OSF HealthPlans Inc 2000
OSF HealthPlans Inc 2000
A Health Maintenance Organization
Serving Central Illinois and CentralNorthwestern Illinois
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
9F1 Self only
9F2 Self and family
Visit the OPM website at httpwwwopmgovinsure
and
this Plans website at httpwwwosfhealthcareorghealthplans
Authorized for distribution by the
United States
Office of
Personnel
Management
OSF HealthPlans Inc 2000
Table of Contents
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 45
Section 4 What to do if we deny your claim or request for service 67
Section 5 Benefits 817
Section 6 General exclusions Things we dont cover 18
Section 7 Limitations Rules that affect your benefits 1920
Section 8 FEHB FACTS 2123
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits Inside back cover
Premiums Back cover
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OSF HealthPlans Inc 2000
Introduction
OSF HealthPlans
7915 N Hale Ave Suite D
Peoria IL 616152047
This brochure describes the benefits you can receive from OSF HealthPlans under its contract CS 2829 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 3
Premiums are listed at the end of this brochure
Plain Language
The President and Vice President are making the Governments 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 OSF HealthPlans 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 rewritten the Benefits section of this brochure You will find new benefits language next year
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OSF HealthPlans Inc 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plans 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
6 General exclusions Things we dont 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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OSF HealthPlans Inc 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventive care such
as routine office visits physical exams wellbaby 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 or approved outofnetwork specialist services you may have to
submit claim forms
You should join an HMO because you prefer the plans 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 andor
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Programwide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes care office visits
This year you have a right to more information about this Plan care management our net
works 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
OBGYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not
amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer
Changes to this Your share of the nonpostal premium will decrease by 56 for Self Only and by 61 for Self
Plan and Family
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy are
now subject to a 7 copay per prescription unit or refill for generic drugs and a 15 copay per
prescription unit or refill for name brand drugs for up to a 34day supply Previously there was
a 5 copay per prescription unit or refill for generic or name brand drugs for up to a 34day
supply See page 16
Mail order prescription drugs are now subject to a 14 copay per prescription unit or refill for
generic drugs and a 30 copay per prescription unit or refill for name brand drugs for up to a
90day supply Previously there was a 5 copay per prescription unit or refill for generic or
name brand drugs for up to a 90day supply See page 16
The Plans service area has been expanded in the State of Illinois to include the counties of Lee
and Whiteside See page 4
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OSF HealthPlans Inc 2000
Section 3 How to get benefits
What is this Plans service To enroll with us you must live or work in our service area This is where our providers
area practice Our service area is
Central Illinois Dewitt Fulton Knox Livingston Marshall McLean Peoria Tazewell and
Woodford Counties
CentralNorthern Illinois Boone Bureau DeKalb Henderson Henry Kane LaSalle Lee
McDonough McHenry Mercer Ogle Putnam Stark Stephenson Warren Whiteside and
Winnebago Counties
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 or urgent care
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 feeforservice plan or an HMO that has
agreements with affiliates in other areas If you or a family member move you do not have to
wait until Open Season to change plans Contact your employing or retirement office
How much do I pay for You must share the cost of some services This is called either a copayment a set dollar
services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
After you pay 1000 in copayments or coinsurance for one family member or 2000 for two
or more family members you do not have to make any further payments for certain services for
the rest of the year Benefits for these covered services will be provided at 100 This is
called a catastrophic limit However copayments or coinsurance for your prescription drugs
durable medical equipment prosthetic devices or orthopedic devices 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 respon
sible for informing us when you reach the limits
Do I have to submit claims You normally wont have to submit claims to us unless you receive emergency services from a provider who doesnt 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 health OSF HealthPlans Inc is a Mixed Model Prepayment MMP plan The Plan contracts with
care hospitals group physician practices individual physician practices and other health care providers that provide medical care to members in central Illinois and centralnorthern Illinois
The Plan offers primary care services through pediatricians family practitioners and internists
Female members may access care from network OBGYNs without a referral from their
Primary Care Physician PCP The network provider OBGYN or the members primary care
physician must make further referrals and preauthorizations for covered services
If for any reason you would like to change your Primary Care Physician please contact
Member Services You may change two 2 times a year with a thirty 30 day interval
between changes If you contact us by the fifteenth 15th of the month your change will be
effective the first of the following month If you contact us after the fifteenth 15th there will
be a month between changes This allows enough time for offices to schedule appointments
and to notify Primary Care Physicians of new patients
What do I do if my primary Call us We will help you select a new one
care physician leaves the
Plan
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OSF HealthPlans Inc 2000
Section 3 How to get benefits continued
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 manage your care
What do I do if Im in First call our Member Service Department at 800OSF5222 If you are new to the FEHB
the hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program and
