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Presbyterian Health Plan 2000
A Health Maintenance Organization

Serving
All counties of New Mexico except for Otero and southern Eddy County

Enrollment code
P21 Self Only
P22 Self and Family

Enrollment in this Plan is limited see page 4 for requirements

Visit the OPM Website at http www opm gov insure
and
this Plan's Website at http www phs org

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE RI 73 563 1
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Presbyterian Health Plan 2000
Table of Contents

Introduction .1
Plain language .1
How to use this brochure .2
Section 1 Health Maintenance Organizations .3
Section 2 How we change for 2000 .3
Section 3 How to get benefits .4 6
Section 4 What to do if we deny your claim or request for service .6 8
Section 5 Benefits .9 16
Section 6 General exclusions Things we don't cover .17
Section 7 Limitations Rules that affect your benefits .17 -18
Section 8 FEHB FACTS .19 22
Inspector General Advisory Stop Healthcare Fraud .23
Summary of benefits .25
Premiums .26

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Presbyterian Health Plan 2000
Introduction

Presbyterian Health Plan
2501 Buena Vista SE
Albuquerque NM 87106
PO Box 27489
Albuquerque NM 87125 7489

This brochure describes the benefits you can receive from Presbyterian Health Plan under its contract CS2627 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 3 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 Presbyterian Health Plan as this Plan throughout this brochure even though in other legal documents you will see a
plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not re written the Benefits section of this brochure You will find new benefits language next year

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Presbyterian Health Plan 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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Presbyterian Health Plan 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 premium 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

Changes to this Plan Your share of the non postal premium will increase by 21.1 for Self Only or 21.1 for Self and Family

The office visit copay has been increased from 5 to 10 per visit See page 9
For obstetrical care the copay maximum increased from 50 to 100 per pregnancy See page 9
The urgent care copay inside the service area has been increased from 5 to 10 per visit See page
12

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Presbyterian Health Plan 2000
Section 3 How to get benefits

What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice
service area Our service area is all counties of New Mexico except for Otero County and southern Eddy County

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 benefits 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 Full time dependent students attending school outside Presbyterian Health Plan's
service area may also receive care at a Student Health Center without a Referral from their Primary
Care Physician Services provided outside of the Student Health Center are limited to medically
necessary services for the initial care or treatment of an Emergency or Urgent Care Situation If you
or a family member move you do not have to wait until Open Season to change plans Contact your
employing or retirement office

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

After you pay 2,000 in copayments or coinsurance for one family member or 4,000 for two or
more family members you do not have to make any further payments for certain services for the rest
of the year for total copayment charges for services provided or arranged by the plan This is called a
catastrophic limit However copayments or coinsurance for your prescription drugs dental services
and vision 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 submit You normally won't have to submit claims to us unless you receive emergency services from a
claims provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year

you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides my Presbyterian Health Plan operates a mixed model health plan This means that doctors provide care
health care either in contracted medical centers or in their own offices PHP utilizes Physician Directed Teams This allows primary care medical groups to choose their own network of specialists and hospitals in

order to provide all the services required to care for patients

Receiving care from Participating Providers For a PHP member there is never any barrier to
receiving care Services are accessible through convenient fully staffed medical centers with
extended hours or through participating doctors who practice out of their own offices In addition
emergency care is available 24 hours a day 365 days a year

How to use PHP Each PHP member selects a participating individual practice primary care
physician from the provider directory who is closest to home or work It is important to remember
that the benefits and services under the PHP plan are available only through participating doctors
specialists or pharmacies or at hospitals when under the care of a participating provider Locations
and telephone numbers of the participating doctors are listed in the provider directory or can be
obtained by calling the Member Service Department 505 923 5678 or 1 800 356 2219 By selecting
a PCP who belongs to a Physician Directed Team members are selecting their corresponding network
4 of specialists hospitals and other providers to serve their healthcare needs 6
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Presbyterian Health Plan 2000
Section 3 How to get benefits continued

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

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

What do I do if I'm in First call our customer service department at 505 923 5678 or 800 356 2219 If you are new to the
the hospital when I FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program
join this Plan and are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or

