page 4 Enrollment in this plan is limited see page 8 for requirements see
Columbus Cleveland Portsmouth area This plan has commendable
Enrollment code accreditation from the NCQA See the
VC1 Self Only 200 Guide for more information on
VC2 Self and Family NCQA
Dayton Springfield Cincinnati Toledo area
Enrollment code
3U1 Self Only
3U2 Self and Family
Visit the OPM websiteat http www opm gov insure
and
Visit this Plan s web page at http www uhc com
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance RI 73 608
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UnitedHealthcare of Ohio Inc 2000
Table of Contents
Introduction 2
Plain language 2
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
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB FACTS 21
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits 25
Premiums back cover
Introduction
UnitedHealthcare of Ohio Inc 9200 Worthington Road Westerville Ohio 43082 8823
This brochure describes the benefits you can receive from UnitedHealthcare Of Ohio Inc HMO under its contract CS2671 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 UnitedHealthcare of Ohio Inc HMO as this Plan throughout this brochure even though in other legal documents you will
see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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UnitedHealthcare of Ohio Inc 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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UnitedHealthcare of Ohio Inc 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 changes 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
You may review and obtain copies of your medical records on request You may ask that a physician
amend a record that is not accurate relevant or complete If the physician does not amend your record
you may add a brief statement to the record
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 For enrollment code VC1 or VC2 your share of the Non Postal premium will increase by 19.8 for Self Only or 18.2 for Self and Family
For enrollment code 2U1 or 3U2 your share of the Non Postal premium will decrease by 5.5
for Self Only or 5.1 for Self and Family
Under Prescription Drug Benefit Drugs are dispensed in accordance with the Plan's drug
formulary See page 16
Under Prescription Drug Benefit The copay increased from 5 to 10 for generic drugs See
page 16
Under Prescription Drug Benefit You pay 15 copay for formulary name brand drugs See
page 16
Under Prescription Drug Benefit You pay 30 copay for non formulary name brand drugs
See page 16
Prescription Drug Benefit For a 90 day supply through Mail Order Prescription Drug you pay
a 20 copay for generic drugs you pay a 30 copay for name brand formulary drugs a 60
copay per for name brand non formulary drugs See page 16
Medical and Surgical Benefit The copay increased from 10 up to 15 for specialty care office
visits See page 15
Hospital Extended Care Benefits A per hospital admission copay is being added You pay
100 per hospital admission See page 12
Under Medical and Surgical Benefits Limited Benefits coverage for cyrosurgery to treat
localized prostate cancer is added See page 11
The plan's address changed for codes VC1 VC2 to 9200 Worthington Road Westerville
Ohio 43082
The plan's fax number changed for codes VC1 VC2 to 614 410 7399
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UnitedHealthcare of Ohio Inc 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
Columbus Cleveland Portsmouth area
Enrollment Code VC1 Self Only VC2 Self and Family
The counties of Adams Ashland Ashtabula Athens Belmont Brown Carroll Columbiana
Coshocton Crawford Cuyahoga Delaware Erie Fairfield Fayette Franklin Gallia Geauga
Guernsey Harrison Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking
Lorain Madison Mahoning Marion Medina Meigs Monroe Morgan Morrow Muskingum
Noble Perry Pickaway Pike Portage Richland Ross Scioto Seneca Stark Summitt Trumbull
Tuscarawas Union Vinton Washington Wayne and Wyandot
Dayton Springfield Cincinnati area
Enrollment code 3U1 Self Only 3U2 Self and Family
The counties of Allen Auglaize Boone Butler Campbell Champaign Clark Clermont Clinton
Darke Grant Greene Hamilton Hardin Highland Kenton Logan Lucas Mercer Miami Montgomery
Preble Shelby Warren and Wood
Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another plan
If your dependents live out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in
other areas If you or a family member move you do not have to wait until Open Season to change
plans Contact your employing or retirement office
How much do I pay for You must share the cost of some services This is called either a copayment a set dollar amount or services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services
After you pay 500 in copayments or coinsurance for Self Only enrollment or 1,000 for Self and
Family enrollment you do not have to make any further payments for
certain services for the rest of the year This is called a catastrophic limit However copayments or
coinsurance for your orthopedic devices prosthetic devices durable medical equipment medical
supplies but not diabetic supplies growth hormones and hospital emergency room copayments 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 provider claims who doesn't contract with us If you file a claim please send us all of the documents for your claim
as soon as possible You must submit claims by December 31 of the year after the year you received
the service Either OPM or we can extend this deadline if you show that circumstances beyond your
control prevented you from filing on time
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UnitedHealthcare of Ohio Inc 2000
Section 3 How to get benefits continued
Who provides my UnitedHealthcare of Ohio Inc is a health maintenance organization We contract individually health care with over 18,000 physicians and 150 hospitals in our service area to provide care to
