Pages 1--29 from 00brchr

For changes in benefits see Page 4

Serving West Central Wisconsin
Enrollment in this Plan is limited see page 5 for requirements

Enrollment Code
VH1 Self Only
VH2 Self and Family

Visit the OPM website at http www opm gov insure
RI 73 606 1
1 Page 2 3
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations .4
Section 2 How we change for 2000 .4
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 16
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18 19
Section 8 FEHB Facts 20 23
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits Inside Back Cover
Rates Back Cover 2
2 Page 3 4
Introduction
Valley Health Plan Inc 2270 EastRidge Center Eau Claire WI 54701
This brochure describes the benefits you can receive from Valley Health Plan Inc under its contract CS 2669 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 Valley Health Plan Inc as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

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

We have not re written the Benefits section of this brochure You will find new benefits language next year
How to use this 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 3
3 Page 4 5
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 changes To keep your premium as low as possible OPM has set a minimum copayment of 10 for certain services Please see the Summary of Benefits inside the back cover

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 premium will increase by 5.2 for Self Only or 5.6 for Self and Family 4
4 Page 5 6
Section 3 How to get benefits
What is this Plan's To enroll with us you must live in our service area This is where our providers practice Our
service area service area is The Wisconsin counties of Barron Buffalo Chippewa Dunn Eau Claire

Jackson Pepin Pierce Polk Rusk St Croix Trempealeau and Washburn
plus the zip codes of the following counties Clark County 54420 54436
54437 54446 54456 54460 54493 54498 54746 54771 and Taylor County
54433 54434 54439 54447

Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care We will not pay for any other
health care services

If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements
with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office

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

Your out of pocket expenses for benefits covered under this Plan are limited to the stated
copayments which are required for a few benefits

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 claims You normally won't have to submit claims to us unless you receive emergency services from a 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 Valley Health Plan is a group model HMO providing pre paid health care Services are provided
health care by over 300 physicians in 35 different specialties and subspecialties including physicians at Midelfort Clinic Mayo Health System Eau Claire's largest multi specialty group medical

practice Our clinics are located throughout a 15 county service area Families must choose to
receive their care from one of four options Midelfort Option Red Cedar Option Cumberland
Option or Indianhead Option All family members must belong to the same option and are
encouraged to choose a primary care physician from within their chosen option Each family
member may have a different primary care physician within their chosen option Primary care
physicians are those with a specialty in Internal Medicine Pediatrics and Family Practice

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 to Talk to your Plan physician If you need to be hospitalized your primary care physician or
go into the hospital specialist will make the necessary hospital arrangements and supervise your care 5
5 Page 6 7
Section 3 How to get benefits continued
What do I do if I'm in First call our Member Service Department at 715 836 1254 If you are new to the FEHB
the hospital when I Program we will arrange for you to receive care If you are currently in the FEBH 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 care Referrals to a participating provider of the Plan for specialty care do not require prior written authorization from Valley Health Plan A women may see her plan gynecologist for her annual
routine exam without a referral Prior written authorization from the Plan is required when
receiving care through providers not affiliated with Valley Health Plan except in the case of an
emergency

If you need to see a Plan 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
Plan specialist without a referral

If you need to see a specialist outside of our network because of a chronic complex or serious
medical condition and our providers are not able to provide the care you need your primary
care physician or Plan specialist will submit a request for prior written authorization to Valley
Health Plan It is your responsibility to make sure the prior written authorization referral is
approved before receiving services In some cases Valley Health Plan may grant a standing

referral for up to one year if the condition warrants

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

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 Plan receive services from your current specialist until we can make arrangements for you to see
someone else

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

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 referring you to a non Plan specialist Before giving
medical services approval we consider if the service is medically necessary and if it follows generally accepted medical practice It is your responsibility to make sure the referral is authorized before receiving

services 6
6 Page 7 8
Section 3 How to get benefits continued
How do you decide if a The following describes this Plan's criteria for determining when a medical treatment or
service is experimental procedure drug device or biological product is experimental or investigational We consider
or investigational several factors when determining whether a drug or device is experimental investigational They are

1 Current medical literature
2 Recommendation of our Medical Director Pharmacy Therapeutic Committee and
3 Where applicable approval by the appropriate government regulatory body to commercially
market the treatment service or supply

A request for an advance determination may be submitted in writing to our Provider Member
Service Departments Where we give prior written approval for a drug or device benefits will be
paid if the member's coverage is in force and if the approval has not expired at the time such drug

or device is provided

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious Call us at 715 836 1254 and we will expedite our review
or life threatening condition
and you haven't responded
to my request for service

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will
my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious OPM's health benefits Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifeor
life threatening threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible 7
7 Page 8 9
Section 4 What to do if we deny your claim or request for service continued
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our 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 OPM Your request must be complete or OPM will return it to you You must send the following 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 request Those who have a legal right to file a disputed claim with OPM are 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

Send your request for review to Office of Personnel Management Office of Insurance Programs
Contract Division IV 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

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 8
8 Page 9 10
Section 5 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 member
copayment for office visits laboratory tests and x rays Within the service area house calls will
be provided if in the judgment of the Plan doctor such care is necessary and appropriate You pay
a 20 copayment for a doctor's house call and You pay a 10 member copayment for home visits
by nurses and home health aides