The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get specialty Your primary care physician will arrange your referral to a specialist
care Except in a medical emergency or when a primary care doctor has designated another doctor to see

his or her patients or for gynecological or maternity care you must receive a referral from your
primary care doctor before seeing any other doctor or obtaining specialty services 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 arrangements for appropriate referrals
The Plan has a paperless referral process and the physician simply provides the referral to the
Presbyterian Health Plan

All follow up care must be provided or arranged by the primary care doctor Referrals from the
primary care doctor will include the expiration date of the referral and the number of visits If the
consultant suggests additional services or visits you must first check with your primary care doctor
Do not go to the specialist unless your primary care doctor has provided the referral into the
Presbyterian Health Plan system

If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan Presbyterian Health Plan will review the need for continuing care
on an annual basis Remember by selecting a PCPwho belongs to a Physician Directed Team
members are selecting their corresponding network of specialists hospitals and other providers to
serve their healthcare needs

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a
seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

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

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Presbyterian Health Plan 2000
Section 3 How to get benefits continued

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

and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice

How do you decide if Presbyterian Health Plan evaluates any new procedures drug therapies treatments devices etc to
a service is determine if they are experimental investigational in nature This evaluation includes review of
experimental or current literature published in peer review journals and appropriate information from governmental
investigational regulatory bodies such as the FDA We also utilize reliable evidence consensus of opinion in the medical community to determine if the procedure drug therapies treatments devices etc is

contraindicated for the particular indication which it has been prescribed Please contact the Plan for
a more detailed explanation of this evaluation process

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 or
denial request for service

What if I have a Call us 505 923 5678 and we will expedite our review
serious or life
threatening condition
and you haven't
responded to my
request for service 8
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Presbyterian Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my request for OPM so that they can give your claim expedited treatment too Alternately you can call OPM's
care and my condition health benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or lifethreatening
is serious or life conditions are ones that may cause permanent loss of bodily functions or death if they are
threatening 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

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

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

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

Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and

3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the
review request

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

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

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies

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Presbyterian Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

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

of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the
court record

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Presbyterian Health Plan 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 Xrays Within the service area house calls will be
provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a 10
copay for a doctor s house call

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including wellbaby care and periodic checkups physicals for school sports or
camp if done in conjunction with periodic check up
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 and above one mammogram every year In addition
to routine screening mammograms are covered when prescribed by the doctor as medically
necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and Xrays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor members pay the 10 office visit copay up to a maximum of
100 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
Voluntary family planning services for sterilization you pay 50 of charges for Norplant
Contraceptive Device insertion 50 copay removal included in 10 office visit copay
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
you pay nothing for the allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver and lung single or double transplants pancreas and
pancreas islet cell transfusion allogeneic donor bone marrow transplants autologous bone
marrow transplants autologous stem cell and peripheral stem cell support for acute lymphocytic
or nonlymphocytic leukemia advanced Hodgkin's lymphoma advanced nonHodgkin'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 Medical Director Related medical and hospital expenses of
the donor are covered when the recipient is covered by this Plan In addition limited travel
benefits are available for the transplant recipient and one companion Covered expenses
include transportation costs for out of state travel lodging and meal expenses for both in
state and out of state travel up to 150 per day for both the transplant recipient and
companion combined All benefits for transportation lodging and meals are limited to
10,000
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 including intravenous fluids and medications and inhalation
therapy
Surgical treatment of morbid obesity
Sleep Disorder Studies You pay nothing
Orthopedic devices such as braces you pay 20 of charges
Care must be received from or arranged by Plan doctors 9 11
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Presbyterian Health Plan 2000
Section 5 Benefits continued