UnitedHealthcare of Ohio Inc members The long list of UnitedHealthcare of Ohio Inc partici
pating physicians assures that our physicians and health facilities will be conveniently located
You do not need to select a primary care physician and you do not need to get written referral to
see a participating specialist for medical services You must call United Behavorial Health at 1 800
860 1123 to obtain authorization for services to use Mental Conditions Substance Abuse Benefits
Women may see a Plan gynecologist for her routine examinations
The Plan's provider directory list primary care doctors generally family practitioners pediatricians
and internist with their locations and phones numbers and note whether or not the doctor is accepting
new patients Directors are updated on a regular basis and are available at the time of enrollment or
upon calling the Customer Service Department 614 442 0503 or 800 225 7951 for VC1 VC2 or
937 439 89033 or 800 231 3918 for 3U1 3U2 When you enroll in this Plan services except for
emergency benefits are provided through the Plan's delivery system the continued availability and
or participation of any one doctor hospital or participation of any one doctor hospital or other
provider cannot be guaranteed
The Plan will provide benefits for covered services only when the services are medically necessary to
prevent diagnose or treat your illness or condition Reimbursement for prosthetic devices or durable
medical equipment when the item cost more than 100 requires prior authorization
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 hospital will make the necessary hospital arrangements and supervise your care
What do I do if I'm in First call our customer service department at 800 231 2918 for 3U1 3U2 and 800 225 7951 for VC1 the hospital when I join VC2 If you are new to the FEHB Program we will arrange for you to receive care If you are currently
this Plan in the FEHB Program 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 You do not need to have a referral to see a participating specialist If you need the care of a specialist care you may select a specialist from our Provider Directory or call your primary care doctor who will
arrange for you to see a specialist If your current specialist is a Plan participating doctor you may
continue to see that doctor without a written referral
What do I do if I am If your current specialist does not participate with us you must receive treatment from a specialist who seeing a specialist when does Generally we will not pay for you to see a specialist who does not participate with our Plan
I enroll
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UnitedHealthcare of Ohio Inc 2000
Section 3 How to get benefits continued
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive specialist leaves the services from your current specialist until we can make arrangements for you to see someone else
Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or third Plan or this Plan leaves trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Program 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 sending you to a hospital for inpatient care unless it is medical services an emergency If it is an emergency you should contact the plan with in 48 hours of the emergency
admission Follow up emergency care by a provider who does not contract with us must have an
authorization from the Plan Before giving approval we consider if the service is medically necessary
and if it follows generally accepted medical practice
How do you decide if a The UnitedHealthcare of Ohio Inc determines Medical surgical diagnostic psychiatric substance service is experimental abuse or other health care technologies supplies treatments diagnostic procedures drug therapies
or investigational or devices to be experimental or investigational when one of the following applies at the time it makes a determination regarding coverage in a particular case 1 Not approved by the U S Food and Drug
Administration FDA to be lawfully marketed for the proposed use and not identified in the
American Hospital Formulary Service as appropriate for the proposed use 2 Subject to review and
approval by any Institutional Review Board for the proposed use 3 The subject of an ongoing clinical
trial that meets the definition of a Phase 1 2 or 3 Clinical Trial set forth in the FDA regulations
regardless of when the trial is actually subject to FDA oversight 4 Not demonstrated through
prevailing peer reviewed medical literature to be safe and effective for treating or diagnosing the
condition illness or diagnosis for which its use is proposed UnitedHealthcare of Ohio Inc Reserves
the right to make final judgement regarding coverage for Experimental Investigational or Unproven
Services
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UnitedHealthcare of Ohio Inc 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request
must
1 Be in writing
2 Refer to specific brochure wording in 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 OPM to review a denial 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 Call us for codes 3U1 3U2 at 800 231 2918 800 225 7951 for codes VC1 VC2 and we will serious or life expedite our review
threatening condition and you haven't
responded to my request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM at
care and my condition 202 606 0 755 between 8 a m and 5p m Serious or life threatening conditions are ones that may cause is serious or life permanent loss of bodily functions or death if they are not treated as soon as possible
threatening
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we do not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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UnitedHealthcare of Ohio Inc 2000
