
the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
FILING CLAIMS FOR NON PLAN PROVIDERS
With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt
of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for
the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the
identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you
will receive notice of the decision including the reasons for the denial and the provisions of the contract on which denial
was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed
claims procedure described on page 7
Urgent Care Benefits
What is Urgent Care
Urgent Care means health care services that are appropriately provided for an unforeseen medical condition that would require
medical attention without delay but that does not pose a threat to the life limb or permanent health of the injured or ill person
Urgent Care within the service area
If you are in an urgent situation please call your primary care doctor If your primary care doctor can not be reached
call the Plan's 24 hour emergency number 740 695 3585 or 800 624 6961
Urgent care services within the Plan's service area are provided by a participating urgent care center only when services
cannot be promptly addressed by the your Primary Care Physician first
Plan pays Reasonable charges for urgent care services to the extent the services would have been covered if received
from Plan providers
You pay 25 per urgent care center visit for urgent care services that are covered benefits of this Plan
Urgent Care outside the service area
If you are in an urgent situation please call your primary care doctor If your primary care doctor can not be reached
call the Plan's 24 hour emergency number 740 695 3585 or 800 624 6961
Urgent care services incurred while temporarily out of the Plan's service area requiring prompt medical attention
may be provided by a physician's office or urgent care center
Plan pays Reasonable charges for urgent care services to the extent the services would have been covered if received
from Plan providers
You pay 25 per urgent care center visit for urgent care services that are covered benefits of this Plan
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
WHAT IS COVERED
Urgent care at a doctor's office or an urgent care center
Ambulance service approved by the Plan
WHAT IS NOT COVERED
Urgent care provided outside the service area if the need for care could have been foreseen before leaving the service area
Non urgent non emergency care
Maintenance therapy for chronic or continuing conditions
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Preventive care such as routine physical examinations
Follow up care after emergency treatment or urgent care treatment that is not coordinated by your primary care physician
Elective or planned care
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
Mental Conditions For services contact our Behavioral Health Administrator at 1 800 782 2052
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 5 copay
for each covered visit all charges thereafter One individual outpatient visit can be exchanged for two group sessions up to a
maximum of 40 group visits per year
Inpatient Care
Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
WHAT IS NOT COVERED
Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement
through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term
psychiatric condition
Treatment that is not pre authorized by the Plan or its Behavioral Health Administrator
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 All necessary visits to Plan providers for treatment you pay a 5.00 copay for each covered visit
all charges thereafter
Inpatient Care All necessary days for substance abuse rehabilitation intermediate care programs per benefit year in an
alcohol detoxification or rehabilitation center approved by the Plan you pay nothing
WHAT IS NOT COVERED
Treatment that is not pre authorized by the Plan or its Behavioral Health Administrator
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
Prescription Drug Benefits
WHAT IS COVERED
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day
supply You pay 5 copay per prescription unit or refill for generic drugs You pay 10 copay per prescription unit or refill for
brand name drugs If a prescription order is brand specific when a generic equivalent exists or the prescription order allows for
generic substitution and you elect brand you pay the price difference between the generic and brand name as well as the
10 copay per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Nonformulary drugs will
be covered when prescribed by Plan doctors The Health Plan maintains an open formulary with certain restrictions across
several therapeutic classes In these classes the preferred products will be a covered benefit when dispensed at participating
pharmacies Drugs not listed are not covered without written medical statements of necessity Statements of medical necessity
are subject to review by the Medical Director and when necessary the Pharmacy and Therapeutics Committee
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive devices are covered under Medical and Surgical Benefits
Insulin
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin glucose test tablets and test tape Benedict's solution or equivalent and acetone
test tablets
Intravenous fluids and medication for home use some injectable drugs such as Depo Provera are covered under Medical
and Surgical Benefits provided under home health services at no cost
Limited benefits
Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
WHAT IS NOT COVERED
Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medications including nicotine patches
Drugs for weight control unless medically necessary
Infertility drugs
Other Benefits
Dental Care Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace
sound natural teeth The need for these services must result form an accidental injury You pay nothing
WHAT IS NOT COVERED
Other dental services not shown as covered
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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THE HEALTH PLAN HMO 2000
Section 5 Benefits continued
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB deductible out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedures
Medicare Choice product This Plan offers Medicare recipients the opportunity to enroll in its Medicare Choice product
The Plan's service area for Medicare Choice is different then its FEHB program service area You must have Medicare part
A B to enroll in the Medicare Choice product For more information about the Medicare Choice product please contact
us at 740 699 6100 or 800 624 6961
Vision One eyecare program The Plan is pleased to offer its FEHB members savings on your eyecare needs frames lenses
contacts and exams Operated in conjunction with Cole Vision you may now obtain substantial savings on a wide range of vision
services at any of the 1600 participating Sears JC Penny Montgomery Wards or Pearle Vision Express Departments nationwide
