Serving Utica Rome New York area
Enrollment in this Plan is limited See page 10 for requirements
Enrollment Code SH1 Self Only
SH2 Self and Family
Visit the OPM web site at http www opm gov insure and
Visit this Plan's web site at http www univerahealthcare org
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance
RI 73 560
1
1
Page 2
3
PHP Mohawk Valley Region 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
8 Section 4 What to do if we deny your claim or request for service
Section 5 Benefits 1
Section 6 General exclusions Things we don't cover 22
Section 7 Limitations Rules that affect your benefits 23
Section 8 FEHB facts 30
Inspector General Advisory Stop Healthcare Fraud 31
Summary of benefits 33
Premiums
2
2
Page 3
4
PHP Mohawk Valley Region 2000
Introduction
Health Services Medical Corporation of CNY Inc
d b a PHP Mohawk Valley Region
8278 Willett Parkway
Baldwinsville NY 13027
This brochure describes the benefits you can receive from PHP Mohawk Valley Region a Univera program under its
contract CS 2623 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 PHP Mohawk Valley Region 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
1
3
3
Page 4
5
PHP Mohawk Valley Region 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
2
4
4
Page 5
6
PHP Mohawk Valley Region 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
Section 2 How we change for 2000
Program wide To keep your premiums as low as possible OPM has set a minimum copay of 10 for all primary
changes care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request
you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend
your record you may add a brief statement to it If they do not provide you your records call us
and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer
3
5
5
Page 6
7
PHP Mohawk Valley Region 2000
Changes to this Plan Your share of the non postal premium will increase by 15 7 for Self Only and 28.8 for Self and Family
Limited benefits under Medical and Surgical Benefits covers medically necessary acupuncture
services or massage therapy services up to 10 visits per contract year You pay a 20 copay per visit
Coverage for diabetic supplies and equipment is now covered under Medical and Surgical
Benefits subject to a 10 copay per 30 day supply
Under Mental Conditions Substance Abuse Benefits there is no dollar limit for outpatient
psychiatric facility care
Section 3 How to get benefits
What is this Plan's service area
To enroll with us you must live or work in our service area This is where our providers practice Our service area is
The New York counties of Herkimer Oneida and the following zip codes in Madison County
13310 Bouckville 13408 Morrisville
13314 Brookfield 13409 Munnsville
13052 DeRuyter 13418 North Brookfield
13332 Earlville 13421 Oneida
13334 Eaton 13133 Perryville
13061 Erieville 13134 Peterboro
13072 Georgetown 13432 Poolville
13346 Hamilton 13434 Pratts Hollow
13355 Hubbardsville 13151 Sheds
13085 Lebanon 13465 Solsville
13364 Leonardsville 13163 Wampsville
13402 Madison 13484 West Eaton
Ordinarily you must get your care from providers who contract with us The Plan provides for emergency and urgent care
services to members traveling outside the service area The services do not include routine and specialty care and is limited to
areas where there is a participating health maintenance organization Members are encouraged to arrange for the reciprocal
services through their PHP Mohawk Valley Region doctors prior to obtaining the services
4
6
6
Page 7
8
PHP Mohawk Valley Region 2000
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 500 in copayments or coinsurance for one family member or 1,500 per family 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 dental services and
office visits 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 my PHP Mohawk Valley Region is a network model HMO that has been serving the Mohawk Valley region
health care since 1987 Members receive health care from the Slocum Dickson Medical Group located at 1729 Burrstone Road New Hartford NY the Central New York Medical Systems Network and from the
Independent Providers Network The primary care physician belongs to one or more physician
networks Your primary care physician will refer you to physician within his or her network if specialty
care is needed and the services are available within the network
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
need to go into the will make the necessary hospital arrangements and supervise your care
hospital
5
7
7
Page 8
9
PHP Mohawk Valley Region 2000
What do I do if First call our customer service department at 315 638 0398 or 800 223 4780 If you are new to the
I'm in the hospital FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and
when I join this are switching to us your former plan will pay for the hospital stay until
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 Except in a medical emergency or when a primary care doctor has designated another doctor to see his
specialty care or her patients you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services Other exceptions where a member may self refer to a specialist within
their primary care doctor's network include
Woman may self refer for routine and acute gynecological and maternity services Members may self refer for one routine eye exam per contract year
Members may obtain care for outpatient mental health and chemical dependency services by contacting their primary care doctor or calling the Plan's triage hotline at 315 638 7060 or 1 888
638 7060 for assistance in obtaining an appointment
Referral to a participating specialist is given at the primary care doctor's discretion if non Plan
specialists or consultants are required the primary care doctor will make a request to the Plan for
determination
When you receive a referral from your primary care doctor you must return to the primary care doctor
after the consultation unless your doctor authorizes additional visits All follow up care must be
provided or authorized by the primary care doctor Do not go to the specialist for a second visit unless
your primary care doctor has arranged for and the Plan has issued an authorization for the referral in
advance If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered
services until the Plan can arrange with you for you to be seen by another participating doctor
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 The primary care doctor seeks approval from the
Corporate Medical Director or his her designee for a standing referral to the specialist
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
specialist when us 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
6
8
8
Page 9
10
PHP Mohawk Valley Region 2000
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue
