Serving Northwest and North Central Ohio
Enrollment in this Plan is limited see page 6 for requirements
Enrollment code U21 Self only
U22 Self and family
Special Notice Paramount Health Care Enrollment Code U2 and Medical Value Plan Enrollment Code EV have merged If you are currently enrolled in Medical Value Plan Enrollment Code EV your enrollment will be transferred
automatically to Paramount Health Care Enrollment Code U2 unless you select another FEHB plan during the 1999 Open Season Additionally Paramount Health Care's Service Area does not extend into the State of Michigan and therefore two
counties previously in the service area of Medical Value Plan have been eliminated If you are enrolled in Medical Value Plan and live or work in one of the following areas you must select another plan during Open Season to continue to receive
full Plan benefits the Michigan counties of Lenawee and Monroe If you live or work in one of these areas and do not select another FEHB plan you must travel to a county in Paramount Health Care's Service Area i e northwest or north central
Ohio and be seen by a Plan provider in order to receive full Plan benefits
Visit the OPM website at http www opm gov insure and
our website at http www promedica org
Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNELMANAGEMENT
RETIREMENT AND INSURANCE SERVICE
Officeice RI 73 609
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Paramount Health Care 2000
Table of Contents Page
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 5
Section 3 How to get benefits 5 8
Section 4 What to do if we deny your claim or request for service 9 10
Section 5 Benefits 11 19
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 21 22
Section 8 FEHB FACTS 23 26
Inspector General Advisory Stop Healthcare Fraud 27
Summary of benefits Inside back cover
Premiums Back cover
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Paramount Health Care 2000
Introduction
Paramount Health Care 1901 Indian Wood Circle
Maumee OH 43537 4068
This brochure describes the benefits you can receive from Paramount Health Care under its contract CS 2672 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 5 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 Paramount Health Care 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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Paramount Health Care 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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Paramount Health Care 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you
receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim
forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will
be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all changes primary care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Your share of the non postal premium will increase by 18 6 for Self Only and by 36 9 for Plan Self and Family
The Plan's copay for a Primary Care Physician office visit has increased from 5 to 10 See page 11
The Plan's copay for a doctor's house call has increased from 5 to 10 See page 11
Durable medical equipment now includes diabetic supplies other than disposable needles and syringes such as chem strips test tape glucometers test strips and lancets subject to a
member copay of 50 of charges after the first 750 paid by the Plan Previously these diabetic supplies were subject to the member's 5 office visit copay See page 13
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Paramount Health Care 2000
How we change for 2000 continued
Changes to this Short term rehabilitative therapy physical speech and occupational on an outpatient basis is Plan subject to a member copay of 10 per outpatient session Previously there was no copay per
continued outpatient session See page 13
The copay for a hospital emergency room visit within or outside the service area has increased from 25 to 50 See page 16
The copay for an annual eye refraction has increased from 5 to 10 See page 19
The Plan now covers AZT and growth hormones subject to the regular prescription drug copays Previously they were subject to a member copay of 50 of charges
Paramount Health Care Enrollment Code U2 and Medical Value Plan Enrollment Code EV have merged If you are currently enrolled in Medical Value Plan Enrollment Code EV your
enrollment will be transferred automatically to Paramount Health Care Enrollment Code U2 unless you select another FEHB plan during the 1999 Open Season Additionally Paramount
Health Care's Service Area does not extend into the State of Michigan and therefore two counties previously in the service area of Medical Value Plan have been eliminated If you
are enrolled in Medical Value Plan and live or work in one of the following areas you must select another plan during Open Season to continue to receive full Plan benefits the Michigan
counties of Lenawee and Monroe If you live or work in one of these areas and do not select another FEHB plan you must travel to a county in Paramount Health Care's Service Area
i e northwest or north central Ohio and be seen by a Plan provider in order to receive full Plan benefits See front cover and page 6
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is
area The Ohio counties of Ashland Crawford Defiance Erie Fulton Hancock Henry Huron Lucas
Marion Morrow Ottawa Putnam Richland Sandusky Seneca Williams Wood and Wyandot and portions of Allen Delaware Hardin Knox Lorain and Paulding as described by the
following zip codes
Allen County 45801,45804 45805 45806 45807 45817 45820 45833 45850
Delaware County 43003 43015 43066
Hardin County 43326 43359 45810 45812 45843
Knox County 43011 43014 43019 43022 43050
Lorain County 44001 44035 44039 44044 44050 44052 44053 44054 44055 44074 44089 44090 and
Paulding County 45813 45821 45849 45855 45861 45873 45879 45886
Paramount Health Care 2000
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How to get benefits continued
What is this Ordinarily you must get your care from providers who contract with us If you receive care Plan's service outside our service area we will pay only for emergency care We will not pay for any other
area health care services unless approved in advance by Paramount
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 or coinsurance a set percentage of charges Please remember you must pay this amount when
services you receive services except for emergency care
After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or more family members you do not have to make any further payments for certain services for the
