Serving For changes
Portions of Northern California in benefits see page 5 Enrollment in this Plan is limited see page 6 for
requirements
Enrollment code
5Z1 Self only 5Z2 Self and family
Visit the OPM website at http www opm gov insure and
our website at http www westernhealth com
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service
Western Health Advantage 2000
Table of Contents Page
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB FACTS 23
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits 27
Premiums 28
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Western Health Advantage 2000
Introduction
Western Health Advantage 1331 Garden Highway Suite 100
Sacramento CA 95833
This brochure describes the benefits you can receive from Western Health Advantage under its contract CS 2840 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 5 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff
have worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences
We refer to Western Health Advantage WHA as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Western Health Advantage 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services from a non contracted facility or
provider you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be
available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
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Western Health Advantage 2000
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits
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
Your may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us
and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Plan Your share of the non postal premium will increase by 1.6 for Self Only or 1.5 for Self and Family
Portions of El Dorado County are now in our service area See page 6
The short term rehabilitation benefit has been expanded Treatment is no longer limited to two months Visits are covered when authorized by your Primary Care Physician and
therapy leads to continued improvement of the condition See page 12
Traditional therapies must be ineffective prior to using acupuncture and chiropractic services
See page 13
Copayments for prosthetic and orthotic devices do not count towards the catastrophic limit See page 6
The mail order drug program is available for maintenance medications at a reduced cost See page 17
The prescription drug copayment for non preferred drugs not listed on the formulary Preferred Drug List increased from 15 to 20 for a 30 day supply See page 17
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Western Health Advantage 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is All of Sacramento and Yolo County Western Placer County Western El
Dorado County zip copes below and portions of Solano County zip codes shown below
El Dorado County zip codes
95613 95614 95619 95623 95633 95634 95635 96636 95656 95667 95672 95675 95682 95684 95709 95726 95762
Solano zip codes
94512 95620 95625 94533 94571 94585 94535 95687 95688 95696
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other
health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount pay for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services
After you pay 750 in copayments or coinsurance for one family member or 1500 for two or more family members you do not have to make any further payments for services for the rest of
the year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs durable medical equipment prosthetic and orthotic devices do not count
toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are 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 or you receive urgent or emergency care outside the service
area If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service
Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time
Who provides my Our plan doctors treat patients in a group practice arrangement at multiple convenient locations health care near your home or office WHA features some of the region's premiere medical professionals
giving our members access to more than 500 primary care doctors and more than 1100 specialty physicians Each member of your family can choose their own primary care doctor He she is
responsible for coordinating your health care with specialists and other medical providers To give you more flexibility in choosing specialty care WHA offers you access to all the specialty
physicians in the network not just those who are affiliated with your primary care doctor's medical group
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Western Health Advantage 2000
Section 3 How to get benefits continued
Who provides my When you enroll you will be asked to let the Plan know which primary care doctor s you've health care selected for you and each member of your family by sending a Primary Care selection form to the
continued Plan If you need help choosing a doctor call the Plan Members may change their doctor selection monthly by notifying the Plan 30 days in advance Each member of the family may
choose their own primary care doctor from the complete list of participating primary care physicians Your Primary Care doctor will make arrangements for you to seek specialty care
when the need arises Women can self refer to participating OB Gyn doctors whenever they need these services without a referral and everyone can self refer for an annual eye exam to one of the
participating eye specialists
WHA wants you to receive the care you need when you need it In most cases your primary care doctor will be available for urgent visits When that is not possible we also offer a unique
program which ensures access to another primary care doctor for acute medical needs within one working day Please call your primary care doctor's office when you have an urgent situation and
need to see a doctor
What do I do if my Call us We will help you select a new one primary care
physician leaves the Plan
What do I do if I 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 hospital arrangements and supervise your care
hospital
What do I do if First call our customer service department at 888 563 2250 If you are new to the FEHB I'm in the hospital Program we will arrange for you to receive care If you are currently in the FEHB Program and
when I join this are switching to us your former plan will pay for the hospital stay until 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 only apply to the person who is hospitalized at the time of enrollment
How do I get Your primary care physician will arrange your referral to a specialist You may however request specialty care to be referred to any of the WHA network specialists If you already have a relationship with a
network specialist or prefer another participating specialist you may ask to be referred to him or her Your primary care doctor will provide a written or verbal referral to your selected specialist
that includes details about the referral such as number of visits ordered by your physician
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 treatment plan will permit you to visit
your specialist without the need to obtain further referrals
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for I enroll you to see a specialist who does not participate with our Plan
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Western Health Advantage 2000
Section 3 How to get benefits continued
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the receive services from your current specialist until we can make arrangements for you to see
Plan someone else
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to a serious illness continue seeing your provider for up to 90 days after we notify you that we are terminating our
