Foundation Health 2000 A Health Maintenance Organization
For changes benefits
in page 4
See
Serving The Florida Area
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
5D1 Self Only 5D2 Self and Family
5E1 Self Only 5E2 Self and Family
This Plan has full accreditation from the
NCQA See the 2000 Guide for more
information on NCQA
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www fhfl com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance
Table of Contents Page
Introduction 1
Plain Language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 22
Section 7 Limitations Rules that affect your benefits 23
Section 8 FEHB facts 25
Inspector General Advisory Stop Healthcare Fraud 29
Summary of benefits Inside back cover
Premiums Back cover
Foundation Health HMO 2000
Introduction
Foundation Health a Florida Health Plan
1340 Concord Terrace
Sunrise FL 33323
This brochure describes the benefits you can receive from Foundation Health HMO under its contract CS 2715 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 Foundation Health 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
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
Foundation Health HMO 2000
How to use this brochure
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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Foundation Health HMO 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 listed in this brochure When you receive emergency services you may have to submit claim forms if traveling outside
of the country
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
Foundation Health HMO 2000
Section 2 How we change for 2000
Program wide changes
To keep your premiums as low as possible OPM has set a minimum copay of 10 for all 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 Plan
l Your share of the non postal premium will increase by 10.3 for Self Only code 5D1 or 9.7 for Self and Family code
5D2 and by 5.7 for Self Only code 5E1 or 5.7 for Self and Family code 5E2
l The copayment for office visits has increased from 5 to 10 per visit
l The Plan has added coverage for prosthetic devices and orthotics including breast prosthesis See page 11
l The Plan has added coverage for vision care services including frames and lenses See page 20
l The copayment for allergy testing and treatment has increased from 5 per visit to 15 per visit
l Coverage for voluntary sterilization has decreased from covered in full to covered with a 200 copay
l Home health services of nurses and health aides is covered with a 10 copay
l The copayment for outpatient short term rehabilitative therapy physical speech occupational and audio has increased
from 5 per session to 10 per session
l The maximum that you must pay for out of pocket expenses is 1,500 per Self Only enrollment and 3,000 per Family
enrollment This does not include copayments for prescription drugs and vision care services
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Foundation Health HMO 2000
Section 3 How to get benefits
What is this Plan's service area
To enroll with us you must live or work in our service area This is where our providers practice Our service area is Broward
Dade Palm Beach code 5E Brevard Hillsborough Martin Okeechobee Orange Osceola Pasco Pinellas St Lucie Seminole
code 5D
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 that are not coordinated through your primary care
physician
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 Foundation Health provides care for students within the all the Foundation
Health service areas regardless of which enrollment code the student is enrolled under Reciprocity arrangements do not exist in
any other Foundation Health Services networks If you or a family member move you do not have to wait until Open Season to
change plans Contact your employment or retirement office
How much do I pay for services
You must share the cost of some services This is called a copayment a set dollar amount or coinsurance a set percentage of
charges Please remember you must pay this amount when you receive services except for services provided when you are
admitted to a hospital
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 for your prescription drugs and vision services do not count toward these limits and you must continue to make these
payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach
the limits
Do I have to submit claims
You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't contract with
us or you are seeking care outside of the country If you file a claim please send us all of the documents for your claim as soon as
possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can
extend this deadline if you show that circumstances beyond your control prevented you from filing on time
Who provides my health care
Foundation Health is an individual practice prepayment IPP plan that contracts with doctors to provide services for you out of
their own offices
What do I do if my primary care physician leaves the Plan
We should have already contacted you and selected a physician for you on an interim basis Call us to make any physician change
and we will help you select a new one
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Foundation Health HMO 2000
Section 3 How to get benefits
What do I do if I need to go into the hospital
If your hospital visit is not due to an emergency contact your Plan physician If you need to be hospitalized your primary care
physician or specialist will make the necessary hospital arrangements and supervise your care
If you have an emergency please call your primary care doctor In extreme emergencies if you are unable to contact your doctor
contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell
the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member should notify the
Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely
notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full
What do I do if I'm in the hospital when I join this Plan
First call our customer service department at 877 FHS 6899 If you are new to the FEHB Program we will arrange for you to
receive care If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until
