Pages 1--24 from Untitled

For changes
to benefitssee page 3

Serving Parts of Nevada
Enrollment code
K91 Self Only
K92 Self and Family

See the FEHB Guide
for more information on NCQA

Enrollment in this Plan is limited see page 4 for requirements
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www pacificare com

Authorized for distribution by the
UNITED
STATES

United States Office of Federal Employees OFFICE Personnel Management
Health Benefits Program OF

MANAGEMENT
Retirement and Insurance PERSONNEL RI 73 777 1
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PacifiCare of Nevada 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 4 5
Section 4 What to do if we deny your claim or request for service 6 7
Section 5 Benefits 7 15
Section 6 General Exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16 17
Section 8 FEHB FACTS 17 20
Inspector General Advisory Stop Healthcare Fraud 20
Summary of Benefits 21
Premiums 22

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PacifiCare of Nevada 2000
Introduction
PacifiCare of Nevada 700 E Warm Springs Rd

Las Vegas Nevada 89119 4323
This Brochure describes the benefits you can receive from PacifiCare Nevada under its contract CS 2835 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 Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health Plan representatives and Office of Personnel Management staff have

worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and shorter sentences

We refer to PacifiCare of Nevada 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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PacifiCare of Nevada 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to

make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMO's 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 service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General Exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this information about the Federal Employees Health Benefits FEHB Program

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PacifiCare of Nevada 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMO's are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes

preventative care such as routine office visits physical exams well baby care and Immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits

This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB
Program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask
that a physician amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to Your share of the premium will increase by 5.5 for Self Only or 5.5 for Self and Family this Plan

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PacifiCare of Nevada 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Our Plan's service service area is
area Clark 88901 88905 89004 89007 89009 89011 89012 89014 89015 89016 89018 89019
89021 89024 89025 89026 89027 89030 89031,89032 89033 89036 89039,89040,89046,89052 89070 89100 89135 89137 89138
89139,89141,89142,89143,89144,89145 89146 89147,89148,89149 89150 89151 89152 89153 89154 89155,89156 89158 89159 89160 89163 89164 89170 89177 89180 89185 89191
89193 89195 and 89199
Nye 89003 89020 89022 89023 89045 89049 and 89409
Carson City County 89701 89702 89703 89705 89706 89710 89711 89712 89713 89714 89721

Douglas County 89410 89411 89413 89423 89448 and 89449
Esmeralda County 89010 89013 and 89047
Lyon County 89408 89428 89429 89430 89444 and 89447
Mineral County 89415 89416 89420 89422 and 89427
Storey County 89440
Washoe County 89402 89405 89412 89431 89432 89433 89434 89435 89436 89439 89424 89442 89450 89451 89452 89501 89507 89509 89512 89523 89599 and 89704

Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another Plan If your dependent lives 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 You share the cost of some services This is called either a copayment a set dollar amount or I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 1,200 for self or 2,700 for a family per calendar year you do not have to make any more payments for certain services for the rest of the year This is called a catastrophic limit
However copayments or coinsurance for your prescription drugs and dental services do not count towards these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time
Who provides PacifiCare of Nevada is a mixed model Plan MMP This means the doctors provide care in their my health own offices which are either part of PacifiCare's contracted Independent Physicians Association
care IPA or PacifiCare's individual practice plans IPP There are 253 primary care physicians and 580 specialists participating in this Plan

What do I do if Call us We will help you select a new one my primary
care physician leaves the Plan

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PacifiCare of Nevada 2000
Section 3 How to get benefits continued
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or need to go into the specialist will make the necessary arrangements and supervise your care
hospital
What do I do if First call our customer service department at 1 800 347 8600 If you are new to the FEHB I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and are
hospital when switching to us your former plan will pay for the hospital stay until I join this
Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former Plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions apply only to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist A woman may self refer to specialty care her OB Gyn for a well woman's exam once per year

If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan the physician may have to get an
authorization or approval beforehand
What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a if I am seeing a specialist ask if they can refer you to your current specialist If your current specialist does not
specialist when participate with us you must receive treatment from a specialist who does Generally we will not I enroll pay for you to see a specialist who does not participate with our Plan

What do I do Call your primary care physician who will arrange for you to see another specialist You may if my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the program