this Plan are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist
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 physi
cian and specialist will work together with you and the Plan when creating your treatment plan
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to
seeing a specialist when a specialist ask if you can see your current specialist If your current specialist does not
I enroll 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
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to
illness and my provider continue seeing your provider for up to 90 days after we notify you that we are terminating our
leaves the Plan or this Plan contract with the provider unless the termination is for cause If you are in the second or third
leave the Program trimester of pregnancy you may continue to see your OBGYN 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
OBGYN care you receive from your current provider until the end of your postpartum care
How do I authorize Your physician must get our approval before sending you to a hospital referring you to a
medical services specialist or recommending followup care Before giving approval we consider if the service is a covered benefit is medically necessary and if it follows generally accepted medical
practice guidelines
How do you decide if a The Plan uses a range of sources to decide if a new procedure process or pharmaceutical is or
service is experimental or is not experimental or investigational These sources include but are not limited to an inde
investigational pendent third party evaluation where valid an agreement of specialists in the related field the Food and Drug Administration Medicare Guidelines Hayes Technology Assessment and other
available sources of medical information All information is given to the Plans Utilization
Management Committee by the Plans Medical Director for a decision The Medical Director
also uses the resources of the Plans Technology Assessment Committee
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OSF HealthPlans Inc 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days
after we receive the additional information If we do not receive the requested information within 60 days we will make our decision
based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or
OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service
What if I have a Call us at 800OSF5222 and we will expedite our review
serious or life
threatening condition
and you havent
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can
for care and my call OPMs Health Benefits Contracts Division 3 at 2026060755 between 8 am and 5 pm
condition is serious Serious or lifethreatening conditions are ones that may cause permanent loss of bodily func
or life threatening tions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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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 provi
sions 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
persons representative They must send a copy of the persons specific written consent with
the review request
Where should I Send your request for review to Office of Personnel Management Office of Insurance Pro
mail my disputed grams Contracts Division 3 PO Box 436 Washington DC 20044
claim to OPM
What if OPM OPMs decision is final There are no other administrative appeals If OPM agrees with our
upholds the Plans decision your only recourse is to sue
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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will
I file a lawsuit 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 treat
ment services supplies or drugs covered by us until you have completed the OPM review
procedure described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from
the Privacy Act 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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OSF HealthPlans Inc 2000
Section 5 Benefits
Medical and Surgical A comprehensive range of preventive diagnostic and treatment services is provided by Plan
Benefits 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 Xrays when provided at this visit
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 doctors house call and nothing for
home visits by nurses and health aides
What is covered The following services are included and are subject to the office visit copay unless stated
otherwise
Preventive care routine hearing and vision screening up to age 18 wellbaby care and
periodic checkups
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 and for women age 50 and older one mammogram every year In addition to routine
screening mammograms are covered when prescribed by the doctor as medically necessary
to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and Xrays
Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor The mother at her option may remain in the hospital
up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient
stays will be extended if medically necessary If enrollment in the Plan is terminated during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary
nursery care of the newborn child during the covered portion of the mothers hospital
confinement for maternity will be covered under either a Self Only or Self and Family
enrollment other care of an infant who requires definitive treatment will be covered only if
the infant is covered under a Self and Family enrollment You pay a 50 copay per preg
nancy which includes all prenatal and postnatal care
Voluntary sterilization and family planning services
Infertility services diagnosis and treatment including the following types of artificial
insemination intracervical insemination ICI intrauterine insemination IUI and intrav
aginal insemination IVI in vitro fertilization and embryo transfers Fertility drugs are
covered under the Prescription Drug Benefit
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy
serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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OSF HealthPlans Inc 2000
Medical and Surgical Benefits continued
Cornea heart heartlung kidney kidneypancreas liver and lung single and double
transplants allogeneic donor bone marrow transplants autologous bone marrow trans
plants autologous stem cell and peripheral stem cell support for the following conditions
acute lymphocytic or nonlymphocytic leukemia advanced Hodgkins lymphoma advanced
nonHodgkins 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 and provided by
Plan providers Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on
an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medica
tions when prescribed by your Plan doctor who will periodically review the program for
continuing appropriateness and need you pay nothing
All necessary medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization proce dures 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 intraoral areas surrounding the teeth are not covered including any dental care
involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or from an injury or surgery that has produced a major effect on the members appear
ance 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
Shortterm rehabilitative therapy physical speech and occupational is provided on an
inpatient basis for up to 60 days per calendar year you pay nothing and on an outpatient basis
for up to 60 treatments per calendar year you pay 10 per outpatient session Speech therapy
is limited to treatment of certain speech impairments of organic origin Occupational therapy is
limited to services that assist the member to achieve and maintain selfcare and improved
functioning in other activities of daily living
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
is provided for Phases I and II as preauthorized by the members primary care doctor you
pay a 10 copay
Durable medical equipment such as wheelchairs and hospital beds Prosthetic devices such
as artificial limbs lenses following cataract removal and breast prostheses surgical bras and
their replacements and Orthopedic devices such as braces and foot orthotics which are an
integral part of a lower body brace are covered You pay 20 of charges up to a combined
10000 calendar year benefit maximum
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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OSF HealthPlans Inc 2000
Medical and Surgical Benefits continued
What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgicallyinduced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Longterm rehabilitative therapy
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as
nearsightedness myopia farsightedness hyperopia and astigmatism blurring
Dental benefits
Cost of donor sperm
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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HospitalExtended 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 neces
sary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits up to 90 days per calendar year when fulltime 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 You pay nothing
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 Conditions for
which hospitalization would be covered include hemophilia and heart disease the need for
anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagno
detoxification sis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 15 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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 immedi ate 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 lifethreatening such as heart attacks strokes
poisonings gunshot wounds or sudden inability to breathe There are many other acute
conditions that the Plan may determine are medical emergencies what they all have in
common is the need for quick action
Emergencies within the If you are in an emergency situation go to the nearest Emergency care facility however if a
service area member has questions as to whether or not an emergency condition exists his or her primary care doctor or covering physician will be available 24 hours a day 7 days a week for assistance
Once at the emergency facility 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 of receiving care or as soon thereafter as medically possible 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 following your
admission unless it is not reasonably possible to notify the Plan within that time If you are
hospitalized in nonPlan facilities and a Plan doctor believes care can be 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 nonPlan 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 followup care recommended by nonPlan providers must be
approved by the Plan
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
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Emergency Benefits continued
Emergencies Benefits are available for any medically necessary health service that is immediately required
outside the because of injury or unforeseen illness
service area If you need to be hospitalized the Plan must be notified within 48 hours following your
admission unless it is not reasonably possible to notify the Plan within that time If you are
hospitalized in nonPlan facilities and a Plan doctor believes care can be 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 followup care recommended by nonPlan providers must be
approved by the Plan
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
What is covered Emergency care at a doctors office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not Elective care or nonemergency care
covered Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area
Medical and hospital costs resulting from a normal fullterm delivery of a baby outside the
service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
nonPlan 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
Plans decision you may request reconsideration in accordance with the disputed claims
procedure described on page 6
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OSF HealthPlans Inc 2000
Mental ConditionsSubstance Abuse Benefits
Members may access mental health services by calling United Behavioral Health UBH at
18004205729 and you may be referred to a participating provider
Mental conditions 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
What is covered Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay a 30 copay for each covered visit all charges thereafter Group outpatient visits may
be substituted on a twotoone basis for individual outpatient visits you pay a 15 copay per
group visit limited to 40 visits per calendar year
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter Care in a day hospital or intensive outpatient mode may be substituted on a
twotoone basis up to 60 days per calendar year
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not
covered subject to significant improvement through relatively shortterm 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 shortterm psychiatric condition
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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OSF HealthPlans Inc 2000
Mental ConditionsSubstance Abuse Benefits continued
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric 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
What is covered
Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 30 copay for each covered visit all charges thereafter Group outpatient visits may be substi
tuted on a twotoone basis for individual outpatient visits you pay a 15 copay per group
visit limited to 40 visits per calendar year
Inpatient care Up to 21 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the
benefit period all charges thereafter Care in a day hospital or intensive outpatient mode