rest of the year This is called a catastrophic limit However copayments or coinsurance for supplemental services such as substance abuse inpatient treatment of mental conditions durable
medical equipment vision care dental care and prescription drugs do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time
Who provides Paramount Health Care is an Individual Practice Association IPA type HMO IPA means that my health plan providers are in independent practice throughout the service area All covered services must
care be provided by in network providers and facilities unless it is an emergency medical condition or authorized in advance by Paramount
Paramount has over 590 primary care physicians PCP Your PCP will be your first contact when you are in need of medical care All female members will have open access to all participating
OB GYNs for treatment of an OB GYN condition without a referral from their primary care physician Paramount has over 1,200 specialists in our network If you need to be seen by a
specialist your primary care physician will make a referral to the appropriate specialist Paramount has 36 hospitals and 3 Centers of Excellence
Each member may have a different primary care physician and will receive their own Paramount Health Care ID card which indicates who the primary care physician is along with the doctor's
phone number and appropriate copayment amounts Payment of your copayment is expected at the time medical services are delivered
What do I do if Call us We will help you select a new one my primary
care physician leaves the
Plan
Paramount Health Care 2000
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How to get benefits continued
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or I need to go authorized specialist will make the necessary hospital arrangements and continue to supervise your
into the care hospital
What do I do if First call our member service department at 419 887 2525 or 800 462 3589 If you are new I'm in the to the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
hospital when I Program and are switching to us your former plan will pay for the hospital stay until join this Plan
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Except for OB GYN visits routine eye exams medical emergencies or when a primary care specialty care physician has designated another physician to see his or her patients you must receive a referral
from your primary care physician before seeing any other physician or obtaining special services Referral to a participating specialist is given at the primary care physician's discretion if non Plan
specialists or consultants are required the primary care physician will arrange appropriate referrals When you receive a referral from your primary care physician you must return to the
primary care physician after the consultation unless your physician authorizes additional visits All follow up care must be provided or authorized by the primary care physician Do not go to the
specialist for a second visit unless your primary care physician has arranged for and the Plan has issued an authorization for the referral in advance
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan Your PCP will consult with your specialist
regarding a plan of treatment The specialist will send regular consultation reports to keep your PCP advised of your progress The PCP may authorize the referral for up to a twelve 12 month
period Once this has been approved you will receive a Referral Confirmation If further services are required beyond the twelve 12 month period you your PCP and the specialist
should agree to a new treatment plan
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you I enroll to see a specialist who does not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the someone else Plan
Paramount Health Care 2000
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How to get benefits continued
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to have a serious continue seeing your provider for up to 90 days after we notify you that we are terminating our
illness and my contract with the provider unless the termination is for cause If you are in the second or third provider leaves trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Plan or this care You may also be able to continue seeing your provider if your plan drops out of the FEHB Plan leaves the Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
Program 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 Your physician must get our approval before sending you to a hospital referring you to a Authorize specialist or recommending follow up care Before giving approval we consider if the service
Medical is medically necessary and if it follows generally accepted medical practice A service is services medically necessary if 1 It is needed to prevent diagnose and or treat a specific condition
2 It is specifically related to the condition being treated or evaluated and 3 It is provided in the most medically appropriate setting that is an outpatient setting must be used rather than a hospital
or inpatient facility unless the services cannot be provided safely in an outpatient setting It is the responsibility of the plan physician or provider to obtain authorization when required
How do you Paramount investigates all requests for coverage of new technology using the HAYES Medical decide if a Technology Directory as a guide If further information is needed Paramount utilizes additional
service is sources including Medicare and Medicaid policy Food and Drug Administration FDA releases experimental or and current medical literature This information is evaluated by Paramount's Medical Director and
investigational other physician advisors
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we
will make our decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
Paramount Health Care 2000
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What to do if we deny your claim or request for service continued
What if I have a Call us at 419 887 2525 or toll free at 1 800 462 3589 and we will 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 Denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can
for care and my call OPM's Health Benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m condition is serious Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or life threatening or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with
the review request
Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs mail my disputed Contracts division 3 P O Box 436 Washington D C 20044