Medical and Surgical Benefits continued
What is covered Prosthetic devices such as artificial limbs lenses following cataract removal and breast continued prostheses and surgical bras following mastectomies as well as their replacement you pay
20 of charges
Durable Medical Equipment such as wheelchairs and hospital beds you pay 20 of charges
One refraction annually
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need you pay nothing
Blood and blood derivatives without requiring replacement
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical
procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to
treatment of fractures and excision of tumors and cysts All other procedures involving the teeth
or intraoral areas surrounding the teeth are not covered
Temporomandibular joint disorders craniomandibular disorders requiring orthodontic
appliances and treatment crowns bridges and dentures are not covered unless the disorder is
trauma related
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
Shortterm rehabilitative therapy physical speech and occupational is provided on an inpatient
or out patient basis for up to four months per condition if significant improvement can be
expected within four months In patient or out patient rehabilitation services may be extended
for a period not to exceed two additional months if significant improvement is expected to
continue You pay a 15 copay per out patient 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
in daily living
Diagnosis and treatment of infertility is covered you pay 50 of charges The following
artificial insemination procedures are covered intracervical insemination ICI and intra uterine
insemination IUI Fertility drugs are covered Cost of donor sperm is not covered Other
assisted reproductive technology ART procedures such as in vitro fertilization and embryo
transfer are not covered
Cardiac rehabilitation is provided in an approved facility for up to 12 sessions with continuous
electrocardiogram ECG monitoring or up to 24 sessions with intermittent ECG monitoring per
calendar year you pay 15 copay per session
Pulmonary rehabilitation is provided in an approved facility for up to 24 sessions per calendar
year you pay 15 copay per session
Acupuncture services are limited to authorized referrals for treatment of chronic pain that is part
of a coordinated plan of care approved by your primary care doctor for up to 20 visits per
condition per calendar year you pay 15 copay per visit
Short term Chiropractic services are covered for acute musculoskeletal conditions related to
subluxation of the spine Maintenance therapy is not a covered benefit you pay 15 copay per
visit

10 Care must be received from or arranged by Plan doctors 12
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Presbyterian Health Plan 2000
Section 5 Benefits continued

Medical and Surgical Benefits continued
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Homemaker services
Long term rehabilitative therapy
Foot orthotics

Hospital Extended Care Benefits
What is covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units blood and blood derivatives

Extended Care The Plan provides a comprehensive range of benefits limited to 60 days per calendar year when fulltime
skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All
necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor

Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
up to 12 months Services include inpatient and outpatient care and family counseling these
services are provided under the direction of a Plan doctor who certifies that the patient is in the
terminal stages of illness with a life expectancy of approximately six months or less

Ambulance service Benefits are provided for ambulance transportation approved by the Plan you pay a 50 copay for
ground transportation and you pay a 100 copay for air transportation

Limited Benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedures the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate

See page 14 for non medical 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 13
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Presbyterian Health Plan 2000
Section 5 Benefits continued

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become

more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if
the service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel

that you are a Plan member so they can notify the Plan You or a family member should notify the
Plan within 48 hours 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 which are covered benefits of this Plan
You pay 25 per hospital emergency room visit or 10 per urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
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

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

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

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

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

You pay 25 per hospital emergency room visit or 15 per urgent care center visit for emergency services
which are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived 12 14
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Presbyterian Health Plan 2000
Section 5 Benefits continued

Emergency 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 you pay a 50 copay for ground transportation and a
100 copay for air transportation

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

Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency care
providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and 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 6

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

Members do not need to go through their primary care physician to access services They must
access the system by contacting PHP Behavioral Health at 1 800 453 4347 or 505 923 5470
The Plan works with your provider for the necessary prior authorizations for all psychiatric
and chemical dependency services

Outpatient Care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay a 10 copay for each covered visit all charges thereafter

Inpatient Care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter

One 1 day of Inpatient Mental Health hospitalization can be traded for two 2 days of partial
hospitalization day treatment as deemed therapeutically necessary

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

Care must be received from or arranged by Plan doctors 13 15
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Presbyterian Health Plan 2000
Section 5 Benefits continued

Mental Conditions Substance Abuse Benefits continued
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness or condition and to the extent shown below the services necessary for
diagnosis and treatment

