This Plan has full accreditation from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www upmc edu upmchealthplan
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service
RI 73 797
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UPMC Health Plan 2000 Table of Contents
Introduction .3
Plain language .3
How to use this brochure .3
Section 1 Health Maintenance Organizations .4
Section 2 How we change for 2000 .4
Section 3 How to get benefits .5
Section 4 What to do if we deny your claim or request for service .8
Section 5 Benefits .10
Section 6 General exclusions Things we don't cover .17
Section 7 Limitations Rules that affect your benefits .18
Section 8 FEHB FACTS .19
Inspector General Advisory Stop Healthcare Fraud .22
Summary of benefits .23
Premiums .24
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UPMC Health Plan 2000 Introduction
UPMC Health Plan One Chatham Center Suite 800
112 Washington Place Pittsburgh PA 15219
This brochure describes the benefits you can receive from UPMC Health Plan Enhanced Access HMO under its contract CS2856 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 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 UPMC Health Plan 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
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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UPMC Health Plan 2000 Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However when you receive services you must pay copayments and coinsurance listed in this brochure When you receive emergency services while outside the
service area 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
Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program
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 your 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 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 UPMC Health Plan is new to the FEHB Program for 2000
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UPMC Health Plan 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 the following counties
Allegheny Beaver Bedford Blair Butler Cambria Crawford Fayette Lawrence McKean Mercer Washington Westmoreland
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 urgent or emergency care We will not pay for any
other health care services unless authorized by UPMC Health plan prior to services being rendered
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in
another state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to
wait until Open Season to change plans Contact your employing or retirement office
How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percent of charges Please remember you must pay this amount when you
receive services
Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few benefits
Do I have to submit claims You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't contract with 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 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 UPMC Health Plan is an Enhanced Access HMO an HMO with a choice health care You can coordinate your care through your selected PCP for minimal copays or you may selfrefer
your care to any network specialist at anytime for a slightly higher copay The choice is yours
UPMC Health Plan also In addition to choosing a PCP women may also choose a network OB GYN to coordinate all offers more flexibilty women's care All female related services can be self referred directly to the selected OB GYN
for women women never need to get a referral to see their selected OB GYN
Physicians play an integral role in all we do from quality assurance to health risk assessment
Our primary focus is to keep you and your family healthy We want to provide appropriate preventive care and education so your overall health is improved before problems start
The UPMC Health System and the network's community hospitals provide convenient access to routine acute and emergency care in your neighborhood right where and when you need it
The complete network of care includes doctors offices community surgical centers specialized care rehabilitation and in home care
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UPMC Health Plan 2000 Your Primary Care As a UPMC Health Plan member you need to select a Primary Care Physician PCP to
Physician coordinate your health care Each of your eligible family members may choose a different PCP
Your PCP's primary focus is to keep you healthy not just to treat you when you are sick Your PCP also coordinates your health care studying your medical history monitoring your health
and reviewing records from any other doctors you visit to make sure that all the care you receive is coordinated Your PCP can provide most of the care you need however he or she will make
referrals to specialists if necessary will arrange for hospital admissions and will be responsible for ensuring that you get appropriate tests When your PCP refers you to a specialist the referral
is paperless You are not required to get a form for a specialist visit This helps make your care both efficient and effective By using your PCP for preventive care routine care and referrals to
specialists you receive the highest level of benefits
Your PCP or an associate is available 24 hours a day
You can change your PCP by calling UPMC Health Plan's Member Services Department
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our customer service department at 1 888 876 2756 If you are new to the FEHB hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program
this Plan and are switching to us your former plan will pay for the hospital stay until l You are discharged not merely moved to an alternative care center or
l The day your benefits from your former plan run out or
l The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty care There are TWO ways to receive specialty care under UPMC Health Plan's Enhanced Access HMO
1 Consult your PCP for specialty care If your PCP cannot provide the needed treatment he or she will coordinate your care by referring you to a network specialist This coordinated
specialty care is covered 100 after a 10 copayment 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
2 You may also self refer to any specialist in our network at anytime A 30 copayment applies for the office visit but all medically necessary services within the Plan specific
benefits are covered at 100 as if you were referred by your PCP
When making a referral to a specialist your PCP communicates the information for you The referral process is paperless which means you are not responsible for bringing an
authorization form to your visit
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UPMC Health Plan 2000 What do I do if I am seeing Your primary care physician will decide what treatment you need If they decide to refer you to
a specialist when I enroll a specialist ask if you can see your current specialist If your current specialist does not participate with us you must receive treatment from a specialist who does Generally we will
not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see
someone else
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to illness and my provider continue seeing your provider for up to 90 days after we notify you that we are terminating our
leaves the Plan or this contract with the provider unless the termination is for cause If you are in the second or Plan leaves the Program third trimester of pregnancy you may continue to see your OB GYN until the end of your
postpartum care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician is not required to contact the Plan before sending you to a hospital medical services referring you to a specialist or recommending follow up care Your Plan physician is