Section 4 What to do if we deny your claim or request for service continued
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 Programs my disputed claim 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 decision the Plan's denial your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you 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
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UnitedHealthcare of Ohio Inc 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 up to a 10 office visit copay for
primary care doctor family general and pediatrician but no additional copay for laboratory tests and X rays rendered during the same office visit You pay up to a 15 office visit copay for specialist For
laboratory and X ray services provided in the doctor's office without an office visit you pay up to 10 per
visit for primary care doctor and up to 15 copay for specialist Within the service area house calls
will be provided in the judgment of the Plan doctor such care is necessary and appropriate you pay a 10
copay for a primary care doctor's house call and you pay 15 copay for specialist doctor's house call
You pay nothing for home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered at a minimum as follows for women age 35 through age 39 one
mammogram during these five years for women age 40 through 49 one mammogram every one or
two years for women age 50 through 64 one mammogram every year and for women age 65 and
above one mammogram every two years In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures including laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal
care by a Plan doctor copay waived after first prenatal visit 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 sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints For other
internally implanted time release medications you pay a 10 copay There is no charge when the
device is implanted during a covered hospitalization
Cornea heart lung single and double lung kidney pancreas kidney and liver transplants allogeneic
donor bone marrow transplants autologous bone marrow transplants autologous stem cell and
peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma
testicular mediastinal retroperitoneal and ovarian germ cell tumors and solid tumors such
as breast cancer multiple myeloma and epithelial ovarian cancer Related medical and hospital
expenses of the donor are covered when the recipient is covered by the Plan
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when
prescribed by your Plan doctor who will periodically review the program for continuing appropriateness
and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers at no additional cost to you
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
Medical and Surgical Benefits continued
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 Coverage is provided for dental care necessary to release pain in treatment of
temporomandibular joint TMJ pain dysfunction All other procedures involving the teeth or intra oral areas surrounding the teeth are not cover including any dental care involved in the treatment of
temporomandibular joint dysfunction
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 will decide whether to have breast reconstruction surgery following a mastectomy and whether to have surgery on the
other breast in order 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 copay per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to achieve
and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility as well as artificial insemination is covered you pay a 10 copay in a physician's office nothing in a participating hospital or alternate facility The following types of artificial
insemination are covered intracervical insemination ICI and intrauterine insemination IUI cost of donor sperm is not covered Other assisted reproductive technology ART procedures that enable a woman
with otherwise untreatable infertility to become pregnant through other artificial conception procedures such as in vitro fertilization and embryo transfer gamete intrafallopian transfer GIFT and zygote
intrafallopian transfer ZIFT are not covered
Fertility drugs are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infraction is provided for up to 36 sessions you pay nothing
Hearing exams are covered limited to one per calendar year you pay a 10 copay per visit
Cyrosurgery for localized prostate cancer is covered a Plan preauthorization is necessary
Durable medical equipment such as wheel chairs hospitals beds and glucose monitors and prosthetic devices such as artificial limbs and external lenses following cataract removal are covered Plan
preauthorization is required for items that cost 100 or more Repairs and replacements are covered if needed due to a change in the member's medical condition Orthopedic devices such as braces foot
orthotics excluding shoe inserts medical supplies including colostomy supplies dressings catheters and related supplies and growth hormones are also covered You pay 20 of the charges up to an annual
out of pocket maximum of 500 per Self Only or 1,000 per Self and Family enrollment The Plan then pays charges in full Other charges also apply to these out of pocket maximums see page 5
Prosthetic devices such as breast prostheses or surgical bras and their replacements are covered Plan preauthorization is required for items that cost 100 or more You pay 20 of the charges up to an annual
out of pocket maximum of 500 per Self Only or 1,000 per Self and Family enrollment The Plan then pays charges in full
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
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 a 100 copay per admission for facility
charges All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care
The Plan provides a comprehensive range of benefits for up to 180 days when full time skilled
nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay a 100 copay per admission for
facility charges All necessary services are covered including
Bed board and general nursing
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 You pay a 100 copay per inpatient
admission and you pay nothing for outpatient care
Ambulance service
Benefits are provided for emergency ambulance transportation ordered or authorized by a Plan doctor
You pay nothing
Limited benefits Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
for hospitalization for reasons totally unrelated to the dental procedure you pay a 100 copay per
admission for facility charges the Plan will cover the hospitalization after copay but not the cost
of professional dental services Conditions for which hospitalization would be covered include
hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate See
page 15 for nonmedical substance abuse benefits You pay a 100 copay per admission for
hospitalization
What is not covered
Personal comfort items such as telephone and television
Blood and blood derivatives no charge if replacement is arranged by member
Custodial care rest cures domiciliary or convalescent care
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
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 the If you are in an emergency situation please call your primary care doctor In extreme emergencies Service Area if you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel
that you are a Plan member so they can notify the Plan You or a family member must notify the Plan
within 48 hours It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility 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 participating providers in a medical emergency only if delay
in reaching a participating provider would result in death disability or significant jeopardy to your
condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved
by the Plan or provided by Plan providers
Plan pays
Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay
50 per hospital emergency room visit or 10 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
care copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because the Service Area of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If
a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full You pay a 100 copay per hospital
admission
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
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
Emergency Benefits continued
Plan pays
Reasonable charges for emergency care services to the extent the services would have been covered
if received from Plan providers
You pay
50 per hospital emergency room visit or 10 per 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
care 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 if approved by the Plan
What is not covered
Medical and hospital costs resulting from a normal full term delivery of a baby outside the
Service Area
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 With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan 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 9
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
Mental Conditions Substance Abuse Benefits
Mental conditions Members must contact United Behavioral Health at 1 800 860 1123 before obtaining care
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 30 outpatient visits to participating doctors consultants or other psychiatric personnel
each calendar year you pay a 10 copay for each covered visit for group therapy 20 copay
for each covered visit for individual therapy 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 You may exchange one day of inpatient treatment for two days of
outpatient day treatment
What is not covered Care for psychiatric condition that in the professional judgment of plan doctors are not subject
to significant improvement through relative short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of
a short term psychiatric condition
Treatment that is not authorized by a Plan doctor
Substance abuse 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
What is covered any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care
Up to 30 outpatient visits to participating providers for treatment each calendar year you pay
a 10 copay for each covered visit for group therapy 20 copay for each covered visit for
individual therapy all charges thereafter
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in a participating facility approved by a the Plan you pay nothing for the first 30 days all charges after
You may exchange one day of inpatient treatment for two days of outpatient day treatment
What is not covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a participating or referral doctor and obtained at a participating
pharmacy will be dispensed for up to a 31 day supply or 100 unit supply whichever is less 240
milliliters of liquid 8 oz 60 grams of ointment creams or topical preparation or one commercially
prepared unit i e one inhaler one vial ophthalmic medication or two vials insulin
You pay a 10 copay per prescription unit or refill for generic drugs You pay a 15 copay per
prescription unit or refill for name brand drugs on the Plan's Formulary Drug List and a 30
Copay per prescription unit or refill for name brand drugs not on the Plan's Formulary Drug
List
Prescription drugs prescribed by a plan or referral doctor can also be obtained via a mail order
program for up to a 90 day supply You pay a 20 copay per prescription unit or refill for generic
drugs and a 30 copay per prescription unit or refill for name brand drugs on the Plan's
Formulary Drug List and a 60 Copay per prescription unit or refill for brand name drugs not
on the Plan's Formulary Drug List To access the mail order program call 800 585 5791 for
