Pages 1--28 from footers.PDF

For changes
Serving Most areas of West Virginia in benefits see page 4

Enrollment in this plan is limited see page 5 for requirements
Enrollment Code
8T1 Self Only
8T2 Self and Family

Visit the OPM website at http www opm gov insure
and
our website at http www msbcbs com

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United States
Office of
Personnel
Management

RI RI 73 73 769 769 1
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SuperBlue HMO 2000

Table of Contents

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB FACTS 20
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits Inside back cover
Premiums Back cover

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SuperBlue HMO 2000

Introduction

SuperBlue HMO 700 Market Square Parkersburg WV 26101

This brochure describes the benefits you can receive from SuperBlue HMO under its contract CS2827 with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of
benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for
Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 4
Premiums are listed at the end of this brochure

Plain Language

The President and Vice President are making the Government's communication more responsive accessible and understandable to the
public by requiring agencies 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

This brochure refers to SuperBlue HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure Benefit language will be revised next year

How To Use This Brochure

This brochure has eight sections Each section has important information you should read If you want to compare our benefits with
benefits from other FEHB plans you will find 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 to deny
your claim or 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
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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SuperBlue HMO 2000

Section 1 Health Maintenance Organizations

We require you see Plan providers specific physicians hospitals and other providers contracted by us These providers coordinate your
health care services The care you receive includes preventive 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 from providers who do not contract with the local
BlueCross BlueShield plan you may have to submit claim forms

You should join SuperBlue HMO because you prefer our 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 or group of physicians hospital or other provider
will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any
course of treatment

Section 2 How we change for 2000

Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our
networks facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our
request you may continue to see your specialist for up to 90 days If your provider leaves
the Plan and you are in the second or third trimester of pregnancy you may be able to
continue seeing your OB GYN until the end of your postpartum care You have similar
rights if this Plan leaves the FEHB program See Section 3 How to get benefits for more
information

You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not
amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you

If you are over age 50 we will cover a screening sigmoidoscopy every five years This
screening helps detect colorectal cancer

Changes to this Plan Your share of Super Blue HMO's non postal premium will increase by 7.1 for Self Only or 1.5 for Self and Family

Beginning January 1 2000 you may seek treatment at any network specialist's office
without a referral from your Primary Care Physician PCP If your network specialist
prescribes services outside the office setting this additional care must be coordinated with
your Primary Care Physician The copay for PCP visits continues to be 10 The copay for
specialist office visits is 20 Beginning January 1 the office visit copay is waived for Well
Baby and Well Child preventive care for children through age 17 including well baby care
and periodic check ups

Beginning January 1 we have added vision benefits to our Non FEHBP Dental plan

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SuperBlue HMO 2000 During 1999 we expanded our service area making this coverage available in areas where
most West Virginia residents live If you have family members such as a student living
away from home in or near West Virginia they now have much more convenient access to
SuperBlue HMO providers

Section 3 How to get benefits

What is this Plan's 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 located in the following counties in West Virginia Barbour Berkeley Brooke Cabell Doddridge Fayette Greenbrier Hancock Harrison Jackson

Jefferson Kanawha Lincoln Marion Marshall Mercer Monongalia Monroe Morgan
Ohio Pleasants Preston Putnam Raleigh Ritchie Summers Taylor Wayne Wirt Wood
and Wyoming

You may also enroll with us if you live or work in the following additional geographic areas
the counties of Athens County OH Belmont County OH Jefferson County OH Meigs
County OH and Washington County OH

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 services or services approved by
the SuperBlue HMO Medical Director as described on page 14 We will not pay for other
health care services

If you or a covered family member move outside of our service area you can enroll in
another plan If your dependents live out of the area for example if your child goes to
college in another state you should consider enrolling in a fee for service plan or an HMO
that has agreements with affiliates in other areas If you or a family member move you do
not have to wait until Open Season to change plans Contact your employing or retirement
office

How much do I pay for You must share the cost of some services This is called either a copayment a set dollar
services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for

Well baby and Well Child Preventive care for children through age 17
Routine immunizations and boosters up to age 17
Outpatient surgery
Outpatient hospital services
Inpatient hospital admissions
Maternity care when global fees are charged

After you pay 500 in copayments or coinsurance for one family member or 1,500 for two
or more family members you do not have to make any further payments for certain services
for the rest of the year This is called a catastrophic limit However copayments or
coinsurance for your prescription drugs infertility and family planning benefits durable
medical equipment orthotic devices and services prosthetic devices and 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