l You are discharged not merely moved to an alternative care center or
l The day your benefits from your former plan run out or
l The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty care
You may self refer to the following specialties
Chiropractor 12 times per calendar year
Dermatologist 5 times per calendar year
Podiatrist 12 times per calendar year
OB GYN once a year Well Woman Exam
Your primary care physician will arrange for all other referrals to a specialist
If you have a chronic complex or serious medical condition that requires you to see a specialist frequently your primary care
physician will develop a treatment plan that allows you to see your specialist for a prescribed number of visits without additional
referrals Your primary care physician will use Foundation Health's criteria when creating your treatment plan Your physician will
have to get an authorization for services for ongoing treatment prior to initial referral
What do I do if I am seeing a specialist when I enroll
It is critical for you to visit you PCP immediately if you are currently seeing a specialist when you enroll Your primary care
physician must coordinate your course of treatment If your PCP decides to refer you to a specialist ask if you can see your
current specialist If your current specialist does not participate with us you must receive treatment from a specialist who does
Generally we will not pay for you to see a specialist who does not participate with our Plan
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Foundation Health HMO 2000
Section 3 How to get benefits
What do I do if my specialist leaves the Plan
Call your primary care physician who will arrange for you to see another specialist You may receive services from your current
specialist until we can make arrangements for you to see someone else
But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the Program
Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your provider for up to
90 days after we notify you that we are terminating our contract with the provider unless the termination is for cause If you are in
the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB
plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your
new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care
How do you authorize medical services
Foundation Health operates a Physician Guided Open Access Plan Simply stated this gives your primary care doctor the ability to
authorize most specialty services without Plan approval However your doctor must get our approval before sending you to a
hospital Before giving approval this Plan considers if the service is medically necessary and if it follows generally accepted
medical practice for any inpatient or outpatient procedures and selected diagnostic services
How do you decide if a service is experimental or investigational
Experimental services and supplies generally include any procedure treatment therapy drug biological product facility
equipment device or supply which has not been demonstrated to be safe effective and medically appropriate for use in the
treatment of the illness injury or condition at issue as compared with the conventional means of treatment or diagnosis
Foundation in its sole discretion shall determine whether such service or supply is safe effective and medically appropriate for
the injury or condition at issue according to the criteria set forth in the definition of Experimental
In most instances the procedure or service must be approved by the Food and Drug Administration FDA as non experimental or
investigational must be medically necessary and must follow generally accepted medical practice
Denials of coverage for Experimental services or supplies for Members with an incurable or irreversible condition that has a high
probability of causing death within one year or less may be reviewed pursuant to Foundation Health's Grievance and Appeal
Procedures
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Foundation Health HMO 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control
Foundation Health has 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 to review a denial
You may ask OPM to review a denial after you ask us to reconsider our initial denial or refusal OPM will determine if we correctly
applied the terms of our contract when we denied your claim or request for service
What if I have a serious or life threatening condition and you haven't responded to my request for service
Call us at 877 FHS 6899 and we will expedite our review
What if you have denied my request for care and my condition is serious or life threatening
If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so that they can give your
claim expedited treatment too Alternatively you can call OPM's health benefits Contract Division IV at 202 606 0737 between
8 a m and 5 p m Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they
are not treated as soon as possible
What if I have a serious or life threatening condition and you haven't responded to my request for service
Call us at 877 FHS 6899 and we will expedite our review
Are there other time limits
You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service
You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you
asked us to reconsider your claim
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Foundation Health HMO 2000
Section 4 What to do if we deny your claim or request for service
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must
receive your request within 120 days of the date we asked you for additional information
What do I send to OPM
Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and
explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make the request
Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and or
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative These
representatives must send a copy of the insured person's specific written consent with the review request
What address should I send my disputed claim to
Send your request for review to Office of Personnel Management Office of Insurance Programs Contract Division IV P O
Box 436 Washington D C 20044
What if OPM upholds the Plan's denial
OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which
you received the disputed services or supplies
What laws apply if I file a lawsuit
Federal law governs your lawsuit benefits and payment of benefits The Federal court will base 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
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Foundation Health HMO 2000
Section 4 What to do if we deny your claim or request for service
Your records and the Privacy Act
Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you 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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Foundation Health HMO 2000
Section 5 BENEFITS
What is covered
A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers These
services include 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 There is no cost to you for home visits by nurses and or health aides
The following additional services are also included
l Preventive care including well baby care and periodic check ups
l Mammograms
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
l Routine immunizations and boosters
l Consultations by specialists
l Diagnostic procedures such as laboratory tests and X rays
l Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor
The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery Inpatient stays will be extended if medically necessary Services of a Licensed nurse midwife or midwife and the
services of a birth center are available if a request is made to the Plan 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
l Voluntary sterilization you pay 200
l Family planning services
l Diagnosis and treatment of diseases of the eye
l Allergy testing and treatment including test and treatment materials such as allergy serum you pay a 15 copay per allergy
testing visit and nothing for allergy serum
l The insertion of internal prosthetic devices such as pacemakers and artificial joints
l Cornea heart heart lung kidney liver single lung double lung and pancreas transplants in conjunction with 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
l Mastectomies women at their option may have this procedure performed on an inpatient basis and remain in the hospital up
to 48 hours after the procedure
l Routine hearing and vision examinations up to age 18
l Dialysis
l Chemotherapy radiation therapy and inhalation therapy
l Surgical treatment of morbid obesity
l 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
l Durable medical equipment
l Prosthetic devices such as breast protheses an surgical bras artificial limbs and lenses following cataract removal and
orthotics Repair and replacement is covered when as a result of normal usage or changes in condition Over the counter
foot devices are not covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
Limited Benefits
The following services are covered with restrictions
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 treatment of temporomandibular joint TMJ pain
dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery
that has produced a major effect on the member's appearance and if the condition can reasonably be expected to be corrected by
such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech occupational and audio 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 is covered you pay a 10 copay per office visit The following types of artificial
insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you
pay 50 of covered charges cost of donor sperm is not covered Fertility drugs are not covered Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Outpatient Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided subject to
a 10 office visit copay
Inpatient cardiac rehabilitation is covered for up to 100 days per year you pay nothing
Chiropractic services are covered you pay a 10 copay per visit
What is not covered
The following services are not covered by Foundation Health
l 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
l Reversal of voluntary surgically induced sterility
l Surgery primarily for cosmetic purposes
l Hearing aids
l Long term rehabilitative therapy
l Homemaker services
l Transplants not listed as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 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 nothing All necessary services are covered including
l Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private
accommodations or private duty nursing care
l 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 doctor and approved by the
Plan You pay nothing All necessary services are covered including
l Bed board and general nursing care
l 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
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for
reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental
services unless such services are covered under the Plan's dental benefits 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 17 for nonmedical substance abuse benefits
What is not covered
l Personal comfort items such as telephone and television
l Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
EMERGENCY BENEFITS
What is a medical emergency
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could
result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if
not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to
breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in
common is the need for quick action
Emergencies within the service area
If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are unable to contact
your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room
Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member
should notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the
Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would
result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by
Plan providers
Plan pays
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay
25 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 outside the service area
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen
illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a
Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided
by Plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
Plan pays
Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan
providers
You pay
25 per hospital emergency room visit or 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 for emergencies both in and outside
of the service area
What is covered
l Emergency care at a doctor's office or an urgent care center
l Emergency care as an outpatient or inpatient at a hospital including doctors services
l Ambulance service approved by the Plan
What is not covered
l Elective care or nonemergency care
l Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
FILING CLAIMS FOR NON PLAN PROVIDERS
With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims
Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized
bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based If you
disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on
page 8
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
MENTAL CONDITIONS SUBSTANCE ABUSE BENEFITS
Mental conditions
What is covered
To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric
conditions including the treatment of mental illness or disorders
l Diagnostic evaluation
l Psychological testing
l Psychiatric treatment including individual and group therapy
l Hospitalization including inpatient professional services
Outpatient care
There are no limits on the number of visits to Plan doctors consultants or other psychiatric personnel during the calendar year
You pay a 10 copay for each covered private therapy session and a 10 copay for each covered group therapy session
Inpatient care
Covered in full at no cost to you with no day limitations
What is not covered
l Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement
through relatively short term treatment
l 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
l 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 40 outpatient visits to Plan providers for treatment each calendar year you pay a 10 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 40 outpatient visits per calendar year with the applicable mental
conditions benefit copayments
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
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 nothing
What is not covered
Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
PRESCRIPTION DRUG BENEFITS
What is covered
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day
supply You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not
available When generic substitution is available 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 5 copay per prescription unit or refill Drugs are prescribed by Plan doctors and dispensed in accordance with the
Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor
Foundation Health utilizes a formulary for prescription drug benefits Inclusion or removal of a particular drug on the formulary is
the consensus decision made by knowledgeable doctors pharmacists and nurses from a wide range of specialties The Pharmacy
and Therapeutics Committee meets quarterly For a committee to review a new drug for inclusion exclusion from its formulary the
drug must be on the market for at least six 6 months unless such drug constitutes a breakthrough for available therapies
l l Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs IUD's and diaphragms
Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent
and acetone test tablets
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medications for home use implantable drugs such as Norplant and injectable drugs such as
Depo Provera are covered under Medical and Surgical Benefits
l Limited benefits
Drugs to treat sexual dysfunction are limited to 4 pills or dosage units per month Prior approval is required
What is not covered
l Drugs available without a prescription or for which there is a nonprescription equivalent available
l Drugs obtained at a non Plan pharmacy except for out of area emergencies
l Vitamins and nutritional substances that can be purchased without a prescription
l Medical supplies such as dressings and antiseptics
l Drugs for cosmetic purposes
l Drugs to enhance athletic performance
l Smoking cessation drugs and medication including nicotine patches
l Fertility drugs
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
Other benefits
Vision care
What is covered
In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this Plan provides
annual eye refractions including written lens prescriptions from Plan providers You pay a 19 copay per visit The following
is covered
You pay
l Standard frames Nothing
l Single vision lens 20
l Bifocal lenses 25
l Trifocal lenses 30
l Daily wear contact lenses 10
l Extended wear contact lenses 15
l Disposable lenses 48
l All eyewear including contact lenses outside of the Plan standard 25 of charges
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB out of pocket maximum copay
charges etc These benefits are not subject to the FEHB disputed claims procedures
Medicare Prepaid Plan Enrollment This Plan offers Medicare beneficiaries whether actively working or annuitant the
opportunity to enroll in the Plan through Medicare As indicated on page 23
certain annuitants and former spouses who are covered
by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB Prior to dropping
your FEHB enrollment to change to a Medicare prepaid health plan you should contact your retirement system for more
information Contact us at 877 FHS 6899 or by fax at 954 846 8873 for information on the Medicare prepaid plan and the cost of
that enrollment
If you are entitled to Medicare benefits you may also choose to enroll in a Medicare HMO sponsored by this plan without
dropping your enrollment in this Plan's FEHB plan If you are interested in this option and would like more information on the
benefits available under the Medicare HMO and how they coordinate with your FEHB benefits contact us at 877 FHS 6899 or by
fax at 954 846 8873
Expanded Vision Care Discounts on vision services are available to Foundation Health members Services include Eye exams
Contact Lens Eye glasses Designer glasses sun glasses etc
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 5 BENEFITS