mail order customer service
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs
Injectable contraceptive drugs such as Depo Provera
Contraceptive devices and supplies that require a prescription
Implanted contraceptive drugs such as Norplant
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's
solution or equivalent and acetone test tablets
Disposable needle and syringes needed for injecting covered prescribed medication
Insulin with a copay charge applied to every two vials
Intravenous fluids and medication for home use implantable drugs and some injectable drugs
are covered under Medical and Surgical Benefits see page 15
Limited Benefits Drugs to treat sexual dysfunction are limited Contact the plan for dose limits
What is not covered Drugs available without a prescription or for which there is a non prescription 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
Fertility drugs
Dental prescriptions
Appetite suppressants
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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UnitedHealthcare of Ohio Inc 2000
Section 5 BENEFITS
Other Benefits
Dental care The following dental services are covered when provided by participating dentists Contact the Dental
Customer Service Department on 800 7623159 for a current participating dental provider directory
What isuu covered Preventive and diagnostic treatment you pay 50 of charges maximum annual benefit is 500 per
person combined including basic services
Oral exam two per year
Prophylaxis cleaning two per year
Fluoride one application per year under age 12
Bitewing one set each year
Complete dental series or panoramic survey once every five years
Up to three periapical x rays per year
Emergency treatment limited to the relief of pain bleeding swelling or other life threatening
conditions but not the cure of disease is also covered You pay 50 of charges
Accidental injury Covered under Medical Surgical Benefits Restorative services and supplies necessary to promptly benefit
repair but not replace sound natural teeth are covered The need for these services must result from
an accidental injury not biting or chewing You pay nothing Services must be completed within six
6 months of the injury unless medical necessity does not permit
What is not covered All 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 may be obtained from Plan
providers You pay a 15 copay per visit
What is not covered Corrective lenses or frames Eye exercises
Contact lens fitting
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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UnitedHealthcare of Ohio Inc 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket
maximum These benefits are not subject to the FEHB disputed claims procedures
OPTUM Care 24 Offers assistance to employees for virtually any type of personal family or work related problem Through a tollfree
24 hour a day phone service or face to face consultation members receive confidential help in coping with family problems
drug abuse or financial struggles Master's level counselors will be available to provide you and your family members information
and support for a wide variety of concerns 24 hours a day 365 days a year
Registered nurses can provide you with helpful information on just about any medical condition 24 hours a day everyday of the week
Nurses can assist you in understanding diagnostic tests the benefits and side effects of medications specific dietary regimes and
treatment options Call Nurseline at 888 259 3038 or 800 255 1049 V TDD
Car seats for newborns
Bicycle helmet coupons
3U1 and 3U2 only
For information about this benefit contact newborns bicycle Customer Service at
937 439 8903 or 800 231 2918
Wellness programs
3U1 and 3U2
Discounts are offered at the following facilities
Medicare prepaid plan enrollment
This plan offers Medicare recipients the opportunity to enroll in the Plan referred to as UnitedHealthcare of Ohio Inc s Medicare
Complete through Medicare As indicated on page 4 annuitants and former spouses with FEHB converge and Medicare Part B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later
re enroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare
prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan ask whether
the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan Contact us at 800 504 4848 for information on the Medicare prepaid
plan and the cost of that enrollment
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment
in this Plan's FEHB plan call 800 711 6089 for information on the benefits available under the Medicare HMO
Benefits on this page are not part of the FEHB contract
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UnitedHealthcare of Ohio Inc 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 Services drugs or supplies that are not medically necessary following 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 For information on the Medicare Choice plan
offered by this Plan see page 18
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
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UnitedHealthcare of Ohio Inc 2000
Section 7 Limitations Rules that affect your benefits continued
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 that responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover the
cost of treatment that exceeds the amount you received in the settlement If you do not seek damages
you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
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
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UnitedHealthcare of Ohio Inc 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 right information about your to information about your health plan its networks providers and facilities You can also find out
HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 231 2918 for code 3U1 3U2 or 800 225 7591 code