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SuperBlue HMO 2000
Do I have to submit claims You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't contract with a BlueCross BlueShield Plan 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 This deadline can
be extended if you show circumstances beyond your control prevented you from filing on
time

Who provides my health care The first and most important decision each member must make is the selection of a primary care doctor The decision is important since it is through this doctor that other health
services like hospital care are obtained It is the responsibility of your primary care doctor
to obtain any necessary authorizations from us before making arrangements for
hospitalization Services of other providers are covered only when you have been referred
by your primary care doctor with the following exceptions

Treatment of life threatening accidents and medical emergencies are covered when rendered by any provider
Members can obtain treatment at any network specialist's office without a referral
A female member of any age may obtain an annual well woman exam from her SuperBlue HMO Women's Health Care Provider without a referral and

A female member of any age may obtain prenatal or obstetrical care from a SuperBlue HMO Women's Health Care Provider without a referral

SuperBlue HMO Women's Health Care Providers are contracted obstetricians
gynecologists advanced nurse practitioners practicing in women's health and certified
nurse midwives or physician assistant mid wives practicing within the lawful scope of their
practice

How do I choose my doctor Our provider directory lists primary care doctors family practitioners pediatricians and internists with their locations and phone numbers and notes whether or not the doctor is
accepting new patients Directories are updated twice a year and are available at the time of
enrollment or upon request by calling the Membership Services Department at 1 800 391
4441 you can also find out if your doctor participates with us by calling this number If you
are interested in receiving care from a specific provider who is listed in the directory call the
provider to verify that he or she still participates with us and is accepting new patients
Important note When you enroll in this Plan services except for emergency benefits and
other exceptions stated on pagexx are provided through the Plan's delivery system the
continued availability and or participation of any one doctor hospital or other provider
cannot be guaranteed

When you enroll you will need to advise us of the primary care doctor s you've selected for
yourself and each member of your family by sending us a Primary Care Physician selection
form If you need help choosing a doctor call Member Services at 1 800 391 4441
Members may change their doctor selection by notifying SuperBlue HMO Member
Services in writing or by phone no more than 30 days in advance Changes received before
the 15 th of the month will be effective at the first of the month For example if you call with
your change on January 10 th it will be effective on February 1 You will receive a new
identification card to confirm the change In the event you fail to choose a primary care
physician on a timely basis SuperBlue HMO will choose one for you You retain the right
to change primary care physician by calling Member Service

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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SuperBlue HMO 2000
What do I do if I need to go Talk to your Plan physician If you need to be hospitalized your primary care physician or
into the hospital specialist will make the necessary hospital arrangements and supervise your care

What do I do if I'm in the First call our customer service department at 1 800 391 4441 If you are new to the FEHB
hospital when I join this Plan Program we will arrange for you to receive care If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until

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
You may self refer for treatment in any plan specialist's office or your primary care
physician will arrange your referral to a specialist

How do I get specialty care If you need to see a specialist or other plan providers frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment
plan that allows you to receive a certain number of treatments without additional referrals
Your primary care physician will use our criteria when creating your treatment plan with you
and the SuperBlue HMO Medical Director The treatment plan will permit you to obtain
treatment during a specific period of time or number of visits without the need to obtain
further referrals However your primary care doctor remains responsible for establishing
referrals to non physician providers for care outside a plan specialist's office and obtaining
authorization for all hospital admissions You your primary care doctor and your medical
providers will each receive written notification when a plan of treatment is approved and
services are authorized

What do I do if I am seeing a If your specialist is a SuperBlue HMO physician you can continue to seek treatment at this
specialist when I enroll physician's office without a referral If your current specialist does not participate with us you must receive treatment from a specialist who does Generally we will not pay for you to

see a specialist who does not participate with our Plan Your primary care physician will
decide what treatment you need

What do I do if my specialist Call your primary care physician who will arrange for you to see another specialist You
leaves the Plan may receive services from your current specialist until we can make arrangements for you to see someone else

What if I have a serious illness Please contact us if you believe your condition is chronic or disabling You may be able to
and my provider leaves the continue seeing your provider for up to 90 days after we notify you that we are terminating
Plan or this Plan leaves the our contract with the provider unless the termination is for cause If you are in the second
Program or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care