claim to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue If you decide to sue you must file the suit against OPM in
denial Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
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What to do if we deny your claim or request for service continued
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base I 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the 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
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers This includes all necessary office visits you pay a 10 office
visit copay but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate
you pay a 10 copay for a doctor's house call you pay nothing for house visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two
years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS Paramount Health Care 2000
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Medical and Surgical Benefits continued
What is covered Complete obstetrical maternity care for all covered females including prenatal delivery and continued postnatal care by a Plan doctor Copays are waived for maternity care The mother at her
option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a 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
mothers 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 contraceptive devices such as diaphragms and IUDs injectable contraceptive drugs implanted time release medications
such as Norplant
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum you pay a 25 copay per testing session
The insertion of internal prosthetic devices such as pacemakers and artificial joints the cost of a cochlear or penile implanted device is not covered
Bowel cornea heart heart lung kidney liver lung single or double pancreas and pancreas kidney transplants allogeneic donor bone marrow transplants autologous bone
marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian
germ cell tumors Related medical and hospital expenses of the donor are covered 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
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan physician who will periodically review the program for
continuing appropriateness and need you pay nothing
All necessary medical or surgical care in a hospital or extended care facility from Plan physicians and other Plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS Paramount Health Care 2000
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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 All other procedures involving the teeth or
intra oral areas surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance Breast prostheses surgical bras as well as their replacements are covered
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 nothing per inpatient session but you pay 10 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 selfcare and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 30 of charges The following type of artificial insemination is covered intrauterine insemination IUI you pay 30 of charges cost
of donor sperm is not covered Outpatient self administered fertility drugs are not covered under the Prescription Drug Benefit but fertility drugs administered in the physician's office are covered
you pay 30 of charges Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is covered at a Plan facility you pay nothing
Durable medical equipment is covered such as wheelchairs and hospital beds as well as ostomy supplies support hose and diabetic supplies other than disposable needles and syringes such as
chem strips test tape glucometers test strips and lancets The Plan pays the first 750 per member per calendar year then 50 of charges You pay 50 of charges after the first 750
Prosthetic devices such as artificial limbs and lenses following cataract removal are covered for the initial device required as a result of surgery up to a maximum benefit of 5,000 per member
per calendar year Repair and or replacement is not covered
Nicotine patches or other smoking deterrents furnished on a prescription basis are covered you pay 20 of charges up to a maximum Plan payment of 300 per member per lifetime Member
must first complete a smoking cessation class approved by the Plan
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS Paramount Health Care 2000
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Medical and Surgical Benefits continued What is not covered Physical examinations that are not necessary for medical reasons such as those required
for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives not replaced by the member
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services
Orthopedic devices such as braces foot orthotics
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as
nearsightedness myopia farsightedness hyperopia and astigmatism blurring
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 physician You pay nothing All necessary services are
covered including
Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician 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 100 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 physician and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan physician
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS Paramount Health Care 2000
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Hospital Extended Care Benefits continued
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 physician who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan physician service
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient 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 17 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television covered
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
Private duty nursing
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that a emergency medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might
become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care physician In extreme the service area emergencies if you are unable to contact your physician 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS Paramount Health Care 2000
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Emergency Benefits continued
Emergencies within If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or the service area on the first working day following your admission unless it was not reasonably possible to notify
continued the Plan within that time If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with