Outpatient Care Up to 20 outpatient visits per calendar year to Plan providers for treatment you pay a 10 copay for each covered visit all charges thereafter
These substance abuse benefits may be combined with the outpatient mental conditions benefits
shown above provided such treatment is necessary as a mental conditions service and is approved by
the Plan to permit an additional 30 outpatient visits per calendar year with the applicable mental
conditions copayments

Inpatient Care Lifetime maximum of two 30 day substance abuse rehabilitation intermediate care programs in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the
benefit period all charges thereafter

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

Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply whichever is less or one commercially

prepared unit i e one inhaler one vial ophthalmic medication or insulin You pay a 5 copay for
formulary generic drugs and a 15 copay for formulary brand name drugs unless otherwise
specified below

Your plan pharmacist will automatically substitute an FDA approved generic drug when available
for brand name prescriptions If you request the brand name drug in place of the generic you pay
the difference in price between the brand and generic plus the 5 copay

You may purchase maintenance formulary medications through the mail Under the mail order
pharmacy benefit you may purchase a 90 day supply or 300 units whichever is less For each
prescription you pay a 10 copay for formulary generic drugs and a 30 copay for formulary brand
drugs If you request a brand drug that has a generic alternative on the formulary you pay a 10
copay plus the difference in cost between the brand and generic Mail order drugs are available
through Walgreens Healthcare Plus Order forms are available from the Plan's customer service
department

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Nonformulary drugs will be covered when prescribed by a Plan doctor You pay a 15 copay for
non formulary drugs

14 Care must be received from or arranged by Plan doctors 16
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Presbyterian Health Plan 2000
Section 5 Benefits continued

Prescription Drug Benefits continued
What is covered Covered medications and accessories include
continued Drugs for which a prescription is required by law All FDA approved oral and injectable contraceptive drugs and contraceptive devices

Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles glucose test tablets and test tape
Benedict's solution or equivalent and acetone test tablets
Disposable needles and syringes needed to inject covered prescribed medication
Fertility drugs you pay 50 of cost
Injectable drugs Recombinant DNA Purified Biological Products you pay 10 of cost

Drugs used to treat sexual dysfunction are limited Prior authorization must be obtained Contact the
Plan for details

Intravenous fluids and medication for home use you pay 50 of the cost implantable drugs you
pay 50 of the cost and some injectable drugs you pay 10 of the cost are covered under
Medical and Surgical Benefits

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 medication including nicotine patches

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 may be obtained with a
referral from Plan providers You pay a 10 copay per visit

What is not covered Eye exercises
Corrective lenses or frames

Dental Care
What is covered Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury you pay a 10 copay

What is not covered Other dental services not shown as covered

Care must be received from or arranged by Plan doctors 15 17
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Presbyterian Health Plan 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 These benefits are optional 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 or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedures

1 DentalSource Dental Plan Inc is a discount referral dental plan available to Presbyterian Health Plan members enrolled
through the FEHB Program Members select a personal dentist from a list of participating dentists throughout the community
Copayments are paid at the Dental Office at the time services are received

The DentalSource Dental Plan features no deductibles no claim forms no waiting periods no maximums and no pre existing
condition exclusions It is a comprehensive plan including preventive and diagnostic services restoratives dentures oral
surgery endodontists periodontists and orthodontics for adults and children

For more information about enrolling with DentalSource Dental Plan Inc call 505 237 1501 or reference the enclosed
brochure

2 American Health Shield Voluntary Indemnity Dental Plan allows you to seek care from any dentist There are two plans
offered There is now a flat per calendar year deductible for all services excluding orthodontia with a 3 per family maximum
and coinsurance levels apply The deductible for Plan A is 75 and the deductible for Plan B is 50 Preventative services
include regular check ups with no waiting period Basic services include routine cleanings simple extractions oral surgery
fillings and x rays with a six month waiting period Major services include endodontics periodontics crowns dentures and
bridges subject to a 18 month waiting period Orthodontics for insured children under age 19 are covered to a maximum
benefit of 500 Othodontia services are subject to a 24 month waiting period For more information about enrolling with
American Health Shield Voluntary Dental Plan refer to the enclosed brochure or call 1 800 274 4222 or 881 1235