You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you
have a serious or chronic condition or are in your second or third trimester Your new plan
will pay for or provide your care for up to 90 days after you receive notice that your prior
plan is leaving the FEHB Program If you are in your second or third trimester your new
plan will pay for the OB GYN care you receive from your current provider until the end of
your postpartum care

How do you authorize medical Your physician must get our approval before sending you to a hospital referring you to a
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

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SuperBlue HMO 2000
How do you decide if a service A treatment procedure drug device supply or technology is Experimental or
is experimental or Investigational if it does not meet all of the following criteria
investigational 1 Final approval from the appropriate government regulatory bodies for the application proposed if applicable

2 Scientific evidence permits a conclusion regarding the effect on outcomes
3 Improves the net health outcome
4 Is as beneficial as any established alternatives if any alternatives are available and
5 Improvement is attainable in a non investigational setting

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 to You may ask OPM to review the denial after you ask us to reconsider our initial denial or
review a denial refusal OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious or life threatening condition and you haven't responded to my
request for service

Call us at 1 800 391 4441 and we will expedite our review

What if you have denied my If we expedite your review due to a serious medical condition and deny your claim we will
request for care and my inform OPM so that they can give your claim expedited treatment too Alternatively you can
condition is serious or life call OPM's health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5
threatening p m Eastern Time Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible

Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your
request within 120 days of the date you asked us to reconsider your claim
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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SuperBlue HMO 2000 What do I send to OPM Your request must be complete or OPM will return it to you You must send the following
information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents
apply to which claim

Who can make the request Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
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 my Send your request for review to Office of Personnel Management Office of Insurance
disputed claim to OPM Programs Contract Division III P O Box 436 Washington D C 20044

What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
Plan's denial decision your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of
the third year after the year in which you received the disputed services or supplies

What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will
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
treatment services supplies or drugs covered by us until you have completed the OPM
review procedure described above

Your records and the Privacy Chapter 89 of title 5 United States Code allows OPM to use the information it collects from
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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SuperBlue HMO 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 for services received from your primary care doctor and a 20 office visit
copay for services from a Plan specialist but no additional copay for laboratory tests and Xrays
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 house call by your
primary care doctor 20 by a Plan specialist and 10 for home visits by nurses and health
aides

The following services are included and are subject to the office visit copay unless stated
otherwise

Well Baby and Well Child Preventive care for children through age 17 including wellbaby
care and periodic check ups no office visit copay applies

Adult Preventive Care for persons age 18 and older including 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 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 copay is waived for visits for pediatric
immunizations for children up to age 17

Office visits with or outpatient consultations by specialists are subject to a 20
copayment regardless of the age of the patient

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 provider Copays are waived for maternity care
when global care fees are billed 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
mother's hospital confinement for maternity will be covered under either a Self Only or
Self and Family enrollment other care of an infant who requires definitive treatment
will be covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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SuperBlue HMO 2000
What is covered continued The insertion of internal prosthetic devices such as pacemakers and artificial joints
Breast prosthesis and surgical bras as well as their replacement

Cornea heart 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 and performed at facility approved by
SuperBlue HMO 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
Chiropractic services
Home health services of nurses and health aides including intravenous fluids and
medications when prescribed by your Plan doctor who will periodically review the
program for continuing appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers at no additional cost to you

Medical surgical and dental processes commonly used to treat temporomandibular joint TMJ pain dysfunction syndrome are covered up to a maximum Plan payment of

1,000 per calendar year

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 except any care
involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome are
subject to the annual 1,000 maximum benefit for TMJ services

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

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SuperBlue HMO 2000
Limited benefits continued Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 sessions per condition if significant improvement
can be expected within two months you pay a 20 copay per outpatient session Speech
therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist the member to achieve and maintain
self care and improved functioning in other activities of daily living

Diagnosis and treatment of infertility is covered you pay 50 of charges The
following type of artificial insemination is covered intrauterine insemination IUI you pay
50 of charges The cost of donor sperm is not covered Fertility drugs are covered under
the Prescription Drug Benefit Other assisted reproductive technology ART procedures
such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction is provided for up to 60 sessions you pay 20 per outpatient session

Orthopedic devices including braces and foot orthotics are covered but are limited to a
maximum Plan payment of 1,000 per calendar year you pay 20 of charges until the
maximum Plan payment is reached and then any charges in excess of the maximum Plan
payment Benefits in excess of the maximum Plan payment may be available if approved by
the SuperBlue HMO Medical Director