and my provider contract with the provider unless the termination is for cause or the provider leaves the area If leaves the Plan or you are in the second or third trimester of pregnancy you may continue to see your OB GYN until
this Plan leaves the the end of your postpartum care Program
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 authorize medical specialist or recommending follow up care Before giving approval we consider if the service is
services medically necessary and if it follows generally accepted standards of care
How do you decide We do not cover procedures services or supplies that are experimental or investigational In if a service is order to determine whether or not a procedure service or supply is experimental or
experimental or investigational we gather appropriate information for a decision that will be made by medical investigational professionals The information we collect may include medical records current reviews of
medical literature and scientific evidence results of current studies or clinical trials and approvals by regulatory bodies After reviewing all pertinent information we make our determination and
notify you of the decision
We will also notify you of the opportunity to request an external review Your request must be made within 5 business days of the receipt of our denial A panel of physicians or other providers
who are experts in the treatment of your medical condition and knowledgeable about the recommended therapy will do the external independent review All costs associated with the
external review are covered in full and the recommendations of the expert outside reviewers will be followed
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Western Health Advantage 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days
we will make our decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
What if I have a Call us at 888 563 2250 and we will expedite our review serious or life
threatening condition and you
haven't responded to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division III at 202 606 0755 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 are not treated as soon as possible threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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Western Health Advantage 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
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 Send your request for review to mail my disputed Office of Personnel Management
claim to OPM Office of Insurance Programs Contract Division III
P O Box 436 Washington D C 20044
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base I file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record
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Western Health Advantage 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered Plan doctors and other Plan providers provide a comprehensive range of preventive diagnostic and treatment services This includes all necessary office visits you pay a 10 office visit copay
but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate You
pay a 10 copay for a doctor's house call There is no charge for home visits by nurses or health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care no charge birth to two years and periodic check ups
Sigmoidoscopy screening for colorectal cancer every five years for those age 50 and above
Annual eye exams including eye refraction and hearing exams for all ages
Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women age 40 and over every year In addition to routine
screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters are covered at no charge
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays are covered at no charge
Chemotherapy radiation therapy and inhalation therapy
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care 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 including the insertion of intrauterine devices IUDs you pay 10 per visit Norplant and other internally implanted time release
contraceptives are covered at a copayment of 200 One insertion is covered every five years Voluntary removal prior to the five year expiration is not covered
Periodic prostate cancer screening including prostate specific antigen testing and digital rectal examinations
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Western Health Advantage 2000
Section 5 BENEFITS continued
Medical and Surgical Benefits continued
What is covered All non experimental transplants including cornea heart heart lung lung single and continued double kidney pancreas and liver transplants allogeneic donor bone marrow transplants
autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced
Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal
retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical Director Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan
Patients 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
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics when determined to be medically necessary you pay 20 of charges
Prosthetic devices such as artificial limbs breast prostheses and surgical bras and replacement and lenses following cataract removal you pay 20 of charges
Durable medical equipment such as standard wheelchairs and hospital beds oxygen and oxygen equipment replacement and repairs not provided under a manufacturer's warranty or
purchase agreement will be covered you pay 20 of charges
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 at no charge
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
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 the treatment of temporomandibular joint TMJ pain dysfunction
syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's
appearance and if the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have a breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to
produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis when authorized by your Primary Care doctor and therapy leads
to continued improvement of the condition you pay 10 per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Western Health Advantage 2000
Section 5 BENEFITS continued
Medical and Surgical Benefits continued
Limited benefits Occupational therapy is limited to services that assist the member to achieve and maintain continued self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered with prior authorization including consultations examinations diagnostic surgical services related to hospitalizations or
facilities and fertility drug therapy you pay 50 of the charges The cost of donor sperm is not covered The following types of artificial insemination are covered intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI Services may include one gamete interfallopian transfer GIFT or one in vitro fertilization
IVF but only one of these procedures is covered per Lifetime Zygote interfallopian transfers are excluded Other assisted reproductive technology ART procedures such as
embryo transfer are not covered
Sexual dysfunction treatment is covered You pay 50 of charges for durable medical equipment devices and drugs associated with treatment Drugs are payable under the
Prescription Drug benefit provision
Penile Prostheses are limited to those prescribed by a plan doctor and determined to be Medically Necessary e g secondary to penile trauma tumor or physical disease to the
circulatory system or nerve supply and are not of a psychological cause You pay 50 of charges
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infraction is provided for up to 36 sessions you pay 10 per outpatient visit