Please contact us if you believe your condition is chronic or disabling You may able to continue seeing your provider for up to 90 days after we notify you that we are terminating the contract with
the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care
You may also be able to continue seeing your provider if your Plan drops out of the FEHB Program and you enroll in a new FEHB Plan Contact the new Plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new Plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist authorize medical or recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows generally accepted medical practice

How do you Our National and Regional medical committees determine whether or not treatments procedures decide if a service and drugs are no longer considered experimental or investigational Our determinations are based
is experimental on the safety and efficacy of new medical procedures technologies devices and drugs or investigational

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PacifiCare of Nevada 2000
Section 4 What to do if we deny your claim or request for service
If we deny your 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal ask OPM to OPM will determine if we correctly applied the terms of our contract when we denied your claim
review a denial or request for service
What if I Call us at 1 800 347 8600 and we will expedite the review have a serious
or life threatening condition and you
haven't responded to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contracts Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening 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 did 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 do not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
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PacifiCare of Nevada 2000
Section 4 What to do if we deny your claim or request for service continued
Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with
the review request
Where should Send your request for review to Office of Personnel Management Office of Insurance Programs I mail my Contracts Division IV P O Box 436 Washington D C 20044
disputed claim to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the decision your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year in which you received the disputed services or supplies
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and the and us to determine if our denial of your claim is correct The information OPM collects during the
Privacy Act review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this

information to support the disputed claim decision If you file a lawsuit this information will become part of the court record

Section 5 Medical and Surgical Benefits
What is A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors covered and other Plan providers This includes all necessary office visits you pay a 10 office visit copay
but no additional copay for laboratory tests and X rays performed during the same office visit Within the service area house calls will be provided if in the judgement of the Plan doctor such
care is necessary and appropriate you pay nothing for a doctor's house call or for visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic 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 Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 7 9
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PacifiCare of Nevada 2000
Section 5 Medical and Surgical Benefits continued
What is Complete obstetrical maternity care for all covered females including prenatal delivery and covered postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48
continued 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 family planning services
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 Cornea heart kidney and liver transplants allogeneic donor bone marrow transplants
autologous bone marrow transplants autologous stem cell and peripheral stem cell support for acutelymphocytic or nonlymphocytic 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 Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be provided in a non randomized clinical trial when treatment is provided in an NCI or NIH
approved clinical trial at a Plan designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols 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
Orthopedic devices such as braces foot orthotics Durable medical equipment such as wheelchairs and hospital beds including intravenous
fluids and medications Home health services of nurses and health aides 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 Chiropractic services when referred by your primary care physician

Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral
areas surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if
the condition can reasonably be expected to be corrected by such surgery Reconstructive cosmetic surgery is limited to persons who were covered under the FEHB Program at the time of the
accident or surgery which necessitates such reconstruction
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 symmetrical
appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected
within two months you pay a 10 copay per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living

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PacifiCare of Nevada 2000
Section 5 Medical and Surgical Benefits continued
Limited benefits Diagnosis and treatment of infertility including injectable fertility drugs are covered you pay a continued 10 copay per visit The following types of artificial insemination are covered intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay a 10 copay per visit cost of donor sperm is not covered Non injectable fertility drugs are covered
under Prescription Drug Benefits Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following bypass surgery or a myocardial infarction is provided as determined medically necessary and authorized by a Plan physician you pay a 10 copay per visit
Prosthetic devices such as artificial limbs with prior authorization subject to copayment of 50 of charges
Breast prostheses surgical bras and replacements subject to copayment of 50 of charges Prior authorization not required
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 surgically induced sterility Surgery primarily for cosmetic purposes
Transplants not listed as covered Hearing aids
Homemaker services Long term rehabilitative therapy

Section 5 Hospital Extended Care Benefits
What is covered

Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units Blood and blood derivatives not replaced by the member

Extended care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of
hospitalization 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 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 care Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 11
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PacifiCare of Nevada 2000
Section 5 Hospital Extended Care Benefits continued
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 12 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

Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical believe endangers your life or could result in serious injury or disability and requires immediate
emergency medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the

Plan may determine are medical emergencies what they all have in common is the need for quick action