have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy
provider leaves you may 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 medical recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows generally accepted medical practice
How do you The Plan's Corporate Medical Director makes experimental investigational determinations on
decide if a service procedures treatments drugs and devices The director's determinations are made by considering the
is experimental or member's medical history and current status current standing of the procedure protocol with the Food
investigational and Drug Administration FDA and HCFA review of the provider's protocol review of current research literature such as Hayes Teminex and comments from outside consultants
Plan providers will follow generally accepted medical practice in prescribing any course of treatment
Before you enroll in this Plan you should determine whether you will be able to accept treatment or
procedures that may be recommended by Plan providers
7
9
9
Page 10
11
PHP Mohawk Valley Region 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 a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
What if I have a Call us at 315 638 0398 or 800 223 4780 and we will expedite our review
serious or lifethreatening
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 request for service
denied my request for we will inform OPM so that they can give your claim expedited treatment too Alternatively you
care and my can call OPM's health benefits Contracts Division IV at 202 606 0737 between 8 00 a m and
condition is serious or 5 00 p m Serious or life threatening conditions are ones that may cause permanent loss of bodily
life threatening 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
limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
8
10
10
Page 11
12
PHP Mohawk Valley Region 2000
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request
What address should Send your request for review to Office of Personnel Management Office of Insurance
I send my disputed Programs Contracts Division IV P O Box 436 Washington D C 20044
claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our
upholds the Plan's decision your only recourse is to sue
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
9
11
11
Page 12
13
PHP Mohawk Valley Region 2000
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record
10
12
12
Page 13
14
PHP Mohawk Valley Region 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered
A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This
includes all necessary office visits you pay a 10 office visit copay but no additional copay for laboratory tests 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
nothing for home visits by nurses and health aides
The following services are included
Preventive care including well baby care periodic check ups and hearing exams up to age 19 You pay nothing
Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women 50 through 64 one mammogram every year and for women age
65 and above one mammogram every two years In addition to routine screening mammogram are covered when prescribed by
the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters for all ages
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is
terminated during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the
newborn child during the covered portion of the mother's hospital confinement for maternity will be covered under either a Self
Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is
covered under a Self and Family enrollment
Diabetic supplies 30 day supply and equipment including but not limited to insulin syringes for injecting insulin blood glucose tablets and tapes urine testing strips blood glucose monitors insulin pumps and insulin infusion devices
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing you pay a 10 copay per visit treatment and materials such as allergy serum you pay nothing
The insertion of internal prosthetic devices such as pacemakers and artificial joints
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
13
13
Page 14
15
PHP Mohawk Valley Region 2000
Cornea heart heart lung kidney liver lung pancreas kidney 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 Related medical and hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as custom made braces
Prosthetic devices such as artificial limbs breast prostheses and surgical bras including their replacement and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medication 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
Hearing aids
Implanted time released medications such as Norplant For Norplant you pay a 10 office visit copay There is no charge when the device is implanted during a covered hospitalization There will be no refund on any portion of these copays if the implanted
time released medication is removed before the end of its expected life
A second medical opinion by an appropriate medical specialist including a specialist affiliated with a specialty care center for the treatment of cancer
Limited benefits
Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft
lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not
limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas
surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain
dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has
produced a major effect on the member's appearance and if the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce a symmetrical appearance
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
14
14
Page 15
16
PHP Mohawk Valley Region 2000
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient basis for up to 60 days per contract
year you pay nothing On an outpatient basis coverage is provided for up to 30 visits per contract year if significant improvement can
be expected within this period you pay a 10 copay per visit This benefit includes cardiac rehabilitation following a heart transplant
bypass surgery or a myocardial infarction 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
Diagnosis and treatment of infertility is covered you pay a 10 copay per office visit Artificial insemination is covered
intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay a 10 copay per visit
cost of donor sperm is not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo
transfer are not covered Fertility drugs provided by a Plan doctor during an office visit are covered at 50 Fertility drugs ordered or
obtained by prescription through a pharmacy are covered under the Prescription Drug Benefit
Chiropractic services are covered A referral must be obtained from your primary care doctor before receiving these services You
pay a 10 copay per visit
Massage Therapy Services and Acupuncture Services are covered up to 10 visits combined when referred by your Plan doctor