Dental Care Preventive and diagnostic services including Oral exams two per year Annual topical application of fluoride
Prophylaxis or cleaning one every six months All necessary X rays are covered when provided by a Plan dentist at no cost to
you The following dental services are covered when provided by Plan dentists but you are responsible for the outlined copayment
l Sealants per tooth you pay a 10 copay
l One surface amalgams you pay a 10 copay
l Three surface amalgams you pay a 30 copay
l One surface composite you pay a 16 copay
l Three surface composite you pay a 34 copay
l Porcelain crown fused to non precious metal you pay a 220 copay
l Single root canal you pay a 125 copay
Members enrolled in Codes 5D1 and 5D2 are not eligible for these dental benefits
Dental services not covered include
l Cosmetic elective or aesthetic dentistry
l Oral surgery requiring the setting of fractures or dislocations
l Treatment of malignancies cysts or neoplasm or congenital malformities
l Any dental service performed in a hospital
l Any procedure of implantation or experimental procedures
l General anesthesia
For details on specific services and discounts in your service area please call our Member Service Department at 877 FHS 6899
Benefits on this page are not part of the FEHB contract
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Foundation Health HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
l Services drugs or supplies that are not medically necessary
l Services not required according to accepted standards of medical dental or psychiatric practice
l Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred
services
l Experimental or investigational procedures treatments drugs or devices
l 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
l Procedures services drugs and supplies related to sex transformations
l Services or supplies you receive from a provider or facility barred from the FEHB Program and
l Expenses you incurred while you were not enrolled in this Plan
Foundation Health HMO 2000
Section 7 Limitations Rules that affect your benefits
Medicare
Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for
medical services and we will coordinate the payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is
available in your area For information on suspending your FEHB enrollment and changing to a Medicare Choice plan contact
your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at
any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced
We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA
at 1 800 638 6833 For information on the Medicare Choice plan offered by Foundation Health see Non FEHB Benefits
Available to Plan Members on page 20
Other group insurance coverage
When anyone has coverage with us and with another group health plan it is called double 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 your plan is the primary payer it pays benefits first The other plan is secondary it pays benefits
after the primary plan We decide which insurance is primary according to the National Association of Insurance Commissioners
Guidelines
If Foundation Health is secondary we will determine what the reasonable charge for the benefit should be After the primary 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 our control
Under certain extraordinary circumstances we may have to delay your services or be unable to provide them In that case we will
make all reasonable efforts to provide you with necessary care
When others are responsible for injuries
When you receive money to compensate you for medical or hospital care for injuries or illness that another person caused you
must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in
the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
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Foundation Health HMO 2000
Section 7 Limitations Rules that affect your benefits
TRICARE
TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the
CHAMPUS program If both TRICARE and this Plan cover you we are the primary payer See your TRICARE Health Benefits
Advisor if you have questions about TRICARE coverage
Workers compensation
We do not cover services that
l 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
l 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 Agencies
We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
If you have a malpractice claim
If you have a malpractice claim because of services you did or did not receive from a plan provider it must go to binding
arbitration Contact us about how to begin our binding arbitration process
Foundation Health HMO 2000
Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your
health plan its networks providers and facilities You can also 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 877 FHS 6899 or write to
Foundation Health
Attn Customer Services
1340 Concord Terrace
Sunrise FL 33323
You may also contact us by fax at 954 846 8873 or visit our website at www fhfl com
Where do I get information about enrolling in the FEHB Program
Your employment or retirement office can answer your questions and give you a Guide to Federal Employees Health Benefits
Plans brochures for other plans and other materials you need to make an informed decision about
l When you may change your enrollment
l How you can cover your family members
l What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
l When your enrollment ends and
l 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 employment or retirement office
When are my benefits and premiums effective
The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums begin on the first
day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
What happens when I retire
When you retire you can usually stay in the FEHB Program Generally you must have been 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
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Foundation Health HMO 2000
Section 8 FEHB FACTS
What types of coverage are available for me and my family
Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried dependent children
under age 22 including any foster or step children your employing or retirement office authorizes coverage for Under certain
circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your
family You may change your enrollment 31 days before to 60 days after you give birth or add the child to your family The benefits
and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor
will we Please tell us immediately when you add or remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
Are my medical and claims records confidential
We will keep your medical and claims information confidential Only the following will have access to it
l OPM this Plan and subcontractors when they administer this contract
l This plan and appropriate third parties such as other insurance plans and the Office of Worker's Compensation
Programs OWCP when coordinating benefit payments and subrogating claims
l Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
l OPM and the General Accounting Office when conducting audits
l Individuals involved in bona fide medical research or education that does not disclose your identity or
l OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards
We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant
confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a 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
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Foundation Health HMO 2000
Section 8 FEHB FACTS
When you lose benefits
What happens if my enrollment in this Plan ends
You will receive an additional 31 days of coverage for no additional premium when
Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse coverage
If you are divorced from a Federal employee or annuitant you may not continue to get benefits 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
Key points about TCC
l You can pick a new plan
l If you leave Federal service you can receive TCC for up to 18 months after you separate
l If you no longer qualify as a family member you can receive TCC for up to 36 months
l Your TCC enrollment starts after regular coverage ends
l 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
l You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
l You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying
the premium
l You are not eligible for TCC if you can receive regular FEHB Program benefits
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Foundation Health HMO 2000
Section 8 FEHB FACTS
How do I enroll in TCC
If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60
days of leaving or receiving this notice whichever is later
Children You must notify your employment 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 employment or retirement office within 60 days of one of these
qualifying events
l Divorce
l Loss of spouse equity coverage within 36 months after the divorce
Your employment 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 individual coverage
You may convert to an individual policy if
l Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you
cannot convert
l You decided not to receive coverage under TCC or the spouse equity law or
l You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to
us within 31 days after you receive this notice However if you are a family member who is losing coverage the employing or
retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your
health and we will not impose a waiting period or limit your coverage due to pre existing conditions
How can I get a Certificate of Group Health Plan Coverage
If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us You can use this certificate when getting health insurance or other health care coverage You must arrange
for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a
certificate from them as well
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Foundation Health HMO 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
l Call the provider and ask for an explanation There may be an error
l If the provider does not resolve the matter call us at 877 FHS 6899 and explain the situation
l 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
l Try to obtain services for a person who is not an eligible family member or
l Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
Foundation Health HMO 2000
Summary of Benefits for Foundation Health a Florida Health Plan 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 page 5
of this brochure
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 13
Extended Care All necessary services You pay nothing 13
Mental Conditions Diagnosis and treatment of acute psychiatric conditions with no day
limitations You pay nothing 17
Substance Abuse Up to 30 days per year in a substance abuse treatment program You pay nothing 17
OutpatientCare 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 10 per house
call by a doctor 11
Home Health Care All necessary visits by nurses and health aides You pay a 10 copay per visit 11
Outpatient
Mental Conditions No annual limit on outpatient visits You pay a 10 copay per visit 17
Outpatient
Substance Abuse Up to 40 outpatient visits per year You pay a 10 copay per visit 17
Emergency Care Reasonable charges for services and supplies required because of a medical
emergency You pay a 25 copay to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan 14
Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy
You pay a 5 copay per prescription unit or refill 19
Vision Care Annual eye refractions You pay a 19 copay per visit and various copays on
frames and lenses 20
Out of Pocket Maximum Your out of pocket expenses for benefits under this Plan are limited to the stated
copayments required for a few benefits 5
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2000 Rate Information for Foundation Health a Florida Health Plan Inc
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 Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Southern Florida
Self Only 5E1 54.82 18.27 118.77 39.59 64.87 8.22 64.87 8.22
Self and Family 5E2 150.76 50.25 326.64 108.88 178.40 22.61 178.40 22.61
Central Florida
Self Only 5D1 66.32 22.10 143.69 47.89 78.47 9.95 78.47 9.95
Self and Family 5D2 175.97 73.18 381.27 158.56 207.74 41.41 201.02 48.13
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