Emergencies If you are in an emergency situation please call your primary care doctor If you are within the within the Service Area and are unable to contact your doctor call your Plan hospital's emergency room In
service area extreme emergencies contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a
Plan member so they can notify the Plan You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan
has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges
covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers if the emergency results in admission to a hospital If the emergency does not result in admission to a hospital Plan payment is limited to 500 in non Plan emergency

services
You pay 25 per hospital emergency room visit or 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 If the emergency does not result in admission to a hospital in addition to the emergency care copay you pay all charges in excess of 500 for non Plan emergency services

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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PacifiCare of Nevada 2000
Section 5 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 or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred

when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a non Plan hospital the
emergency care copay is waived
What is Emergency care at a doctor's office or an urgent care center covered 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 full term delivery of a baby in a non Plan
hospital
Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency care for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
providers If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 6

Section 5 Mental Conditions Substance Abuse Benefits
Mental conditions
What is To the extent shown below the Plan provides the following services necessary for the diagnosis and covered 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 Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar care year you pay a 5 copay for each covered visit all charges thereafter
Inpatient Up to 30 days of hospitalization each calendar year or up to 48 days of intermediate day care each care calendar year you pay nothing for the first 30 days of inpatient care or 48 days of intermediate day
care all charges thereafter

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
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PacifiCare of Nevada 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
What is not Care for psychiatric conditions which in the professional judgment of Plan doctors are not covered subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is This Plan provides medical and hospital services such as acute detoxification services for the covered 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

Outpatient Up to 20 outpatient visits per calendar year to Plan providers for treatment you pay a 5 copay for care
each covered visit all charges thereafter

These substance abuse benefits may be combined with the outpatient mental conditions benefits shown above provided such treatment is necessary as a mental conditions service and is approved
by the Plan to permit an additional 30 outpatient visits per calendar year with the applicable mental conditions copayments

Inpatient Lifetime maximum of two 30 day substance abuse rehabilitation intermediate care programs or care lifetime maximum of two 48 day substance abuse rehabilitation intermediate day care programs in
an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the benefit period all charges thereafter

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

Section 5 Prescription Drug Benefits
What is Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be covered dispensed for up to a 30 day supply or one commercially prepared unit Prescription unit is the
maximum amount quantity of medication that may be dispensed per prescription for a single copay For most oral medications the prescription unit represents a thirty 30 day supply of

medications The prescription unit for other medications will represent a single container inhaler unit package course of therapy For drugs that could be habit forming the prescription unit is set
at a smaller quantity for the protection and safety of our members Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary You pay a 5 copay per
prescription unit or refill
Nonformulary drugs will be covered when prescribed by a Plan doctor you pay a 20 copayment
The PacifiCare Formulary is a list of over 1600 prescription drugs that Physicians use as a guide when prescribing medications for patients The Formulary plays an important role in providing
safe effective and affordable prescription drugs to PacifiCare members It also allows us to work together with physicians and pharmacies to ensure that our members are getting the drug therapy
they need A Pharmacy and Therapeutics Committee consisting of physicians and pharmacists evaluate prescription drugs based on safety effectiveness quality treatment and overall value

Covered medications and accessories include
Drugs for which a prescription is required by law Oral and injectable contraceptive drugs contraceptive diaphragms
Implanted contraceptive devices such as Norplant For Norplant you pay a 10 medical office visit copay
Insulin with a copay charge applied to each vial Diabetic supplies including insulin syringes and needles glucose test tablets and test tape
Benedict's solution or equivalent and acetone test tablets
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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PacifiCare of Nevada 2000
Section 5 Prescription Drug Benefits continued
What is Disposable needles and syringes needed for injecting covered prescribed medication provided covered under Home health services at no charge
continued Fertility drugs non injectables Intravenous fluids and medication for home use provided under Home health service at no charge
Depo Provera an injectable is under Medical and Surgical Benefits you pay a 10 office visit copay Formulary prescription prenatal vitamins
Metered dose inhaler extender devices
Drugs to treat sexual dysfunction are covered when Plan's medical criteria is met Contact the plan for dose limits You pay 50 of the cost of the medication per prescription unit or refill
Limited benefits up to the dosage limits and all charges above that
Drugs available without a prescription or for which there is a nonprescription equivalent available
What is not Drugs obtained at a non Plan pharmacy except for out of area emergencies covered Vitamins and nutritional substances which 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 including nicotine patches
Implanted time release medications other than Norplant Anorexants weight loss drugs
Penfills Penneedles Insulin pen devices Lifestyle enhancing drugs