and pursuant to a treatment plan approved by the Plan You pay a 20 copay per visit
What is not covered
Physical examinations and immunizations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Long term rehabilitative therapy
Blood and blood derivatives not replaced by the member
Hospital Extended Care Benefits
What is covered
Hospital care
The Plan provides a comprehensive range of benefits with no dollar or day limit with no dollar or day limit when you are hospitalized
under the care of a Plan doctor You pay nothing per inpatient admission All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
15
15
Page 16
17
PHP Mohawk Valley Region 2000
Extended care
The Plan provides a comprehensive range of benefits for up to 240 days per admission when full time skilled nursing care is necessary
and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan This
benefit renews after 90 days only if the member has received no hospital care home health care or skilled nursing care within the 90
day interim 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 A maximum of 210 hospice days is
covered
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons
totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the dentist or oral surgeon fees
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 18 for nonmedical substance abuse benefits
What is not covered
Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
16
16
Page 17
18
PHP Mohawk Valley Region 2000
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 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 your
primary care provider within 48 hours or as soon as it is reasonably possible 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
Plan pays
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay
35 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 copay is waived 10 copayment per urgent care center visit upon referral by the primary care doctor
Emergencies outside the service area
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness
Plan pays
Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay
35 per hospital emergency room visits for emergency services that are covered benefits of this Plan If the emergency results in
admission to a hospital the copay is waived 10 copayment per urgent care center visit upon referral by the primary care doctor
What is covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
17
17
Page 18
19
PHP Mohawk Valley Region 2000
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
Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Out of area routine care
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 9
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
18
18
Page 19
20
PHP Mohawk Valley Region 2000
Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered
To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric
conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care
Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copayment for
each covered visit all charges thereafter
Outpatient psychiatric facility
The Plan covers the first 90 days each year for psychiatric day care or night care at an outpatient psychiatric facility that is provided
instead of inpatient services You pay nothing
Inpatient care
Up to 31 days of hospitalization each calendar year you pay nothing for the first 31 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 unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance Abuse
What is covered
This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of
substance abuse including alcoholism and drug addiction the same as for any other illness or condition and to the extent shown
below the services necessary for diagnosis and treatment
Outpatient care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
19
19
Page 20
21
PHP Mohawk Valley Region 2000
Outpatient visits for the diagnosis treatment referral and medical care of substance abuse including alcoholism and drug abuse are
provided in full for up to 60 visits per calendar year You pay a 10 copay per visit
Inpatient care
Mental health care services are provided in conjunction with the inpatient mental conditions benefit shown above
What is not covered
Treatment that is not authorized by a Plan doctor
All charges if the member does not complete the treatment program
Prescription Drug Benefits
What is covered
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply
You pay a 5 copay per prescription unit or refill for generic drugs or a 10 copay for brand name drugs If a name brand drug is
dispensed and an FDA approved equivalent generic drug is available regardless of whether or not the physician indicates that the
pharmacy is to dispense as written you pay a 5 copay plus the difference in cost between the brand name drug and its generic drug
equivalent
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive diaphragms
Non prescription nutritional formulas for the treatment of Phenylketonuria PKU and other related disorders
Disposable needles and syringes needed for injecting covered prescribed medication
Fertility drugs
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
Medically necessary nutritional supplements and enteral formulas with proven effectiveness to treat specific diseases and disorders The cost of these products shall not exceed 2,500 per contract year
Medically necessary modified solid low protein food products or food products containing modified protein used to treat certain inherited amino acid or organ acid metabolism diseases The cost of these products shall not exceed 2,500 per contract year
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
20
20
Page 21
22
PHP Mohawk Valley Region 2000
Limited benefits
Fertility drugs are covered at 50 when obtained during an office visit
Drugs to treat sexual dysfunction are covered Contact the Plan for dose limits
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 except as stated above
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes including Retin A
Drugs to enhance athletic performance
Drugs prescribed for weight loss
Smoking cessation drugs and medication including nicotine patches
Other Benefits
Dental care
Accidental injury benefit
Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered within one year of the
accident unless medical necessity dictates otherwise Injury to teeth and soft tissue as a result of chewing and biting is not considered
an accidental injury The need for these services must result from an accidental injury You pay nothing
What is not covered
Other dental services not shown as covered
Vision care
What is covered
In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions
which include the written lens prescription for eyeglasses may be obtained from Plan providers You pay a 10 copay for each visit