any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit 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 care copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required outside because of injury or unforeseen illness If you need to be hospitalized the Plan must be notified
the service area 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 physician believes care can be better
provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit 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 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 approved by the Plan
What is not Elective care or non emergency care covered
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS Paramount Health Care 2000
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Mental Conditions Substance Abuse Benefits
Members must get a referral from their primary care physician PCP to access mental health services Members may also contact their Employee Assistance Program EAP if available for a referral Yet another alternative is that members may
contact the Plan's Utilization Case Management Department at 419 887 2420 or toll free at 800 891 2520
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 or other psychiatric personnel each calendar year you pay a 25 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay 20 of charges for the first 30 days all charges thereafter Partial hospitalization comprehensive outpatient treatment arranged
through the case management process in lieu of full hospitalization is available in place of inpatient days on a two for one basis
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not covered 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 providers for treatment each calendar year you pay a 25 copay for each covered visit all charges thereafter
The substance abuse benefit may be combined with the outpatient mental conditions benefit shown above provided such treatment is necessary and is approved by the Plan to permit an additional
20 outpatient visits per calendar year with the applicable mental conditions benefit copays
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay 20 of charges
during the benefit period all charges thereafter
What is not Treatment that is not authorized by a Plan Physician covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Paramount Health Care 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan physician and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply Specific maintenance legend drugs may be dispensed for up
to a 30 day supply or 100 unit supply whichever is greater The maintenance list is reviewed periodically and the Plan reserves the right to change the maintenance list You pay a 5 copay
per prescription unit or refill for generic drugs and a 10 copay per prescription unit or refill for name brand drugs
You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not permissible When generic substitution is permissible i e a generic
drug is available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay the price difference between the generic and name brand
drug as well as the 10 copay per prescription unit or refill
Some drugs which require close monitoring require prior authorization or have limits on the quantity that may be dispensed The Plan reserves the right to implement prior authorizations or
limit quantities of pharmaceuticals based on safety efficacy or inappropriate utilization
Covered medications and accessories include
Drugs for which a prescription is required by Federal or State law
Oral contraceptive drugs
Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medications including insulin
Intravenous fluids and medication for home use implantable drugs such as Norplant and some injectable drugs such as Depo Provera contraceptive devices diabetic supplies other than
disposable needles and syringes smoking cessation drugs and medications and drugs received in the physician's office for treatment of infertility are covered under Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs are subject to dosage limits set by the Plan Contact the Plan for details
What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered 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
Fertility drugs except those administered in a doctor's office See Medical and Surgical Benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Paramount Health Care 2000
Other Benefits
Dental care
What is covered
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound Benefit teeth The need for these services must result from an accidental injury Treatment must be
received within 48 hours of the accident unless the member's medical condition indicates the dental care must be delayed You pay nothing
What is not Other dental services not shown as covered 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 without a referral from your Primary Care Physician You pay a 10 copay per visit
What is not Corrective lenses or frames covered
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Paramount Health Care 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 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 ofpocket maximums These benefits are not subject to the FEHB disputed claims procedure
Preventive Dental Care Coverage Paramount Health Care will reimburse up to a maximum of 100 to each eligible member toward the cost of preventive dental care every twelve 12 months To receive this benefit send a copy of the paid
itemized receipt from any dental provider to the address below Clearly indicate on the receipt the members health plan identification number
Paramount Health Care Dental Plan
P O Box 928 Toledo Ohio 43697 0928
Reimbursement will be sent directly to the Member If submitted charges do not exceed 100 the reimbursement will be for the amount submitted Not covered x rays and new dentures
Vision Hardware Coverage Paramount Health Care will reimburse expenses up to a maximum of 100 to each eligible member toward the cost of prescription lenses contact lenses and or frames every twenty four 24 months To receive this
benefit send a copy of the paid itemized receipt from any vision provider to the address below Clearly indicate on the receipt the members health plan identification number
Paramount Health Care Vision Plan
P O Box 928 Toledo Ohio 43697 0928
Reimbursement will be sent directly to the member If submitted charges will not exceed 100 the reimbursement will be the amount submitted Not Covered Lenses contact lenses or frames ordered more than every twenty four 24 months or