Section 5 Other Benefits
Dental care The following is a complete list of dental services covered when provided by participating Primary Care Plan dentists
What is covered Diagnostic You Pay

X rays including bitewings and panoramic 20.00 once a year oral examination and treatment plan vitality test and oral cancer exam Nothing

Preventive Prophylaxis once every 6 months 20.00
Sealants per tooth 10.00 Annual topical application of fluoride up to age 12 preventive dental instructions Nothing

Restorative fillings Amalgam one surface
Amalgam two surfaces Amalgam three surfaces
Plastic or composite single surface Plastic or composite two surfaces 20 of covered charges

Oral surgery Post operative treatment simple extraction 20 of covered charges
Prosthodontics Full and partial dentures crowns and bridges repair relining and or
reconstruction of dentures 75 of covered charges
Accidental You will be reimbursed up to 50 for emergency services required when member is over 100 miles injury benefit from home and a Plan dentist is not available

Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury you pay nothing

What is not Other dental services not shown as covered covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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PacifiCare of Nevada 2000
Section 5 Other Benefits continued
Vision care
What is In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of covered the eye annual eye refractions which include the written lens prescription may be obtained from

Plan providers You pay 10.00
What is not Eye exercises and low vision aids covered Frames eyeglasses contact lenses
Contact lens examinations fitting and evaluations

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
16 Page 17 18
PacifiCare of Nevada 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor Dental Supplemental Program guaranteed under the contract with the FEHB Program but
are made available to all enrollees and family members Current Members Re enroll for 2000 benefits complete who are members of this Plan The cost of the benefits Dental Election Form
described on this page is not included in the FEHB premium any charges for these services do not count New Members Enroll by completing Dental Election
toward any FEHB deductibles or out of pocket Form maximums These benefits are not subject to the FEHB
No maximum annual limitations disputed claims procedures No billing of premiums

Medicare prepaid plan enrollment This Plan offers No claim forms to submit Medicare recipients the opportunity to enroll in the Plan Wide range of procedures covered
through Medicare As indicated on page 16 annuitants and For a more detailed explanation of benefits please refer to former spouses with FEHB coverage and Medicare Part B
the dental information enclosed in your member packet may elect to drop their FEHB coverage and enroll in a
Medicare prepaid plan when one is available in their area Annual Premiums They may then later reenroll in the FEHB Program Most Self 50.00

Federal annuitants have Medicare Part A Those without Self and Family 140.00 Medicare Part A may join this Medicare prepaid plan but
PacifiCare Vision Eyewear Only Plan will probably have to pay for hospital coverage in addition Members enjoy great savings on prescription eyewear The

to the Part B premium Before you join the plan ask savings begin with an eye exam arranged through your whether the plan covers hospital benefits and if so what
medical plan before you take advantage of PacifiCare's you will have to pay Contact your retirement system for Vision Eyewear Only Plan Then take your prescription to

information on dropping your FEHB enrollment and the provider on our eyewear only plan list select your changing to a Medicare prepaid plan Contact us at
eyewear glasses or contacts If you choose eyewear from 1 800 347 8600 for information on the Medicare prepaid a provider on our list and stay within the frame allowance

Plan and the cost of that enrollment you can obtain eyewear at virtually no cost If you choose
If you are Medicare eligible and are interested in enrolling more expensive frames or see a provider not on our list in a Medicare HMO sponsored by this Plan without you will pay additional but discounted fees

dropping your enrollment in this Plan's FEHB plan call 1 800 347 8600 for information on the benefits available For a detailed explanation of benefits please refer to the
under the Medicare HMO vision information enclosed in your member packet
Smoking Cessation Program Enroll by completing the PacifiCare Vision Eyewear only PacifiCare provides a StopSmoking Program for anyone enrollment form

member non member wishing to participate The Annual Premiums program consists of
Self 58.44
StopSmoking Kit includes Video Tape Audio Tape Self and one dependent 116.76 Seven Quit Booklets Urge Tamer Bag and program Self and Family 163.44

evaluation For questions please call PacifiCare Vision Member Counselor Support Provided via Telephone
Service at 1 800 228 3384 Counseling of use of Smoking cessation aides

Habitrol or Zyban are available to members with Value Added Program pharmacy benefits covered through PacifiCare for a PacifiCare members can access an extensive high quality