VC1 VC2 or write to for codesVC VC2 9200 Worthington Road Westerville OH 43802 for codes
3U1 3U2 6601 Centerville Business Pkwy Dayton OH 45459 You may also contact us by fax at
614 410 7399 for codes VC1 VC2 or 937 436 8813 for code 3U1 3U2 or visit our website at
www uhc com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the FEHB make an 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 and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been enrolled retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement
you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which
is described later in this section
What types of 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 or
family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give
birth or add a child to your family You may change your enrollment 31 days before to 60 days after
you give birth or add the child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
family member
Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled
in another FEHB plan
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UnitedHealthcare of Ohio Inc 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 coordination 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 If you enrolled through Employee Express you can request
a confirmation letter
What if I paid a deductible under my old plan
Your old plan's deductible continues until our coverage begins
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this Plan
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 under coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You
may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
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UnitedHealthcare of Ohio Inc 2000
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 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
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
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UnitedHealthcare of Ohio Inc 2000
Section 8 FEHB FACTS continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well
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 xxx xxx xxxx Plan specific and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate
anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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UnitedHealthcare of Ohio Inc 2000
Summary of Benefits for UnitedHealthcare of Ohio Inc 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth
in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure
ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY
WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpat ient care Hospital Comprehensive range of medical and surgical services without a dollar or a 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 a 100 copay per admission 12
Extended care All necessary services for up to 180 days in a skilled nursing facility You pay a 100 copay per admission 12
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing One inpatient day may be exchanged for two days of outpatient day treatment 15
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay nothing One inpatient day may be exchanged for two days of outpatient day treatment 15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations
laboratory tests and X rays complete maternity care You pay a 10 copay per office visit copay waived after first prenatal visit you pay a 10 copay per house call by a doctor you pay a 15 copay per
specialist visit 10
Home health care All necessary visits by nurses and health aides You pay nothing 10
Mental conditions Up to 30 outpatient visits per year You pay a 10 copay per visit for group therapy 20 copay per visit for individual therapy 15
Substance abuse Up to 30 outpatient visits per year You pay a 10 copay per visit for group therapy 20 copay per visit for individual therapy 15
Emergency care ` Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit or a 10 copay per urgent care center visit and any
charges for services that are not covered by this Plan 13 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy For retail prescription drugs you pay a 10 copay for generic drugs a 15 copay for brand name drugs per prescription unit or refill for
drugs on the Plan's Formulary Drug List or 30 copay for brand name drugs per prescription unit or refill for drugs not on the Plan's Formulary Drug List Maintenance drugs are available by mail you pay a 20
copay for generic drugs or a 60 copay for brand name drugs not on the Plan's Formulary Drug List for a 90 day supply 16
Dental care Accidental injury benefit you pay nothing Preventive dental care you pay 50 of charges 17
Vision care One eye exam for refractions per calendar year You pay a 15 copay per visit 17
Out of pocket limit Copayments and coinsurance are required for a few benefits However they will not be required for the following benefits for the remainder of the calendar year after your out of pocket expenses excluding
office visit copays for these services provided or arranged by the Plan reach 500 per Self Only enrollment or 1,000 per Self and Family enrollment orthopedic devices prosthetic devices durable
medical equipment medical supplies but not diabetic supplies growth hormones and emergency room copayments 5
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UnitedHealthcare of Ohio Inc 2000
2000 Rate Information for
UnitedHealthcare of Ohio
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
Cincinnati Dayton Springfield Toledo Ohio
Self Only 3U1 78.83 28.13 170.80 60.95 93.06 13.90 93.26 13.70
Self and Family 3U2 175.97 70.04 381.27 151.75 207.74 38.27 201.02 44.99
Central South Central Ohio
Self Only VC1 78.83 32.53 170.80 70.48 93.06 18.30 93.26 18.10
Self and Family VC2 175.97 80.15 381.27 173.66 207.74 48.38 201.02 55.10
26 26