A Health Maintenance Organization
For
changes
In benefits
See page 6
Serving Oklahoma City Tulsa Enid and Lawton Areas
Enrollment in this plan is limited see page 7 for requirements
Enrollment code
6W1 Self Only
6W2 Self and Family
Visit the OPM website at HYPERLINK http www opm gov insure
and
our website at http www healthcare ok com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
HealthCare Oklahoma 2000
Table of Contents
Page
Introduction
3
Plain language
3
How to use this brochure
4
Section 1 Health Maintenance Organizations
5
Section 2 How we change for 2000
6
Section 3 How to get benefits
7
Section 4 What to do if we deny your claim or request for service
11
Section 5 Benefits
13
Section 6 General exclusions Things we don't cover
24
Section 7 Limitations Rules that affect your benefits
25
Section 8 FEHB facts
27
Inspector General Advisory Stop Healthcare Fraud
31
Summary of benefits
32
Premiums
34
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HealthCare Oklahoma 2000
Introduction
HealthCare Oklahoma 3030 NW Expressway Suite 140 Oklahoma City OK 73112
This brochure describes the benefits you can receive from HealthCare Oklahoma under its contract CS2796 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
6 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 HealthCare Oklahoma 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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HealthCare Oklahoma 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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HealthCare Oklahoma 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
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HealthCare Oklahoma 2000
Section 2 How We Change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes care office visits See page 13
This year you have a right to more information about this Plan care management our networks
facilities and providers See page 27
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 See page 28
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer See page 13
Changes to this Your share of the non postal premium will decrease by 2.5 for Self Only or 2.5 for Self and
Plan Family
HealthCare Oklahoma has been re designated as a Mixed Model plan as it now
contracts with four Global Medical Risk Groups The four groups are the Oklahoma City Clinic
Integris MSO ProMedica and Central Oklahoma Medical Group COMG See page 8
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HealthCare Oklahoma 2000
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 We have expanded our service area to include all of Blaine and Custer Counties See below County Zip Code
Blaine Entire County
Canadian 73014 73022 73036 73047 73064 73078 73085 73090 73097
73099
Cherokee 74441 74444 74451 74452 74464 74465
Cleveland Entire County
Comanche Entire County
Creek Entire County
Custer Entire County
Delaware Entire County
Garfield Entire County
Grady Entire County
Grant Entire County
Kay Entire County
Kingfisher Entire County
Lincoln Entire County
Logan Entire County
Mayes Entire County
McClain 73010 73031 73065 73080 73093
Muskogee 74436
Noble Entire County
Oklahoma Entire County
Okmulgee Entire County
Osage 74035 74054 74060 74070
Ottawa Entire County
Pawnee Entire County
Payne Entire County
Pottawatomie Entire County
Rogers Entire County
Seminole Entire County
Tulsa Entire County
Wagoner Entire County
Washington 74082
Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care We will not pay for any other
health care services
If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements with
affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office
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HealthCare Oklahoma 2000
Section 3 How to get benefits continued
How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount
for services or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
After you pay 300 in copayments or coinsurance for one family member or 750 for three 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 your
prescription drugs durable medical equipment chemical dependency vision services and dental
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 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 my HealthCare Oklahoma's network includes approximately 659 primary care doctors 1621
health care specialists and 36 hospitals When you enroll in HealthCare Oklahoma you choose a primary care doctor for you and each member of your family You can choose from a large list of family
medicine general practice internal medicine and pediatric doctors You can choose a different
primary care doctor for each member of your family If you select a primary care doctor from the
Oklahoma City Clinic Integris MSO ProMedica or Central Oklahoma Medical Group your
specialty care including self referrals must be provided by that group's specialists unless the care
you need is not available within that group
What do I do if I want Call our customer service department at 405 951 4750 918 523 6550 or 800 535 2244 and request a change Any requests received on or before the 25 th day of any month are made effective
to change the first day of the following month Requests made after the 25 th day of any month are effective
my primary care the first day of the second following month You can change as often as you like to any of the
doctor primary care doctors in our network
What do I do if my Call us We will help you select a new one
primary care
physician leaves the
Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or
to go into the hospital specialist will make the necessary hospital arrangements and supervise your care
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HealthCare Oklahoma 2000
Section 3 How to get benefits continued
What do I do if I'm in First call our customer service department at 405 951 4750 918 523 6550 or 800 535 2244 If
the hospital when I you are new to the FEHB Program we will arrange for you to receive care If you are currently in
join this Plan the FEHB Program and are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