except there is no copay for children up to age 19
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19
21
21
Page 22
23
PHP Mohawk Valley Region 2000
What is not covered
Corrective lenses or frames including the fitting of the lenses
Eye exercises
20
22
22
Page 23
24
PHP Mohawk Valley Region 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedures
Health education classes Your primary care physician may refer you to educational programs on preventive care childbirth nutrition and disease intervention
Educational programs are covered when authorized by your primary care physician Charges may apply to classroom materials
Safe Beginnings A members only catalog promoting preventive health care by offering health and safety items such as bike helmets and car seats at
reduced cost
Discount Programs Discounts are available for admission costs to special local events and more
Member Newsletter Quarterly newsletter covering plan news and a wide range of health and lifestyle topics
Mail Order Prescriptions PHP offers convenient mail order service for maintenance prescription refills For more information about Prescriptions By Mail call
PHP Customer Service at 800 223 4780 Monday through Friday between 8 00 a m and 5 30 p m
Benefits on this page are not part of the FEHB contract
21
23
23
Page 24
25
PHP Mohawk Valley Region 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it
unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
22
24
24
Page 25
26
PHP Mohawk Valley Region 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
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 However
control the Plan will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel
23
25
25
Page 26
27
PHP Mohawk Valley Region 2000
When others When you receive money to compensate you for medical or hospital care for injuries or illness that
are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers 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 or
Government indirectly pays for
Agencies
PHP Mohawk Valley Region 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov
lists the specific types of information that we must make
available to you
If you want specific information about us call 315 638 0398 or 800 223 4780 or write to 8278
Willett Parkway Baldwinsville New York 13027 You may also contact us by fax at 315 635
7489 or visit our website at www univerahealthcare org
or email at
service univerahealthcare org
You may also contact us by TTY at 315 638 5485 or 1 800
396 9393
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
enrolling in the make an informed decision about
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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1
25
27
27
Page 28
29
PHP Mohawk Valley Region 2000
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What types of 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 me and or retirement office authorizes coverage for Under certain circumstances you may also get
my family 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
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plan 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
26
28
28
Page 29
30
PHP Mohawk Valley Region 2000
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election
cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan
Pre existing 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 if You will receive an additional 31 days of coverage for no additional premium when
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
spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices
27
29
29
Page 30
31
PHP Mohawk Valley Region 2000
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child
is no longer an eligible family member That office will send you information about enrolling
in TCC You must enroll your child within 60 days after they become eligible for TCC or
receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline
28
30
30
Page 31
32
PHP Mohawk Valley Region 2000
How can I convert You may convert to an individual policy if
to 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
Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health health insurance or other health care coverage You must arrange for the other coverage within
Plan Coverage 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
29
31
31
Page 32
33
PHP Mohawk Valley Region 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 800 323 9343 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
30
32
32
Page 33
34
PHP Mohawk Valley Region 2000
Summary of Benefits for PHP Mohawk Valley Region 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 13 without dollar or day 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
Extended Care All necessary services up to 240 days per admission You pay 14
nothing
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up 14
to 31 days of inpatient care per year You pay nothing
Substance Abuse Detoxification covered under Medical Conditions You pay nothing 14
Outpatient Care Comprehensive range of services such as diagnosis and treatment of 17 illness or injury including specialist's care you pay 10 per office
visit Preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays and complete
maternity care you pay nothing
Home Health Care All necessary visits by nurses and health aides You pay nothing 17
Mental Conditions Up to 20 outpatient visits per year You pay a 10 copay per outpatient 17
visit
Substance Abuse Up to 60 visits per calendar year You pay a 10 copay per visit 18
Emergency care Reasonable charges for services and supplies required because of a 15 medical emergency You pay 35 per emergency room visit or 10
for each urgent care visit and any charges for services that are not
covered by this Plan Copay is waived if admitted through an emergency
room
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy 18 You pay a 5 copay for generic 10 copay for brand name per prescription
unit or refill Mandatory generic brand difference applies
Dental care Accidental injury benefit you pay nothing 19
31
33
33
Page 34
35
PHP Mohawk Valley Region 2000
Benefits Plan pays provides Page
Vision care Routine eye examinations including refractions You pay 10 per office 19 visit
Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are 5 limited to the stated copayments which are required for a few benefits
If you incur 500 individually or 1,500 as a family in copayments
within a calendar year the Plan will waive copayments for the remainder
of the calendar year
32
34
34
Page 35
PHP Mohawk Valley Region 2000
2000 Rate Information for
PHP Mohawk Valley Region
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
Utica area
Self Only SH1 75.98 25.32 164.61 54.87 89.90 11.40 89.90 11.40
Self and Family SH2 175.97 92.61 381.27 200.65 207.74 60.84 201.02 67.56
33 35