Prosthetic devices such as artificial limbs and lenses following cataract removal are
covered but are limited to the initial device only and coverage is limited to a maximum Plan
payment of 1,000 per calendar year you pay 20 of charges until the maximum Plan
payment is reached and then any charges in excess of the maximum Plan payment Benefits
in excess of the maximum Plan payment may be available if approved by the SuperBlue
HMO Medical Director

Standard Durable Medical Equipment DME and medical supplies such as
wheelchairs hospital beds oxygen and hearing aids are covered but are limited to a
maximum Plan payment of 1,000 per calendar year you pay 20 of charges until the
maximum Plan payment is reached and then any charges in excess of the maximum Plan
payment Benefits in excess of the maximum Plan payment may be available if approved by
the SuperBlue HMO Medical Director

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 except as specified
Transplants not listed as covered
Long term rehabilitative therapy

Blood and blood derivatives
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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SuperBlue HMO 2000
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

Extended care The Plan provides a comprehensive range of benefits 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 procedures Hospitalization for certain inpatient 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 covers the hospitalization 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
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is

not medically appropriate See page 15 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care

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SuperBlue HMO 2000
Emergency Benefits

What is a medical emergency
A medical emergency is a condition that manifests itself by acute symptoms of sufficient
severity including severe pain such that you reasonably expect the absence of immediate
medical attention could result in

serious jeopardy to your health
if you are pregnant serious jeopardy to the health of your unborn child
serious impairment to bodily functions or
serious dysfunction of any bodily organ or part

Some problems are emergencies because if not treated promptly they might become more
serious examples include deep cuts and broken bones Others are emergencies because
they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan
may determine are medical emergencies what they all have in common is the need for
quick action

Emergencies within the service If you are in an emergency situation call your primary care doctor In extreme emergencies
area if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest medical facility able to treat your condition Be sure

to make your SuperBlue HMO identification card available so the provider will know you
are a HMO member AND so they can notify us or your Primary Care Physician whose
phone number is on the back of your card You or a family member must notify your
primary care physician or SuperBlue HMO within 48 hours unless it was not physically
possible to do so It is your responsibility to ensure that the Plan has been timely notified
Timely notification permits your primary care physician to become involved in your care
and provide additional Plan resources which may be immediately needed to properly treat
your condition

If you need to be hospitalized in a non Plan facility your primary care physician or
SuperBlue HMO must be notified within 48 hours or on the first working day following
your admission unless it was not physically possible to do so 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 20 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital the emergency care copay is waived

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SuperBlue HMO 2000 Emergencies outside the Benefits are available for any medically necessary health service that is immediately required
service area because of injury or unforeseen illness
If you need to be hospitalized your primary care physician or SuperBlue HMO must be
notified within 48 hours or on the first working day following your admission unless it was
not physically 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 20 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital the emergency care copay is waived

Emergency care at a doctor's office or an urgent care center
What is covered 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 nonemergency 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

Out of Area Claims Your Blue Cross and Blue Shield membership card the Blue Card gives you access to emergency care throughout the United States and in some foreign countries Your card tells
any participating hospital or physician which independent Blue Cross and or Blue Shield
Plan is yours Your card also ensures that you receive all the conveniences you're
accustomed to from SuperBlue HMO

When accessing emergency or Plan Approved care from a Blue Cross Blue Shield
contracted provider remember the following

your obligation is to pay cost sharing copays or coinsurance as provided by this Plan
the contracted provider will bill services to the local Blue Cross Blue Shield Plan who will forward your claim to this Plan

the provider will be paid by the local Blue Cross Blue Shield Plan
You will receive an Explanation of Benefits when this process is complete

Filing claims for non Plan With your authorization the Plan will pay benefits directly to the providers of your
providers emergency care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills

and your receipts to the Plan along with an explanation of the services and the

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SuperBlue HMO 2000 Filing claims for non Plan identification information from your ID card Payment will be sent to you or the provider if
providers continued you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with the Plan's decision you may request reconsideration
in accordance with the disputed claims procedure described on page 8

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 outpatient visits to Plan doctors or other psychiatric personnel each calendar year
you pay a 20 copay for each covered visit all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter

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 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit all charges thereafter