Your primary care physician will arrange your referral to a specialist How do I get specialty
care 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 primary care doctor will contact
HealthCare Oklahoma for an authorization when necessary
You must get a referral from your primary care doctor for all specialty care except for the
Can I self refer to a following
specialist
Routine Well Woman Exam You may self refer to an OB Gyn in our network once a year for a routine well woman exam Remember if you picked a primary care doctor from one of the
groups listed above you must self refer to an OB Gyn within that group
Mental Health and Chemical Dependency You do not need a referral from your primary care doctor for these services Simply call Integris Behavioral Specialists at 888 720 2912 for an
appointment with one of their many specialists
Your primary care physician will decide what treatment you need If they decide to refer you to a
What do I do if I am specialist ask if you can see your current specialist If your current specialist does not participate
seeing a specialist with us you must receive treatment from a specialist who does Generally we will not pay for you
when I enroll to see a specialist who does not participate with our Plan
Call your primary care physician who will arrange for you to see another specialist You may
What do I do if my receive services from your current specialist until we can make arrangements for you to see
specialist leaves the someone else
Plan
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HealthCare Oklahoma 2000
Section 3 How to get benefits continued
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or third
Plan or this Plan trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
leaves the Program care
You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a
medical services specialist or recommending follow up care Before giving approval we consider if the service
is medically necessary and if it follows generally accepted medical practice
How do you decide if a A service is considered experimental or investigational if reliable evidence shows at least one of
service is experimental the following
or investigational the drug device or medical service is the subject of ongoing Phase I II or III clinical trials
or under study to determine its maximum tolerated dose its toxicity its safety or its
efficacy as compared with the standard means of treatment or diagnosis or
the consensus among appropriately qualified consultants of HealthCare Oklahoma about the drug device or medical service is that further studies or clinical trials are needed to decide
its maximum tolerated dose its toxicity its efficacy or its efficacy as compared with the
standard means of treatment or diagnosis
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HealthCare Oklahoma 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
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a Call us at 405 951 4750 918 523 6550 or 800 535 2244 and we will expedite our review
serious or life
threatening condition
and you haven't
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
care and my condition health benefits Division III at 202 606 0755 between 8 a m and 5 p m Serious or lifethreatening
is serious or life conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
threatening
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
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HealthCare Oklahoma 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians'letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim Contract Division III P O Box 436 Washington D C 20044
OPM's decision is final There are no other administrative appeals If OPM agrees with our What if OPM upholds
decision your only recourse is to sue the Plan's denial
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record
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HealthCare Oklahoma 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10
office visit copay but no additional copay for laboratory tests and 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 and nothing for home 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
At a minimum 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 no copay if no associated office visit
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor You pay a 10 copayment for the initial prenatal visit and
then nothing for the rest of your prenatal and postnatal care The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after cesarean
delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is
terminated during pregnancy benefits will not be provided after coverage under the Plan has
ended Ordinary nursery care of the newborn child during the covered portion of the mother's
hospital confinement for maternity will be covered under either a Self Only or Self and Family
enrollment other care of an infant who requires definitive treatment will be covered only if the
infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services implantable drugs injectables You pay
Depo Provera Injection 10 copayment
Norplant Insertion Removal 50 of charges
IUD Insertion Removal 50 of charges
Female Sterilization no copayment
Male Sterilization 10 copayment
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued What is covered The insertion of internal prosthetic devices such as pacemakers and artificial joints
continued
Cornea heart lung single and double heart lung kidney pancreas kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions acute
lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced
non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma
epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell
tumors Transplants are covered when approved by the Medical Director Related medical
and hospital expenses of the donor are covered when the recipient is covered by this Plan
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 no copayment
Chemotherapy radiation therapy and inhalation therapy no copayment
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need no copayment
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
Blood and blood plasma