purchased before this coverage began on or after this coverage ended
Fitness Programs All members of Paramount Health Care are eligible to obtain a 15 discount on annual YMCA of Greater Toledo memberships
Medicare Choice prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 21 annuitants and former spouses with FEHB coverage and Medicare Part B may
elect to drop their FEHB coverage and enroll in a Medicare Choice prepaid plan when one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part
A may join this Medicare Choice 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 Choice prepaid plan Contact us at Paramount Elite at 419 887 2582 or 1 888 891 0707 for information on the Medicare Choice
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 419 887 2582 or 1 888 891 0707 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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Paramount Health Care 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 physician 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 For information on the Medicare Choice
plan offered by this Plan see page 20
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage You must tell us if you or a family member has double coverage You must also send us
documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines Paramount Health Care 2000
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Limitations Rules that affect your benefits continued
Other group If we pay second we will determine what the reasonable charge for the benefit should be After Insurance the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness are responsible that another person caused you must reimburse us for whatever services we paid for We will
for injuries 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 We do not cover services and supplies that a local State or Federal Government agency directly Government or indirectly pays for
Agencies
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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 419 887 2525 or write to Paramount Health Care 1901 Indian Wood Circle Maumee OH 43537 You may also contact us by fax at 419 887 2018
or visit our website at www promedica org
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the an informed decision about FEHB Program
When you may change your enrollment How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and coverage are your unmarried dependent children under age 22 including any foster or step children your
available for my employing or retirement office authorizes coverage for Under certain circumstances you may family and me 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
Paramount Health Care 2000
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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 for for for for new new new new members members members members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can
also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled
When When When When you you you you lose lose lose lose benefits benefits benefits benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage
choices
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
Paramount Health Care 2000
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FEHB FACTS continued
What is TCC Key points about TCC continued
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 If you leave Federal service your employing office will notify you of your right to enroll under in 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 You may convert to an individual policy if convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or coverage did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
Paramount Health Care 2000
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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 Certificate of that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other coverage Plan 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
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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 419 887 2525 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
Paramount Health Care 2000
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Summary of Benefits for Paramount Health Care 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you
wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE
EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
BENEFITS PLAN PAYS PROVIDES PAGE
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital 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 14
Extended care All necessary services up to 100 days per calendar year You pay nothing 14
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay 20 charges 17
Substance abuse Up to 30 days per year in a substance abuse and treatment program You pay 20 of charges 17
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 copays are waived
for maternity care 10 per house call by a doctor 11
Home health care All necessary visits by nurses and health aides You pay nothing 12
Mental conditions Up to 20 outpatient visits per year You pay a 25 copay per visit 17
Substance abuse Up to 20 outpatient visits per year You pay a 25 copay per visit 17
Emergency care Reasonable charges for services and supplies required becauseof a medical emergency You pay a 50 copay to the hospital for each emergency room
visit and any charges for services that are not covered by this Plan 15
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for generic drugs and a 10 copay
for name brand drugs 18
Dental care Accidental injury benefit You pay nothing 19
Vision care One refraction annually You pay a 10 copay per visit 19
Out of pocket Copayments are required for a few benefits however after your Maximum out of pocket expenses reach a maximum of 1,500 per self only or 3,000
per self and family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include charges for
supplemental services such as substance abuse inpatient treatment of mental conditions durable medical equipment vision care dental care and prescription
drugs 7
2000 Rate Information for 28
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Paramount Health Care
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 Premiu
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Y Enrollment Share Share Share Share Share Share Share Sh
Self Only U21 78.83 26.33 170.80 57.05 93.06 12.10 93.26 1 Self and Family
U22 175.97 102.65 381.27 222.41 207.74 70.88 201.02 7
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