Chiropractic care for spinal manipulation only for conditions causing headache or neck and back pain when traditional therapies have been ineffective Services must be obtained
by referral from your primary care doctor and obtained from a participating plan provider Up to 20 visits per calendar year are covered with prior authorization and a 15 copayment
per visit
Acupuncture for pain management services only when traditional therapies have been ineffective Services must be obtained by referral from your primary care doctor and
obtained from a participating plan provider Up to 20 visits per calendar year are covered with prior authorization and a 15 copayment per visit
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
Homemaker services
Hearing aids
Long term rehabilitative therapy or custodial care
Infant formulas
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and blurred vision astigmatism
Penile Prostheses are excluded unless you meet the above criteria
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Western Health Advantage 2000
Section 5 BENEFITS continued
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semi private 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 with no dollar limit for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a Plan doctor 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
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 17 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
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 BENEFITS continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions
that the Plan may determine are medical emergencies what they all have in common is the need for quick action
Emergencies In emergencies contact the local emergency system e g the 911 telephone system or go to the within the service nearest hospital emergency room Be sure to tell the emergency room personnel that you are a
area 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 notified in a timely manner
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 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 15 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
copay is waived
Emergencies Benefits are available for any Medically Necessary health service that is immediately required outside the service because of injury or unforeseen illness
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 services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is waived
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Western Health Advantage 2000
Section 5 BENEFITS continued
Emergency Benefits continued
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital
Ambulance service
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
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your non Plan emergency care upon receipt of their claims Physician claims should be submitted on the
providers HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification
information from your ID card Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the
decision including the reasons for the denial and the provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration
in accordance with the disputed claims procedure described on page 10
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 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 and all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days you pay all charges thereafter Inpatient days may be exchanged for outpatient or day care
treatment visits at a rate of 2 day treatments visits for each inpatient day
What is not Care for psychiatric conditions that 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
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Western Health Advantage 2000
Section 5 BENEFITS continued
Mental Conditions Substance Abuse Benefits continued
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 and all charges thereafter
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing for the first 30
days all charges thereafter
What is not Treatment that is not authorized by a Plan doctor covered
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay a 5 copay per prescription unit or refill for generic
drugs or 10 copay per prescription for name brand drugs on the Preferred Drug formulary list or 20 copay per prescription for Non Preferred non formulary Brand Name Medications per
each 30 day supply or 120 unit supply whichever is less In no event will the copay exceed the cost of the prescription drug When generic substitution is permissible i e a generic drug is
available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay the price difference between the generic and name brand
drug as well as the 10 copay per prescription unit or refill Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's formulary policy Non formulary drugs will be
covered when prescribed by a Plan doctor
Covered Prescription Medications that are to be taken beyond 60 days are considered Maintenance Medications Maintenance Medications are used in the treatment of chronic conditions like
arthritis high blood pressure heart conditions and diabetes Oral contraceptives are also available through the mail order program Maintenance Medications may be obtained through
Western Health Advantage's Mail Order Program You can request the order form and brochure for this benefit by contacting WHA's Member Service Department at 888 563 2250 The initial
Prescription for Maintenance Medications is dispensed through a Participating Pharmacy limited to a 30 day supply Subsequent refills for a 90 day supply may be obtained through the Mail
Order Program You pay a 10 for a 90 day supply of generic medication 20 for a 90 day supply of brand name medication on the Preferred Drug list and 40 for a 90 day supply of brand name
medication which is Non Preferred through the mail order program In this way you receive a 90 day supply of medication for only two copays
WHA Preferred The WHA Pharmacy and Therapeutics P T Committee developed a Preferred Drug List PDL Drug Formulary based on Quality Care and Cost Effectiveness The Committee did not consider pharmaceutical
List Development rebates in this process The group first looked at clinical efficacy safety profile and alternatives within the drug category Lastly the committee looked at comparative cost The P T Committee
felt that a limited number of the medications on the Preferred Drug List should have a prior authorization for clinical or benefit reasons
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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Western Health Advantage 2000
Section 5 BENEFITS continued
Prescription Drug Benefits continued
WHA Preferred Drug The Benefits for most members were then based on a three tier copay ie Generic 5 Brand on Formulary List the PDL 10 Brand not on the PDL 20 For every medication that is not on the Preferred Drug
Development List there are reasonable alternatives that are on the Preferred Drug List The Pharmacy and continued Therapeutics Committee felt that this approach to a pharmacy benefit would leave more of the
clinical decision making up to the treating physician The differential copay for medications that are not on the PDL simply took into account the added cost of some medications when good
alternatives are available on the PDL
Covered Drugs for which a prescription is required by law medications and
accessories Oral contraceptive drugs up to a 90 day supply per refill with two copayments if received include through the mail or one copay applied to each 30 day supply filled at the local participating
pharmacy
Diaphragms with a prescription
Insulin with a copay charge applied to each vial
Disposable needles and syringes needed to inject covered medications
Glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets are covered up to a 30 day supply per copay
Inhalers limited to two per prescription
Intravenous fluids and medications for home use fertility drugs you pay 50 implantable drugs such as Norplant contraceptive devices other than diaphragms and some injectable drugs such as
Depro Provera are covered under Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs have dosage limitations and you pay 50 of charges Contact the plan for details
Smoking cessation drugs and medication including nicotine patches are covered as a Wellness Benefit You must obtain a prescription from your primary care doctor and are responsible for
100 of the cost of the medication Upon remaining smoke free for 90 days after treatment as certified by your physician WHA will reimburse you in full You must be an active participant in
WHA at the time of the reimbursement
What is not Drugs available without a prescription or for which there are a nonprescription equivalent covered available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Western Health Advantage 2000
Section 5 BENEFITS continued
Other Benefits
Dental Care
What is covered Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury
You pay nothing
What is not covered Any other dental service not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription may be obtained
from Plan providers You pay a 10 copay per visit
What is not Corrective lenses or frames covered
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19
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Western Health Advantage 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 Services drugs or supplies that are not medically necessary the following
Services not required according to generally 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 and
Expenses you incurred while you were not enrolled in this Plan
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Western Health Advantage 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 38 6833
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage You must tell us if you or a family member has double coverage You must also send
coverage us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payor we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover
injuries 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 payor See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
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Western Health Advantage 2000
Section 7 Limitations Rules that affect your benefits continued
Workers We do not cover services that compensation
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 as long as you use our providers
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly Government or indirectly pay
Agencies
If you have a If you have a malpractice claim because of services you did or did not receive from a plan malpractice provider it must go to binding arbitration Contact us about how to begin our binding arbitration
claim process
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Western Health Advantage 2000
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
about your HMO 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 888 563 2250 or write to Western Health Advantage WHA at 1331 Garden Highway Ste 100 Sacramento CA 95833 You may also
contact us by fax at 916 563 3182 or visit our website at www westernhealth 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
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 Annuitants premiums begin January 1
effective
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 for coverage 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 a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
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Western Health Advantage 2000
Section 8 FEHB FACTS continued
Are my medical We will keep your medical and claims information confidential Only the following will have and claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers'Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election cards 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
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former 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
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Western Health Advantage 2000
Section 8 FEHB FACTS continued
Key points about TCC
You can pick a new plan
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
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 or
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
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I convert You may convert to an individual policy if to 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
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Western Health Advantage 2000
Section 8 FEHB FACTS continued
How can I convert If you leave Federal service your employing office will notify you if individual coverage is to individual available You must apply in writing to us within 31 days after you receive this notice
coverage However if you are a family member who is losing coverage the employing or retirement continued 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 Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health Plan health insurance or other health care coverage You must arrange for the other coverage within 63 Coverage 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
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 888 563 2250 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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Western Health Advantage 2000
Summary of Benefits for Western Health Advantage 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care
private room and private nursing care if Medically Necessary diagnostic tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 12
Extended All necessary services up to 100 days in a calendar year You pay nothing 12 care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of conditions inpatient care per calendar year You pay nothing 14
Substance Up to 30 days per calendar year in a substance abuse treatment program abuse You pay nothing 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or care injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit copays are
waived for maternity care 9
Home health All necessary visits by nurses and health aides You pay nothing 10 care
Mental Up to 20 outpatient visits per calendar year You pay a 20 copay per visit 14 conditions
Substance Up to 20 outpatient visits per calendar year You pay a 20 copay per visit 14 abuse
Emergency Reasonable charges for services and supplies required because of a medical care emergency You pay a 50 copay to the hospital for each emergency room
visit and any charges for services that are not covered by this Plan 12
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy drugs You pay a 5 10 20 copay per prescription unit or refill for 30 day supply 15
Dental care Accidental injury benefit You pay nothing 16
Vision care One refraction annually You pay a 10 copay per visit 16
Out of pocket Copayments are required for a few benefits however after your out ofpocket maximum expenses reach a maximum of 750 per Self Only or 1500 per Self
and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include charges for durable
medical equipment prescription drugs and prosthetic and orthotic devices 6
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2000 Rate Information for
Western Health Advantage
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 5Z1 58.71 19.57 127.21 42.40 69.47 8.81 69.47 8.81
Self and Family 5Z2 140.90 46.96 305.27 101.76 166.73 21.13 166.73 21.13
28 28