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 shortening of the mandible or maxillae for
cosmetic purposes correction of malocclusions and 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
Limited Benefits Short term rehabilitative therapy physical speech and occupational is provided on an continued inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within two months 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 self care and
improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 50 of charges The following types
of artificial insemination are covered intravaginal insemination IVI and intracervical
insemination ICI you pay 25 of charges cost of donor sperm is not covered Fertility drugs
are not covered Other assisted reproductive technology ART procedures such as in vitro
fertilization embryo transfer and intrauterine insemination IUI are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided for up to 36 sessions you pay nothing
Durable Medical Equipment such as wheelchairs hospital beds and glucose monitors is
covered You pay 20 of charges Plan provides an annual maximum benefit of 5,000
Prosthetic devices such as artificial limbs and lenses following cataract removal and orthopedic
devices such as braces are covered You pay 20 of charges Plan provides a lifetime benefit
maximum of 10,000 except breast protheses and surgical bras following mastectomies as well as
their replacement are not limited to this maximum
Chiropractic services are covered you pay a 10 copayment for up to 30 visits per calendar year
Treatment is limited to medically necessary manual manipulations of the spine to correct a
subluxation that can be demonstrated by X ray
Smoking cessation program covered drugs medications HealthCare Oklahoma will
reimburse each covered Member one smoking cessation program per year at a 50 copay by the
member with a maximum benefit of 140 Call the Plan for more information including which
providers you should use
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Custodial or personal care not requiring skilled nursing
Foot orthotics
Corrective eyeglasses frames and contact lenses including the fitting of contact lenses except as
necessary for the first pair of corrective lenses following cataract surgery
Refractions including lens prescriptions
Refractive surgery
Uvulopalatopharyngoplasty UPPP and other surgical procedures for the treatment of sleep apnea
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Blood and blood plasma
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
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a 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 Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient
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 Pages 20 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Emergency Benefits What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes
poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions
that the Plan may determine are medical emergencies what they all have in common is the need
for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme
the service area emergencies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency
room personnel that you are a Plan member so they can notify the Plan You or a family member
must 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 in a non Plan facility the Plan must be notified within 48 hours or
on the first working day following your admission unless it was not reasonably possible to notify
the Plan within that time If you are hospitalized in non Plan facilities and 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
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 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan doctor believes care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 50 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
copay is waived
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Emergency Benefits continued
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or non emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency
providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the
Plan along with an explanation of the services and the identification information from your ID
card Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's
decision you may request reconsideration in accordance with the disputed claims procedure
described on Page 11
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or
disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 self referred outpatient visits to the Plan's participating mental health provider each calendar year you pay a 20 copay for each covered visit all charges thereafter The Plan's
mental health provider must assess and evaluate your needs and approve and coordinate all
outpatient mental health care To arrange for any mental health care services call INTEGRIS
Behavioral Specialists at 405 720 2912 or 888 720 2912
Inpatient care Up to 30 days of hospitalization each calendar year you pay 20 of charges for the first 30 days all charges thereafter You may self refer to the Plan mental health provider for these services
The Plan's mental health provider must assess and evaluate your needs and approve and
coordinate all inpatient mental health care To arrange for any mental health care services call
INTEGRIS Behavioral Specialists at 405 720 2912 or 888 720 2912
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing that is 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 self referred outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit all charges thereafter The Plan's mental health
provider must assess and evaluate your needs and approve and coordinate all outpatient
substance abuse care To arrange for any mental health care services call INTEGRIS
Behavioral Specialists at 405 720 2912 or 888 720 2912
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan Two days in a participating day
treatment facility or three intensive outpatient treatment can equal one inpatient day you pay 20
of charges during the benefit period all charges thereafter You may self refer to the Plan