may be substituted on a twotoone basis up to 42 days per calendar year
What is not Treatment that is not authorized by a Plan doctor
covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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OSF HealthPlans Inc 2000
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 34day supply You pay a 7 copay per prescription unit or refill for
generic drugs and a 15 copay per prescription unit or refill for name brand drugs
You pay a 7 copay per prescription unit or refill for generic drugs or for name brand drugs
when generic substitution is not permissible When generic substitution is permissible ie 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 15 copay per prescription unit or refill
Mail order prescription maintenance drugs will be dispensed for up to a 90day supply You
pay a 14 copay per prescription unit or refill for generic drugs and a 30 copay per prescrip
tion unit or refill for name brand drugs Some drugs are not available through the mail order
prescription drug program and must be obtained at a Plan pharmacy and can only be obtained
for up to a 34day supply rather than for up to a 90day supply
The Plan utilizes a voluntary drug formulary Nonformulary drugs are covered when prescribed
by a Plan doctor Any future additions or deletions to the formulary will be brought to the
Plans Utilization Management Committee for discussion and final determination
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Fertility drugs
Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication including
insulin a copay charge applies to each 34day supply
Intravenous fluids and medication for home use implantable drugs and some injectable drugs
are covered under Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs are subject to dosage limits set by the Plan Contact the Plan for details
What is not Drugs available without a prescription or for which there is a nonprescription equivalent
covered available
Drugs obtained at a nonPlan pharmacy except for outofarea 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
Contraceptive drugs and devices including but not limited to oral contraceptives
diaphragms Depo Provera Norplant
Diabetic supplies except needles syringes and insulin
Smoking cessation drugs and medication
Drugs prescribed for weight loss and appetite suppressants
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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OSF HealthPlans Inc 2000
Other Benefits
Dental care
What is covered Restorative services supplies and appliances necessary to promptly repair and replace sound
Accidental injury benefit natural teeth due to accidental injury within 90 days of the injury are covered The need for these services must result from an accidental injury Accidental injury does not include injury
caused by or arising out of the act of chewing You pay nothing
What is not Other dental services not shown as covered
covered
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye you may receive an eye refraction to provide a written lens prescription
every twentyfour months A referral from your primary care doctor is not necessary but
services must be obtained from a Plan provider You pay a 10 copay per exam
What is not Corrective lenses or frames
covered Eye exercises orthoptics
Special Benefits for OSF HealthPlans is a MedicareChoice Organization contracting with Medicare to offer a
Medicare Eligible MedicareChoice Plan OSF Care Advantage OSF Care Advantage offers benefits provided
Enrollees under Medicare Parts A and B as well as some benefits not covered under Medicare These benefits include but are not limited to no plan premiums or deductibles low outofpocket
costs hearing screenings annual physicals and routine vision exams If you are enrolled in
this Plan under the FEHB Program and are eligible to join OSF Care Advantage your copays
for certain services may be waived if you also join OSF Care Advantage
Enrolled members are required to select a primary care physician from the OSF Care Advan
tage provider network to provide or arrange for his or her care All care must be received from
OSF Care Advantage providers except for emergency services and outofarea urgently needed
care Members must reside in the OSF Care Advantage service area
For more information about OSF Care Advantage call tollfree at 8776778205 or the TDD
number for the hearing impaired at 8888170139
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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OSF HealthPlans Inc 2000
Section 6 General exclusions Things we dont 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 nonPlan 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
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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OSF HealthPlans Inc 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 service 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 MedicareChoice 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
MedicareChoice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a MedicareChoice plan contact your retirement office If
you later want to reenroll 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 MedicareChoice 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 MedicareChoice plans contact your local Social Security Administration
SSA office or request it from SSA at 18006386833 For information on the
MedicareChoice plan offered by this Plan see page 17
Other group When anyone has coverage with us and with another group health plan it is called double
insurance coverage You must tell us if you or a family member has double coverage You must also send
coverage 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 cover
age
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our provide them In that case we will make all reasonable efforts to provide you with necessary
control care
When others When you receive money to compensate you for medical or hospital care for injuries or illness
are responsible that another person caused you must reimburse us for whatever services we paid for We will
for injuries cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures
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OSF HealthPlans Inc 2000
Section 7 Limitations Rules that affect your benefits continued
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage
Workers We do not cover services that
compensation You need because of a workplacerelated disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency
Government directly or indirectly pays for
Agencies
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OSF HealthPlans Inc 2000
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease manage ment programs and how we determine if procedures are experimental or investigational
OPMs website www opmgovinsure lists the specific types of information that we must