accountable for providing care that is medically necessary and follows generally accepted medical practice
How do you decide if a Experimental or Investigational services are any treatment service procedure facility service is experimental equipment drug device or supply intervention which is not determined by the Plan
or investigational or its designated agent to be a proven treatment The Plan will consider an intervention to be Experimental Investigative if
a the intervention does not have FDA approval to market for the specific relevant indication s or
b evidence does not demonstrate through prevailing peer reviewed medical literature to be a safe and effective treatment for treating or diagnosing of a condition or illness or
c the intervention is not proven to be as safe or as effective in achieving an outcome equal to or exceeding the outcome of alternative therapies or
d the intervention does not improve health outcomes or
e the intervention is not proven to be able to be replicated outside the research setting
If an intervention as defined above is determined to be Experimental Investigative at the time of service it will not receive retroactive coverage even if it is found to be in accordance
with the above criteria at a later date
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UPMC Health Plan 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 in explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the information we already have
When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I have a serious or Call us at 1 888 876 2756 and we'll expedite our review life threatening condition
and you haven't responded to my request for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and my inform OPM so that they can give your claim expedited treatment too Alternatively you can
condition is serious or call OPM's Health Benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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UPMC Health Plan 2000 What address should I Send your request for review to
send my disputed claim to Office of Personnel Management Office of Insurance Programs
Contracts Division IV P O Box 436
Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will a lawsuit base its review on the record that was before OPM when OPM made its decision on your claim
You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for 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 the Privacy Act you and us to determine if our denial of your claim is correct The information OPM collects
during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make the request Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with
the review request
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UPMC Health Plan 2000 Section 5 Benefits UPMC Health Plan
MEDICAL AND SURGICAL BENEFITS What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan
doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no additional copay for laboratory tests and X rays Within the service area
house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a 10 copay for a doctor's house call and nothing for home visits by nurses
and health aides
The following services are l Preventive care including well baby care and periodic check ups Copay waived included and subject to l Mammograms are covered as follows for women age 35 through age 39 one
the office copay unless mammogram during these five years for women age 40 through 49 one mammogram stated otherwise 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 Copay waived
l Routine immunizations and boosters Copay waived
l Consultations by specialists
l Diagnostic procedures such as laboratory tests and X rays Copay waived
l 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
l Voluntary sterilization and family planning services such as a vasectomies and tubal
ligations
l Diagnosis and treatment of diseases of the eye
l Allergy testing and treatment including testing and treatment materials such as allergy
serum
l The insertion of internal prosthetic devices such as pacemakers and artificial joints
l Cornea heart kidney pancreas heart lung single double lung 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
l 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 Copay waived
l Dialysis
l Chemotherapy radiation therapy and inhalation therapy
l Surgical treatment of morbid obesity
l Orthopedic devices such as braces
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UPMC Health Plan 2000 l Prosthetic devices such as artificial limbs external breast prothesis and surgical bras and
lenses following cataract removal
l Durable medical equipment such as wheelchairs and hospital beds
l Chiropractic services are covered for medically necessary spinal manipulations An initial
evaluation and 25 visits thereafter per calendar year are covered No referral required
l Home health services of nurses and health aides including intravenous fluids and
medications when prescribed by you Plan doctor who will periodically review the program
for continuing appropriateness and need
l 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
l Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
is provided on an outpatient or inpatient basis without limitations You pay nothing
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
LIMITED BENEFITS Oral and maxillofacial surgery is provided for nondental surgical and hospitalization
procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to
treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered including 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
Short term rehabilitative therapy physical speech and occupational is provided on an outpatient basis for up to two months or a combined limit of 60 days per calendar year you pay
10 per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to achieve
and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment up to diagnosis of infertility is covered in full The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay nothing cost of donor sperm is not covered Fertility drugs are not covered Other assisted reproductive technology ART procedures such
as in vitro fertilization and embryo transfer are not covered
What is not covered l Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
l Reversal of voluntary surgically induced sterility
l Surgery primarily for cosmetic purposes
l Homemaker services
l Hearing aids
l Transplants not listed as covered
l Long term rehabilitative therapy
l Foot orthotics or disposable supplies
l Blood and blood derivatives not replaced by the member
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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UPMC Health Plan 2000 HOSPITAL EXTENDED CARE BENEFITS
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
l A semi private room accomodation when a Plan doctor determines it is medically necessary
the doctor may prescribe private accomodations or private duty nursing care
l Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
l Bed board and general nursing care
l 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 service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
LIMITED BENEFITS Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient detoxification Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 14 for non medical substance abuse benefits
What is not covered l Personal comfort items such as telephone and television l Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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UPMC Health Plan 2000 EMERGENCY BENEFITS