The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as ordered by your VHP physician
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to
48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will
be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care
of the newborn child during the covered portion of the mother's hospital confinement for
maternity will be covered under either a Self Only or Self and Family enrollment other care
of an infant who requires definitive treatment will be covered only if the infant is covered
under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney liver kidney pancreas heart lung lung parathyroid and musculoskeletal transplants allogenec 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 when the
recipient is covered by this Plan

Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
9 Page 10 11
Section 5 Medical and Surgical Benefits continued
What is covered cont Surgical treatment of morbid obesity
Chiropractic services
Surgical removal of impacted wisdom teeth
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for
continuing appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers

Durable medical equipment such as wheel chairs and hospital beds are covered Orthopedic devices such as braces foot orthotics Prosthetic devices such as artificial limbs external
breast prothesis and surgical bras and lenses following cataract removal Diabetic supplies
including insulin syringes needles glucose test tablets and test tape Benedict's solution or
equivalent and acetone test tablets and disposable needles and syringes used to administer
covered injectables are covered You pay 20 per purchase or rental out of pocket expense
will not exceed 500 annually per participant

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 covered including any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the member's appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her
attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an
inpatient or outpatient basis for up to two months per condition if significant improvement can be
expected within two months you pay a 10 member copayment for each outpatient therapy visit
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 nothing The following types of
artificial inseminations are covered Intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay nothing cost of donor sperm is not covered
Other assisted reproductive technology ART procedures such as in vitro fertilization and
embryo transfer are not covered Prescription drugs for the treatment of infertility are not covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
10 Page 11 12
Section 5 Medical and Surgical Benefits continued
Limited benefits cont Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided you pay nothing

In hospital administration of blood and blood products including blood processing are covered

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Contraceptive devices except diaphragms and IUD's

Section 5 Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for 120 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor approved by the Plan and in lieu of hospitalization
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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
11 Page 12 13
Section 5 Hospital Extended Care Benefits continued
What is covered
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor up to

300 per occurrence then 20 member copayment Air ambulance is paid in full up to 1000 per
occurrence then 20 member copayment

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which

hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition

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

See page 14 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care

Section 5 Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency 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 If you are in an emergency situation please call your primary care doctor In extreme
service area 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 should notify the Plan within 48 hours It is your responsibility to ensure that the
Plan has been timely notified

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

Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
12 Page 13 14
Section 5 Emergency Benefits continued
Emergencies within
the service area cont

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

You pay 25 copayment per visit for emergency room services which are covered benefits of this Plan If
the emergency results in admission to a hospital the emergency room copay is waived

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

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

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

You pay 25 copayment per hospital emergency room visit or 25 per urgent care center visit for
emergency services that are covered benefits of this Plan If the emergency results in admission to
a hospital the emergency room copay is waived

What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services Ambulance service approved by the Plan

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

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

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

Plan along with an explanation of the services and the identification information from your ID
card Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's
decision you may request reconsideration in accordance with the disputed claims procedure
described on page 7

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
13 Page 14 15
Section 5 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 nothing for the first 20 visits all charges thereafter

Dependent student One clinical assessment from a non Plan provider for a dependent student living outside the Plan
outpatient care Service Area but within the State of Wisconsin If recommended up to five outpatient visits from
a non Plan provider will be covered Additional visits must receive prior Plan approval Each
visit applies toward outpatient maximum

Transitional care You pay nothing for all charges up to 2,700 per person per calendar year all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year in a facility or program approved by the Plan
you pay nothing for the first 30 days all charges thereafter

Mental conditions
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 Up to 20 outpatient visits to Plan doctors for treatment each calendar year you pay nothing for
the first 20 visits all charges thereafter

Dependent student Combined with Dependent Student Outpatient Care provided under Mental Conditions
outpatient care

Transitional Care Combined with Transitional Care provided under Mental Conditions
Inpatient care Up to 30 days each calendar year in a substance abuse rehabilitation intermediate care program
in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing all
charges thereafter

What is not covered Treatment that is not authorized by a Plan doctor except for dependent student outpatient care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
14 Page 15 16
Section 5 Prescription Drug Benefit
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply except that contraceptive pills or other maintenance drugs
included on the maintenance drug list may be dispensed for a three month supply When appropriate
generic drugs will be dispensed You pay an 8 copayment for brand name drugs and a 4
copayment for generic name drugs per prescription unit or refill Drugs are prescribed by Plan
doctors and dispensed in accordance with the Plan's drug formulary Valley Health Plan's Drug
Formulary consists of an established list of Federal Drug Administration FDA approved drugs
that are reviewed by the VHP Pharmacy Committee and are considered to be medically indicated
and cost effective VHP physicians use this drug formulary as their guide in prescribing drugs
The formulary is defined by our third party administer for prescription drugs and the Pharmacy
Committee Non formulary drugs will also be supplied when prescribed by a Plan or referral
doctor subject to the same copayment

Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive diaphragms
Growth hormones with the Plan's prior approval
Insulin is dispensed in a maximum quantity of a three month supply for one 8 copayment
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets You pay 20 out of pocket
expenses that will not exceed 500 annually per participant Covered under Medical and
Surgical Benefits see page 10

Disposable needles and syringes needed to inject covered prescribed medication You pay 20 out of pocket expenses that will not exceed 500 annually per participant Covered
under Medical and Surgical Benefits see page 10

Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered in full under Medical and Surgical Benefits with prior authorization from
the Plan

Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay an 8 copayment for up to the dosage limit and all charges above that

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies 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
Drugs for the treatment of infertility

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
15 Page 16 17
Section 5 Other Benefits
Dental Care
What is covered The following dental services are covered for children under 12 years of age when provided by participating Plan dentists you pay a 10 member copayment for an annual oral exam which

includes
Prophylaxis cleaning
Annual topical application of fluoride
Preventive dental instructions
Bitewing x rays

Accidental injury Restorative services and supplies necessary to promptly repair or replace sound natural
benefit teeth The need for these services must result from an accidental injury occurring while the member is covered under the FEHB Program You pay 20 of the first 500 in

charges nothing thereafter Services must be completed within six months of the date of
injury

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 to provide a written lens prescription for eyeglasses may be

obtained from Plan providers You pay a 10 member copayment

What is not covered Corrective lenses or frames except for the first pair following certain eye surgeries
Eye exercises
Fitting of contact lenses

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
16 Page 17 18
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 procedure

Expanded dental benefits Choose Dentacare 160 for quality coverage convenience and choice

Valuable dental coverage No deductible before benefits begin
No annual dollar maximum No claim forms
No waiting periods No pre existing condition limitations
No pre authorization requirements
Available at low monthly cost Only 12.18 for Self Only coverage
Only 35.56 for Self and Family coverage Billed directly to you on a quarterly basis

100 percent coverage for preventive and diagnostic care 100 for regular exams
100 for regular cleanings 100 for x rays

60 percent coverage for Restorative Services
Endonics Periodontics
Prosthodontics Oral Surgery

Orthodonics covered at 50 up to a lifetime maximum per person of 1,250 for dependents only through age 19 or age 23 if 50 support and full time student
Professional quality care at convenient locations Over 70 professional dental centers
Locations throughout Wisconsin Select the center most convenient for your family
One center services you and all eligible family members Evening and Saturday hours at many centers
Each family member chooses own dentist at selected center

For more information Call our customer service department today 1 888 223 9575 toll free in Wisconsin

Benefits on this page are not part of the FEHB contract 17
17 Page 18 19
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 SSA at 1 800 638 6833 18
18 Page 19 20
Section 7 Limitations Rules that affect your benefits continued
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

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

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

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

Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
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
responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency
Agencies directly or indirectly pays for 19
19 Page 20 21
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 715 836 1254 or write to Valley Health Plan
P O Box 3128 Eau Claire WI 54702 3128 You may also contact us by fax at 715 836 1298

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

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 effective coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1

What happens when 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 coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing
family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self
and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan 20
20 Page 21 22
Section 8 FEHB Facts continued
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 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 Information Information Information Information for for for for for new new new new new members members members members 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

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

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

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

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

What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact

your ex spouse's employing or retirement office to get more information about your coverage
choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You
may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI 79
27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office 21
21 Page 22 23
Section 8 FEHB Facts continued
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 TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline

How can I convert 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 22
22 Page 23 24
Section 8 FEHB Facts continued
How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
of Group Health that indicates how long you have been enrolled with us You can use this certificate when getting
Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or

exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

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 715 836 1254 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
23 Page 24 25
Summary of Benefits for Valley Health Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the definitions limitations and
exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to
enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear
on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or
day limit Includes in hospital 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 120 days per calendar year
You pay nothing 11

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days
of inpatient care per year You pay nothing 14

Substance Abuse Up to 30 days per year in a substance abuse treatment program
You pay nothing 14

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including

well baby care periodic check ups and routine immunizations laboratory
tests and X rays complete maternity care You pay a 10 copay per
office visit 20 per house call by a doctor 9 10

Home Health Care All necessary visits by nurses and health aides
You pay a 10 copay per visit 9

Short term rehab All necessary outpatient physical speeach and occupational therapy visits
therapy You pay a 10 copay per visit 10

Mental Conditions Up to 20 outpatient visits per calendar year You pay nothing 14
Substance Abuse Up to 20 outpatient visits per calendar year You pay nothing 14

Emergency care Reasonable charges for services and supplies required because of a medical emergency 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 13

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 8 copay for brand name drugs and a 4 copay for generic

name drugs per prescription unit or refill 15
Dental care Accidental injury benefit You pay 20 of the first 500 in charges Preventive dental care for children under 12 You pay a 10 copay 16

Vision care One refraction annually You pay a 10 copay 16
Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few

benefits 5 24
24 Page 25 26
2000 Rate Information for
Valley 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 Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

Western Wisconsin
Self Only VH1 78.83 37.64 170.80 81.55 93.06 23.41 93.26 23.21
Self and Family VH2 175.97 122.18 381.27 264.72 207.74 90.41 201.02 97.13 25
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