make available to you
If you want specific information about us call 800OSF5222 or write to OSF HealthPlans
Inc 7915 N Hale Ave Suite D Peoria IL 61615 You may also contact us by fax at
3096778259 or visit our website at wwwosfhealthcareorghealthplans
Where do I get Your employing or retirement office can answer your questions and give you a Guide to
information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the need to make an informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We dont determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your
benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What types of SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and
coverage are your unmarried dependent children under age 22 including any foster or step children your
available for my employing or retirement office authorizes coverage for Under certain circumstances you may
family and me also get coverage for a disabled child 22 years of age or older who is incapable of selfsupport
If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
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OSF HealthPlans Inc 2000
Section 8 FEHB Facts continued
Are my medical and We will keep your medical and claims information confidential Only the following will have
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 andor 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 We will send you an Identification ID card Use your copy of the Health Benefits Election
cards Form SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a Your old plans deductible continues until our coverage begins
deductible under
my old plan
Preexisting We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits What happens if
You will receive an additional 31 days of coverage for no additional premium when
my 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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage under your former spouses 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 exspouses 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 7927 which describes TCC and the RI 705 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
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OSF HealthPlans Inc 2000
Section 8 FEHB Facts continued
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 premi
ums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2percent administrative charge The govern
ment does not share your costs
You receive another 31day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child
is no longer an eligible family member That office will send you information about enrolling
in TCC You must enroll your child within 60 days after they become eligible for TCC or
receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60day deadline
How can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
coverage did not pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice How
ever 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 preexisting conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other coverage
Plan Coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certifi
cate
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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OSF HealthPlans Inc 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 800OSF5222 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
2024183300
US Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 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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OSF HealthPlans Inc 2000
Summary of Benefits for OSF HealthPlans Inc 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to 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 you enrollment form codes appear on the cover of this bro
chure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COV
ERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan paysprovides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit
Includes inhospital doctor care room and board general nursing care private room
and private nursing care if medically necessary diagnostic tests drugs and medical
supplies use of operating room intensive care and complete maternity care
You pay nothing 11
Extended Care All necessary services up to 90 days per calendar year You pay nothing 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient
Conditions care per year Care in a day hospital or intensive outpatient mode may be substituted
on a twotoone basis up to 60 days per Contract Year You pay nothing 14
Substance Abuse Up to 21 days per year in a substance abuse treatment program Care in a day
hospital or intensive outpatient mode may be substituted on a twotoone basis up to
42 days per calendar year You pay nothing 15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialists care preventive care including wellbaby care periodic
checkups and routine immunizations laboratory tests and Xrays complete
maternity care You pay a 10 copay per office visit there is a onetime 50 copay
for maternity care 8
Home health care All necessary visits by nurses and health aides You pay nothing 9
Mental Up to 20 outpatient visits per year You pay a 30 copay per visit Group outpatient
Conditions visits may substituted on a twotoone basis for individual outpatient visits You pay
15 copay per group visit limited to 40 visits per calendar year 14
Substance abuse Up to 20 outpatient visits per year You pay a 30 copay per visit Group outpatient
visits may be substituted on a twotoone basis for individual outpatient visits
You pay a 15 copay per group visit limited to 40 visits per calendar year 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit and any charges
for services that are not covered by this Plan 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 7 copay for generic drugs and a 15 copay for name brand drugs per prescription unit
or refill 16
Dental care Accidental injury benefit you pay nothing 17
Vision care One refraction every 24 months You pay a 10 copay per visit 17
Outofpocket maximum Copayments are required for a few benefits however after your outofpocket expenses reach a maximum of 1000 per Self Only or 2000 per Self and Family
enrollment per calendar year covered benefits will be provided at 100 This
copay maximum does not include charges for durable medical equipment
prosthetic devices orthopedic devices or outpatient prescription drugs 4
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Page 28
2000 Rate Information for
OSF HealthPlans 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
1RQ3RVWDO3UHPLXP 3RVWDO3UHPLXP 3RVWDO3UHPLXP
LZHHNO 0RQWKO LZHHNO LZHHNO
RXU 7SHRI RGH RYW RXU RYW RXU 8636 RXU 8636
QUROOPHQW 6KDUH 6KDUH 6KDUH 6KDUH 6KDUH 6KDUH 6KDUH 6KDUH
Self Only 9F1 57.65 19.21 124.90 41.63 68.21 8.65 68.21 8.65
Self and Family 9F2 151.58 50.52 328.41 109.47 179.36 22.74 179.36 22.74
28