3 ECCA Managed Vision Care is a discount referral vision plan that is automatically available to Presbyterian Health Plan
Members enrolled through the FEHB Program It is available at no additional cost and allows for discounts on Annual Wellness
Exams along with discounts on materials Services are provided by Eye Master and other select providers throughout New
Mexico For additional information and customer service call 1 800 340 0129

16 Benefits on this page are not part of the FEHB Contract 18
18 Page 19 20

Presbyterian Health Plan 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

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

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

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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSAat 1 800 638 6833

Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

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

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

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

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Presbyterian Health Plan 2000
Section 7 Limitations Rules that affect your benefits continued

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

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
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 Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for

If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider
malpractice claim it must go to binding arbitration Contact us about how to begin our binding arbitration process

18 20
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Presbyterian Health Plan 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 find
your HMO out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website

www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 505 923 5678 or write to 2501 Buena Vista SE
Albuquerque NM 87106 or PO Box 27489 Albuquerque NM 87125 7489 You may also contact us
by fax at 505 923 5277 or visit our website at http www phs org

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

What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment

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

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants'premiums begin January 1

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 available unmarried dependent children under age 22 including any foster or step children your employing or
for my family and retirement office authorizes coverage for Under certain circumstances you may also get coverage
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

19 21
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Presbyterian Health Plan 2000
Section 8 FEHB FACTS continued

Are my medical and We will keep your medical and claims information confidential Only the following will have access
claims records to it
confidential OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of

Workers'Compensation Programs OWCP when coordinating benefit 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 cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use

an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Your enrollment ends unless you cancel your enrollment or
Plan ends You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former 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 exspouse's
employing or retirement office to get more information about your coverage choices

20 22
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Presbyterian Health Plan 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 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

21 23
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Presbyterian Health Plan 2000
Section 8 FEHB Facts continued

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

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

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

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

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

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

22 24
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Presbyterian Health Plan 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 505 923 5678 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

23 25
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Presbyterian Health Plan 2000
Notes

24 26
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Presbyterian Health Plan 2000
Summary of Benefits for Presbyterian Health Plan 2000

Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations definitions 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 inhospital 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 11

Extended Care All necessary services for up to 60 days per year You pay nothing 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient
Conditions care per year You pay nothing 13

Substance Each member is entitled to a lifetime maximum of two 30 day substance abuse
Abuse programs You pay nothing 14

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
Care including specialists'care preventive care including wellbaby care periodic checkups and routine immunizations laboratory tests and Xrays complete maternity care You

pay a 10 copay per office visit 10 copay per house call by a doctor 9

Home Health All necessary visits by nurses and health aides You pay nothing 10
Care

Mental Up to 30 outpatient visits per year You pay a 10 copay per visit 13
Conditions

Substance Up to 20 outpatient visits per year You pay a 10 copay per visit 14
Abuse

Emergency Reasonable charges for services and supplies required because of a medical emergency
Care You pay a 25 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan 12

Urgent Care Urgent care services in the service area are covered at a 10 copay out of the service area at a 15 copay 12

Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5
Drugs copay per prescription unit or refill for formulary generic drugs and a 15 copay for both formulary brand and non formulary prescription drugs 14

Dental Care Accidental injury benefit You pay a 10 copay Preventive dental care No current benefit 15

Vision Care One refraction annually You pay a 10 copay per visit 15
Out of pocket Copayments are required for most benefits However copayments will not be required after your out of pocket expenses reach a maximum of 2000.00 per Self Only or
Maximum 4000.00 Self and Family enrollment This copay maximum does not include

25 prescription drugs or dental services 4 27
27 Page 28
Presbyterian Health Plan 2000
2000 Rate Information for
Presbyterian Health Plan

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 Enrollment Code Gov't Your Gov't Your USPS Your USPS Your
Share Share Share Share Share Share Share Share

All NM counties except Otero and S Eddy

Self Only P21 61.80 20.60 133.90 44.63 73.13 9.27 73.13 9.27

Self and Family P22 161.18 53.73 349.23 116.41 190.73 24.18 190.73 24.18

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