20 copayment Participants must be enrolled in the network of complementary health care providers including Stop Smoking program and obtain a prescription Chiropractors Acupuncturists and Message Therapists at
from their Primary Care doctor for one of the significantly discounted rates products Prescription medication is dispensed for a
For more information please refer to the information 30 day supply up to a maximum of 90 days Program enclosed in your member packet

enrollment limited to one time per year Physician Follow up Communication and Summary
Benefits on this page are not part of the FEHB contract Reports

This program is available in English and Spanish You may register by calling 1 800 513 5131 Program fees

20 for members 150 for non members are collected from the participant at the time of enrollment

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PacifiCare of Nevada 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 or eligible self referred services 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 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 the medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice Plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice Plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice Plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 15
Other group When anyone has coverage with us and another group health plan it is called double coverage You insurance must tell us if you or a family member has double coverage You must also send us documents
coverage 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 tell us that you have double coverage
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PacifiCare of Nevada 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care

control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are
the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers We do not cover services that compensation
You need because of work place 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 this Plan and Medicaid covers you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for

If you have a If you have a malpractice claim because of services you did or did not receive from a Plan provider malpractice claim you are not required to go through binding arbitration

Section 8 FEHB FACTS
You have a right OPM requires that all FEHB Plans comply with the Patients Bill of Rights which gives you the to information right to information about your health plan its networks providers and facilities You can also find

about your HMO 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 1 800 347 8600 or write to 700 E Warm Springs Rd Las Vegas NV 89119 You may also contact us by fax at 702 269 2649 or visit our website
at www phs com

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

What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
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PacifiCare of Nevada 2000
Section 8 FEHB FACTS continued
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1

premiums effective Annuitants premiums begin on January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

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

If you have Self Only enrollment you may change to a self and family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical We will keep your medical and claims information confidential Only the following will have and claims access to it
records confidential OPM this plan and subcontractors when they administer this contract
This Plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions OPM and the General Accounting Office when conducting audits
Individuals involved in a bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an employee express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled

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PacifiCare of Nevada 2000
Section 8 FEHB FACTS continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage

under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your Federal 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 You can pick a new plan about TCC
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 32nd 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 If you leave Federal service your employing office will notify you of your right to enroll under enroll 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 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

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PacifiCare of Nevada 2000
Section 8 FEHB FACTS continued
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 If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of Coverage leaving this Plan
Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in this certificate

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

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 1 800 932 3004 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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PacifiCare of Nevada 2000
Summary of Benefits for PacifiCare of Nevada 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pay provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes
Care in hospital doctor care room and board general nursing care private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of

operating room intensive care and complete maternity care You pay nothing 9

Extended Care All necessary services for up to 100 days per year You pay nothing 9
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care Conditions or up to 48 days of intermediate day care per year You pay nothing 11

Substance Each member is entitled to a lifetime maximum of two 30 day substance abuse programs or Abuse a lifetime maximum of two 48 day substance abuse rehabilitation intermediate day care
programs You pay nothing 12

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
Care including specialists care preventive care including well baby care periodic checkups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10

copay per office visit nothing per house call by doctor 7

Home Health Home Health care Care All necessary visits by nurses and health aides You pay nothing 8

Mental Conditions Up to 30 outpatient visits per year You pay a 5 copay per visit 11
Substance Up to 20 outpatient visits per year You pay a 5 copay per visit 12 Abuse

Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each emergency room visit and any charges for
services that are not covered benefits of this Plan 10

Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for formulary 20 per prescription unit or refill for
nonformulary Mail order prescriptions are available for 2 copays per 3 prescription units or refills 12

Dental Care Accidental injury benefit you pay nothing preventive dental care and diagnostic services are subject to various copayments Restorative and extraction services you pay 20
Prosthodontic services you pay 75 13

Vision Care Vision care One refraction annually You pay a 10 copay per visit 14
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses
Maximum reach a maximum of 1,200 for Self or 2,700 a Family per calendar year covered benefits will be provided at 100 This copay maximum does not include prescription drugs or

dental services 4
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PacifiCare of Nevada 2000
2000 Rate Information for
PacifiCare of Nevada

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 postal employees If you are a
career 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

Las Vegas Carson City Reno

Self Only K91 57.36 19.12 124.28 41.43 67.88 8.60 67.88 8.60
Self and Family K92 145.34 48.44 314.90 104.96 171.98 21.80 171.98 21.80

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