Inpatient care Up to 30 days per calendar year and no more than 60 in a lifetime 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

What is not covered Treatment that is not authorized by a Plan doctor

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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SuperBlue HMO 2000
Prescription Drug Benefits

What is covered SuperBlue HMO accesses the CLAIMSPRO preferred pharmacy network for your
prescription drug benefits Each time you have a prescription filled simply present your
SuperBlue HMO Identification Card to one of the pharmacies listed in the SuperBlue
HMO Provider Directory or the Super Blue Pharmacy Directory Refer to the Directory for
the location of a Pharmacy near you If you are out of the area or unsure about the status of a
particular pharmacy call 1 800 837 9600 There is no benefit when drugs are purchased
from a non preferred pharmacy

Prescription drugs prescribed by your Primary care doctor or referral doctor and obtained at
a preferred pharmacy will be dispensed for up to a 34 day supply You pay a 10 copay
per prescription unit or refill for generic drugs or for name brand drugs when generic
substitution is not permissible and a 20 copay per prescription unit or refill for brand name
drugs when generic substitution is permissible whether the prescribing doctor requires the
use of a name brand drug or you request the name brand drug

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
FDA approved contraceptive drugs and devices
Fertility drugs
Insulin Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets

Disposable needles and syringes needed to inject covered prescribed medication
Drugs to aid smoking cessation that require a prescription by Federal law limited to one regimen per calendar year

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 preferred pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication in excess of one regimen per year

Other Benefits
Dental care
Accidental injury benefit Dental Services for an Accidental Injury will be covered only when due to an accidental
injury to the jaw sound natural teeth mouth or face occurring on or after your Effective
Date Restorative services and supplies necessary to promptly repair sound natural teeth
must be incurred within one year from the date of the accident unless otherwise medically
inadvisable You pay a 10 copay per visit for care by your primary care doctor and a 20
copay per visit when any other network physician provides these services

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 17
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SuperBlue HMO 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

Details on accessing these benefits are available from SuperBlue HMO Member Services Call 1 800 654 5028

Dental Care Benefits
What is covered Your Dental Care Benefits reimburses services rendered to the teeth or intra oral areas surrounding the teeth SuperBlue HMO will pay charges for services performed on a
member's teeth or intra oral areas surrounding the teeth up to the amount specified in the
Schedule of Dental Allowances a complete list of covered dental services Only the listed
services are covered Only the listed amount will be paid

You are responsible for the difference between the amount your dentist charges for service
and the amount specified as payment in the Schedule of Dental Allowances A complete
listing of the Schedule of Dental Allowances is available from SuperBlue HMO Just call
Member Services at the number listed on your ID card

What is not covered Services incurred to treat temporomandibular joint TMJ pain dysfunction syndrome nondental surgical and hospitalization procedures for congenital defects such as cleft lip and
cleft palate 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
are considered to be medical and surgical services and are not covered by these Dental Care
Benefits

Vision Care Benefits
What is covered Your vision care benefits cover only the specific listed services available every 12 or 24
months This benefit pays only the listed specific amount

What is not covered Services received more frequently than listed are not covered This benefit does not cover medical or surgical treatment of any vision condition as this is usually covered by your

medical coverage Other service not covered are
Orthoptics vision training or subnormal vision aids tonography or tinting
Lenses obtainable without a prescription Replacement of lost or broken frames lenses

Filing claims for With your authorization SuperBlue HMO will pay benefits directly to the providers upon
Dental or Vision receipt of their claims If you are required to pay for the services submit itemized bills and your receipts to SuperBlue HMO along with an explanation of the services and the
Providers 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 by calling SuperBlue HMO at the toll free number on your ID card

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SuperBlue HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your
Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits

Medicare
Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical
services and we will coordinate the payments On occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is
available in your area For information on suspending your FEHB enrollment and changing to a Medicare Choice plan contact your
retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We
cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1
800 638 6833

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

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SuperBlue HMO 2000 We will always provide you with the benefits described in this brochure Remember Even
if you do not file a claim with your other plan you must still tell us that you have double
coverage

Circumstances beyond our Under certain extraordinary circumstances we may have to delay your services or be unable
control to provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are responsible When you receive money to compensate you for medical or hospital care for injuries or
for injuries illness that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement

If you do not seek damages you must agree to let us try This is called subrogation If you
need more information contact us for our subrogation procedures