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute
conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme service area emergencies if you are unable to contact your doctor contact the local emergency system e g
the 911 telephone system or go immediately to the nearest hospital emergency room Be sure to tell the emergency 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 reasonble 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 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 the 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 30 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 copay is
waived
Emergencies outside the Benefits are available for any medically necessary health service that is immediately required Service Area because of injury or unforeseen illness
If you need to be hospitalized 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
UPMC Health Plan provides an additional service for emergencies outside the Service Area called Assist America Any time you need care when traveling more than 100 miles from home
Assist America can help to direct you to the closest most appropriate medical facility Assist America will then notify the Plan fulfilling your obligation to do so within 48 hours This
service is available 24 hours per day 365 days per year for urgent or emergency care while outside of the service area Please call Assist America in the USA 1 800 872 1414 and outside
the USA 301 656 4152
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UPMC Health Plan 2000 Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 30 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 copay is
waived
What is covered l Emergency care at a doctor's office or an urgent care center l Emergency care as an outpatient or inpatient at a hospital including doctors services
l Ambulance service approved by the Plan
What is not covered l Elective care or non emergency care l Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area l Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area
Filing claims for non Plan With your authorization the Plan will pay benefits directly to the providers of your emergency providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID
card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure
described on page 8
MENTAL CONDITIONS SUBSTANCE ABUSE BENEFITS Mental Conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or
disorders
l Diagnostic evaluation
l Psychological testing
l Psychiatric treatment including individual and group therapy
l Hospitalization including inpatient professional services
Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay for each covered visit all charges
thereafter
Inpatient care Up to 30 days of hospitalization each calendar year for Hospital Services provided for Behavioral Health service Inpatient treatment by a Hospital or Facility Provider
you pay nothing for the first 30 days all charges thereafter
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UPMC Health Plan 2000 What is not covered l Care for psychiatric conditions that in the professional judgment of Plan doctors are not
subject to significant improvement through relatively short term treatment
l 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
l Psychological testing when not medically necessary to determine the appropriate treatment
of a short term psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care Up to 60 outpatient visits to Plan providers for treatment each calendar year 120 visits per lifetime maximum You pay nothing for each covered visit 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 90
days per lifetime maximum You pay nothing during the benefit period all charges thereafter
What is not covered l Treatment that is not authorized or referred by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
PRESCRIPTION DRUG BENEFITS What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan Participating
pharmacy will be dispensed for up to a 30 day supply or 100 units whichever is less or one commercially prepared unit i e one inhaler one vial insulin or prescriptions obtained through
the Plan Participating mail order pharmacy will be dispensed for up to a 90 day supply for Plan approved maintenance medications
You pay a 5 copay per prescription unit or refill for generic drugs or a 15 copay for name brand drugs when generic substitution is not permissible When generic substitution is permissible i e a
generic drug is available and the prescribing doctor does not require the use of a brand namedrug but you request the brand name drug you pay the price difference between the generic and
brand name drug as well as the 15 copay per brand name prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor
Covered medications and l Drugs for which a prescription is required by law
accessories include l Oral contraceptive drugs contraceptive diaphragms IUDs Norplant Depo Provera l
Insulin a copay charge applies to each vial
l Disposable needles and syringes needed to inject covered prescribed medication
l Diabetic supplies including insulin syringes needles blood glucose test strips and lancets
for insulin treated diabetics
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
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UPMC Health Plan 2000 Limited Benefits Drugs for the treatment of sexual dysfunction have dosage limitations Contact the Plan for the
dosage limitations
What is not covered l Drugs available without a prescription or for which there is a nonprescription equivalent available
l Drugs obtained at a non Plan pharmacy except for out of area emergencies
l Vitamins except prenatal and nutritional substances that can be purchased without a
prescription
l Medical supplies such as dressings and antiseptics
l Drugs for cosmetic purposes
l Drugs to enhance athletic performance
l Fertility drugs
l Smoking cessation drugs and medication nicotine patches and nicotine gum
l Drug therapy for weight loss
l Food supplements and other nutritional and over the counter electrolyte supplements except
as required to treat phenylketonuria PKU
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
OTHER BENEFITS Dental care
What is covered Accidental injury benefit Dental services required due to accidental injury to sound natural teeth when approved by the
Plan The need for these services must result from an accidental injury and not as a result of chewing or biting You pay nothing
What is not covered l Other dental services not shown as covered l
Orthodontia and all other dental related services
l Services provided by non Plan dentists
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye eye refractions to provide a written lens prescription may be obtained from
Plan providers You pay nothing per visit
What is not covered l Corrective lenses or frames l
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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UPMC Health Plan 2000 Non FEHB Benefits The benefits described on this page are neither offered nor guaranteed under the contract with the
Available to Plan Members FEHB Program but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and any charges
for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure
Healthy Living Rewards The Healthy Living Rewards program offers value added savings to UPMC Health Plan members As a member you are eligible to receive discounts on products and services that
promote healthy lifestyles such as fitness clubs sporting good stores and health food stores Show your UPMC Health Plan identification card at the time of purchase to receive your