To take advantage of these savings simply show your Health Plan ID card at the above participating eyecare centers Your
savings are applied directly to your purchase There is no paperwork to fill out or claim forms to submit
Benefits on this page are not part of the FEHB contract 17
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THE HEALTH PLAN HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover
it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered
if the fetus were carried to term
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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THE HEALTH PLAN HMO 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 re enroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan offered
by this Plan see page 17
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage 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 Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries 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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THE HEALTH PLAN HMO 2000
Section 7 Limitations Rules that affect your benefits continued
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 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 We do not cover services and supplies that a local State or Federal Government agency directly
Government or indirectly pays for
Agencies
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THE HEALTH PLAN HMO 2000
Section 8 FEHB FACTS
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right
to information to information about your health plan its networks providers and facilities You can also find out about
about your care management which includes medical practice guidelines disease management programs and how
HMO 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 740 695 3585 or write to The Health Plan 52160
National Road East St Clairsville OH 43950 You may also contact us by fax at 740 695 5297
or visit our website at www healthplan org
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information Employees Health Benefits Plans brochures for other plans and other materials you need to make
about enrolling an informed decision about
in the FEHB
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 The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums Annuitants premiums begin January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled
when I 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 unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorizes coverage for Under certain circumstances you may also get coverage
family and me 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 21
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THE HEALTH PLAN HMO 2000
Section 8 FEHB FACTS continued
Are my medical We will keep your medical and claims information confidential Only the following will have access to it
and claims
records OPM this Plan and subcontractors when they administer this contract
confidential This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form
cards 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 We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens You will receive an additional 31 days of coverage for no additional premium when
if my 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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices
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THE HEALTH PLAN HMO 2000
Section 8 FEHB FACTS continued
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect
TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 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 If you leave Federal service your employing office will notify you of your right to enroll under TCC
in 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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THE HEALTH PLAN HMO 2000
Section 8 FEHB FACTS continued
How can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
coverage 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 indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of
Plan 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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THE HEALTH PLAN HMO 2000
Inspector General Advisory
Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy
or hospital has charged you for services you did not receive billed you twice for the same service
or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 740 695 3585 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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THE HEALTH PLAN HMO 2000
Notes
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THE HEALTH PLAN HMO 2000
Notes
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THE HEALTH PLAN HMO 2000
Notes
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Summary of Benefits for The Health Plan HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital physician care room and board general
nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing .11
Extended care All necessary services for up to 120 days per calendar year you pay
25 per day .11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to
30 days of inpatient care per year You pay nothing .15
Substance abuse All necessary days for substance abuse programs per year
You pay nothing .15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including
well baby care periodic check ups and routine immunizations laboratory
tests and X rays complete maternity care You pay a 10 copay per office
visit you pay 10 for initial maternity visit and remaining copays are waived
for maternity care you pay nothing for house call by a doctor .9,10,11
Home health care All necessary visits by nurses You pay nothing 9,10,11
Mental conditions Up to 20 outpatient visits per year You pay a 5 copay per visit .15
Substance abuse All necessary outpatient visits per year You pay a 5 copay per visit .15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each
emergency room visit and any charges for services that are not
covered by this Plan .12,13
Urgent care Reasonable charges for services and supplies required because of an urgent situation You pay a 25 copay to the urgent care facility for each urgent care
visit and any charges for services that are not covered by this Plan .13,14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per generic 10 per brand name prescription
unit or refill .16
Dental care Accidental injury benefit You pay nothing .16
Vision care No current benefit
Out of pocket Copayments are required for a few benefits however after your
maximum out of pocket expenses reach a maximum of 1,500 per Self Only or 3,000 per Self and Family enrollment per calendar year covered
benefits will be provided at 100 This copay maximum does not
include costs of prescription drugs .5
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2000 Rate Information for
The Health Plan of the Upper Ohio Valley Inc
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 U41 68.10 22.70 147.55 49.18 80.59 10.21 80.59 10.21
Self and Family U42 170.17 56.72 368.70 122.90 201.36 25.53 201.02 25.87
30 32