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 Agencies We do not cover services and supplies that a local State or Federal Government agency
directly or indirectly pays for

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 1 800 391 4441 or write to SuperBlue HMO 700 Market Square Parkersburg WV
26101 You may also contact us by fax at 304 424 9890 or visit our website at msbcbs com

Where do I get information about Your employing or retirement office can answer your questions and give you a Guide to
enrolling in the FEHB Program Federal Employees Health Benefits Plans brochures for other plans and other materials you
need to make an informed decision about
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

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SuperBlue HMO 2000 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 and The benefits in this brochure are effective on January 1 If you are new to this plan your
premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1

What happens when I retire When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB Program for the last five years of your Federal service If you do not
meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section

What types of coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse and
available for my family and your unmarried dependent children under age 22 including any foster or step children your employing or retirement office authorizes coverage for Under certain circumstances you
me may also get coverage for a disabled child 22 years of age or older who is incapable of selfsupport

which is also authorized by your employing or retirement office

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 No new
enrollment form is necessary

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

Are my medical and claims We will keep your medical and claims information confidential Only the following will
records confidential have access to it

OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and

subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim

Information Information for for new new members 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

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SuperBlue HMO 2000 What if I paid a deductible Your old plan's deductible continues until our coverage begins
under my 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

When When you you lose lose benefits benefits
What happens if my enrollment in You will receive an additional 31 days of coverage for no additional premium when
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
coverage benefits under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating

a divorce contact your ex spouse's employing or retirement office to get more information
about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC
For example you can receive TCC if you are not able to continue your FEHB enrollment
after you retire You may not elect TCC if you are fired from your Federal job due to gross
misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees from your employing or retirement office

Key points about TCC
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 TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is
later
Children You must notify your 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

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SuperBlue HMO 2000 How do I enroll in TCC Former spouses You or your former spouse must notify your employing or retirement office
continued within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your

coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will
not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions

How can I get a Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health Plan
Group Health Plan Coverage Coverage that indicates how long you have been enrolled with us You can use this certificate when getting health insurance or other health care coverage You must arrange

for the other coverage within 63 days of leaving this Plan Your new plan must reduce or
eliminate waiting periods limitations or exclusions for health related conditions based on the
information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in
other FEHB plans you may request a certificate from them as well

23 23
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SuperBlue HMO 2000

Inspector General Advisory Stop Health Care Fraud

Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you
did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 788 5661 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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SuperBlue HMO 2000
NOTES

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SuperBlue HMO 2000
NOTES

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SuperBlue HMO 2000

Summary of Benefits for 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 EXCEPT EMERGENCY CARE ARE COVERED ONLY WHEN
PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes 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 13

Extended Care All necessary services up to 100 days per calendar year You pay nothing 13
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year
conditions You pay nothing 16

Substance abuse Up to 30 days per year 60 days lifetime maximum in a substance abuse treatment program You pay nothing 16

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic check ups and routine
immunizations laboratory tests and X rays complete maternity care You pay 10 copay for
each office visit with your primary care doctor 20 for each office visit with a network specialist
copays are waived for maternity care when global care fees are billed 10 or 20 per house call
by a doctor Well child care to age 17 no copay applies 10

Home health All necessary visits by nurses and health aides You pay 20 per visit 12
care

Mental Up to 20 outpatient visits per year You pay a 20 copay per visit 16
conditions

Substance abuse Up to 20 outpatient visits per year You pay a 20 copay per visit 16
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 copay to the hospital for each emergency room visit and any charges for services that are not
covered by this Plan 14

Prescription drugs Drugs prescribed by a Plan doctor and obtained preferred pharmacy You pay a 10 copay per generic 20 per brand name per prescription unit or refill 17

Dental care Accidental injury benefit you pay a 10 copay per visit for care by your primary care doctor and 20 for office care by network specialists 17

Vision care No current benefit
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses reach
maximum a maximum of 500 per Self Only or 1,500 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 Infertility and Family Planning benefits Durable Medical Equipment
Orthotic devices and services Prosthetic devices and services 5

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SuperBlue HMO 2000
2000 Rate Information for
SuperBlue HMO

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

Self Only 8T1 75.21 25.07 162.95 54.32 89.00 11.28 89.00 11.28
Self and Family 8T2 175.97 76.07 381.27 164.82 207.74 44.30 201.02 51.02

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