substance abuse provider The Plan's mental health provider must assess and evaluate your needs
and approve and coordinate all inpatient substance abuse care To arrange for any mental health
care services call INTEGRIS Behavioral Specialists at 405 720 2912 or 888 720 2912
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits continued
What is not covered Treatment that is not provided by the Plan's substance abuse provider
Halfway houses and court ordered treatment
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 or 100 unit supply whichever is less You pay a 5 copay per
prescription unit or refill for generic drugs and a 10 copay per prescription unit or refill for brandname
drugs or non formulary drugs A mail order benefit is available that offers a ninety day
supply at two times the applicable copayment contact the Plan for information
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 HealthCare Oklahoma
has a Pharmacy Therapeutics Technology PT T committee that meets every other month
This committee which includes doctors and pharmacists who participate with the health plan
review new FDA approved drugs and technologies This committee decides what drugs should be
added to or removed from the HealthCare Oklahoma drug formulary
Covered medications and accessories include
Drugs for which a prescription is required by Federal or State law
All FDA approved oral contraceptive drugs and contraceptive devices IUDs are covered under Medical and Surgical Benefits
Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets
Intravenous fluids and medication for home use implantable drugs such as Norplant and some
injectable drugs such as Depo Provera are covered under Medical and Surgical Benefits
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent
available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 2000
Section 5 Benefits continued
Other Benefits
What is covered
Dental care
Accidental Restorative services and supplies necessary to promptly repair but not replace sound natural
injury benefit teeth The need for these services must result from an accidental injury You pay 10 per visit
What is not covered Other dental services not shown as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HealthCare Oklahoma 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 of pocket maximums These benefits
are not subject to the FEHB disputed claims procedure
Medicare prepaid plan enrollment this plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As
indicated on page 25 annuitants and former spouses with FEHB coverage and Medicare Part A and Part B may elect to drop their
FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later reenroll in the FEHB
Program Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid
plan
Dental Benefits As a member of HealthCare Oklahoma you are eligible to join Protective DentalCare UDC As a Protective DentalCare UDC
member you and your family can have affordable quality dental care The plan covers preventive basic and major services
Compare these advantages No deductible
No annual or lifetime maximum benefit limit
No claim forms or pre authorization
No limitation on pre existing conditions except for dental work in progress
Orthodontic coverage for both children and adults
Monthly premiums There are no monthly premiums for you to pay Premiums are paid by HealthCare Oklahoma You save
between 9 to 23 per month
How to enroll You will automatically be enrolled when you enroll in HealthCare Oklahoma Your packet includes the
specific schedule of benefits and copayments as well as a participating dentist directory To choose your
participating dentist please call Protective DentalCare at 800 443 0225
Vision Care WE'RE OFFERING YOU MORE
When you sign up with HealthCare Oklahoma you will automatically receive a vision care benefit administered by Vision Service
Plan of America VSP VSP offers a statewide list of vision providers from which you can choose to receive your eye exam as well
as your eye glasses You can find a list of providers in the HealthCare Oklahoma provider directory or you may call 1 800 877 7195
What is covered An eye exam every 12 months from a participating vision provider You pay a 15 copayment If you decide to purchase your eye glasses from the provider at the time of your exam you will receive a 20
discount from the usual and customary fees for your eye glasses
How to receive Call the participating vision provider to schedule the appointment Give your Social Security number and
benefits the doctor will contact VSP for you to verify benefits
What is not covered Costs associated with securing materials such as lenses and frames however there is a 20 discount on eye glasses when obtained from a participating vision provider
Orthoptics or vision training and any associated supplemental testing
Medical or surgical treatment of the eyes
Any eye examination required by an employer as a condition of employment
Benefits on this page are not part of the FEHB contract
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HealthCare Oklahoma 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
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HealthCare Oklahoma 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 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 23
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
our control provide them In that case we will make all reasonable efforts to provide you with necessary care
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HealthCare Oklahoma 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover
the cost of treatment that exceeds the amount you received in the settlement If you do not seek
damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the
military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they
must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly
Agencies or indirectly pays for
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HealthCare Oklahoma 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 405 951 4750 918 523 6550 or 800 535 2244 or write to 3030 NW Expressway
Suite 140 Oklahoma City OK 73112 You may also contact us by fax at 405 951 5046 or visit our website at www healthcareok
com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the FEHB an informed decision about
Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been
retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation
of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are available unmarried dependent children under age 22 including any foster or step children your employing
for my family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
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HealthCare Oklahoma 2000
Section 8 FEHB FACTS continued
What types of If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
coverage are give birth or add a child to your family You may change your enrollment 31 days before to 60
available for my days after you give birth or add the child to your family The benefits and premiums for your Self
family and me and Family enrollment begin on the first day of the pay period in which the child is born or continued 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 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 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 Your old plan's deductible continues until our coverage begins
old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
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HealthCare Oklahoma 2000
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan
ends 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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage
because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You
may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI 79
27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
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HealthCare Oklahoma 2000
When you lose benefits continued
How do I enroll in
TCC Children You must notify your employing or retirement office within 60 days after your child is Continued no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling
in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline
How can I convert to
individual coverage You may convert to an individual policy if Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice However
if you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a
Certificate of Group If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Health Plan indicates how long you have been enrolled with us You can use this certificate when getting
Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
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HealthCare Oklahoma 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 405 951 4750 918 523 6550 or 800 535 2244 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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HealthCare Oklahoma 2000
Summary of Benefits for HealthCare Oklahoma 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 Comprehensive range of medical and surgical services
care Hospital 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 17
All necessary services for up to 100 days per year You
Extended care pay nothing 17
Diagnosis and treatment of acute psychiatric conditions Mental conditions
for up to 30 days of inpatient care per year You pay
20 of charges 20
Up to 30 days per year in an inpatient substance abuse Substance abuse
treatment program You pay 20 of charges 20
Comprehensive range of services such as diagnosis and
Outpatient treatment of illness or injury including specialist's care
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 after
the initial visit 10 per house call by a doctor 13 22
All necessary visits by nurses and health aides You pay Home health care
nothing 14
Up to 20 outpatient visits per year You pay a 20 copay Mental conditions
per visit 20 21
Up to 20 outpatient visits per year You pay a 20 copay Substance abuse
per visit 20 21
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HealthCare Oklahoma 2000
Summary of Benefits for HealthCare Oklahoma 2000 continued
Benefits Plan pays provides Page
Emergency Reasonable charges for services and supplies
care required because of 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 18 19
Prescription Drugs prescribed by a Plan doctor and
drugs obtained at a Plan pharmacy You pay a 5 generic 10 brand name or non formulary
copay per prescription unit or refill 21
Dental care Accidental injury benefit you pay 10 copay Preventive dental care no current benefit 22
Vision care No current benefit
Copayments are required for a few benefits Out of pocket
however after your out of pocket expenses maximum
reach a maximum of 300.00 per Self Only or
750.00 per Self and Family enrollment per
calendar year covered benefits will be
provided at 100 This copay maximum does
not include charges for prescription drugs
durable medical equipment or expenses
incurred for non covered services 8
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HealthCare Oklahoma 2000
2000 Rate Information for
HealthCare Oklahoma Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category
A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member of a
special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United
States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Oklahoma City Lawton Tulsa Enid areas
Self Only 6W1 57.41 19.13 124.38 41.46 67.93 8.61 67.93 8.61
Self and Family 6W2 149.15 49.72 323.17 107.72 176.50 22.37 176.50 22.37
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Filename play1 doc
Directory C My Documents FED2000
Template C Program Files Microsoft
Office Templates NORMAL DOT
Title Health maintenance organizations HMOs are
comprehensive medical plans where you see Plan providers specific doctors
hospitals and other providers which contract with this Plan
Subject
Author Ellen Tunstall
Keywords
Comments
Creation Date 10 06 99 12 58 PM
Change Number 12
Last Saved On 10 06 99 1 32 PM
Last Saved By Wellcor America
Total Editing Time 35 Minutes
Last Printed On 10 06 99 1 33 PM
As of Last Complete Printing
Number of Pages 34
Number of Words 10,216 approx
Number of Characters 58,234 approx
35