savings The discounts apply to services where insurance coverage may not exist A listing of participating vendors can be found in the back of the UPMC Health Plan Enrollment Guide
Wellness Programs UPMC Health Plan together with UPMC Health System offers a variety of health promotion and wellness classes most free of charge for conditions such as Diabetes Childbirth Cancer
Support Groups and Smoking Cessation The classes are taught by trained professionals and are held at convenient locations throughout the area Descriptions of classes can be found in the
back of the UPMC Health Plan Enrollment Guide To get information and details on registration call 1 800 533 UPMC 8762
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 l Services drugs or supplies that are not medically necessary
following l Services not required according to accepted standards of medical dental or psychiatric practice
l Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits
l Experimental or investigational procedures treatments drugs or devices
l 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
l Procedures services drugs and supplies related to sex transformations
l Services or supplies you receive from a provider or facility barred from the FEHB Program
and
l Expenses you incurred while you were not enrolled in this Plan
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UPMC Health Plan 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 re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 UPMC Health Plan does not currently
offer a Medicare Choice plan
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary
care
When others are responsible When you receive money to compensate you for medical or hospital care for injuries or illness for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
Workers compensation We do not cover services that l
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
l 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
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UPMC Health Plan 2000 Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out about care management which includes medical practice guidelines
disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 888 876 2756 Monday thru Friday 7 a m to 7 p m and Saturdays between 8 a m and noon or write to UPMC Health Plan One Chatham Center Pittsburgh PA 15219 attn Member Services You may also contact us
by fax at 412 454 7543 or visit our website at www upmc edu upmchealthplan or www tristate upmc edu physician listings
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to about enrolling in the Federal Employees Health Benefits Plans brochures for other plans and other materials
FEHB Program you need to make an informed decision about
l When you may change your enrollment
l How you can cover your family members
l What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
l When your enrollment ends and
l The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1
What happens when I retire When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section
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UPMC Health Plan 2000 What types of coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
available for my family unmarried dependent children under age 22 including any foster or step children your employing and me or retirement office authorizes coverage for Under certain circumstances you may also get
coverage for a disabled child 22 years of age or older who is incapable of self support
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
Are my medical and claims We will keep your medical and claims information confidential Only the following will have records confidential access to it
l OPM this Plan and subcontractors when they administer this contract
l This plan and appropriate third parties such as other insurance plans and the office of
l Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
l Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
l OPM and the General Accounting Office when conducting audits
l Individuals involved in bona fide medical research or education that does not disclose your
identity or
l OPM when reviewing a disputed claim or defending litigation about a claim
INFORMATION FOR NEW MEMBERS Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election
Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a deductible Your old plan's deductible continues until our coverage begins under my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
WHEN 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 l Your enrollment ends unless you cancel your enrollment or l
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
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UPMC Health Plan 2000 What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your 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 exspouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC l You can pick a new plan l
If you leave Federal service you can receive TCC for up to 18 months after you separate
l If you no longer qualify as a family member you can receive TCC for up to 36 months
l Your TCC enrollment starts after regular coverage ends
l 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
l You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs
l You receive another 31 day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium
l You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you are leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is
later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
l Divorce
l 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
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UPMC Health Plan 2000 How can I convert to You may convert to an individual policy if
individual coverage l Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
l You decided not to receive coverage under TCC or the spouse equity law or
l You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer
eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Group Health Plan Coverage that indicates how long you have been enrolled with us You can use this certificate when getting
health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
limitations or exclusions for health related conditions based on the information in the certificate If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
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
l Call the provider and ask for an explanation There may be an error
l If the provider does not resolve the matter call us at 888 876 2756 and explain the situation
l 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
l Try to obtain services for a person who is not an eligible family member or
l 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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UPMC Health Plan 2000 Summary of Benefits for the UPMC Health Benefit Plan 2000
Do not rely on this chart alone All benefits are 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 care All necessary services no dollar or day limit You pay nothing .12
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing per inpatient day .14
Substance Abuse Up to 30 days per year 90 days per lifetime in a substance abuse treatment program You pay nothing .15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay 10 copay per office visit copays are waived
for adult and pediatric preventive care and maternity care 10 per house call by a doctor .10
Home health care All necessary visits by nurses and health aides you pay nothing .11
Mental Conditions Up to 40 outpatient visits per year You pay a 10 copay per visit .14
Substance Abuse Up to 60 outpatient visits per year 120 visits lifetime maximum You pay nothing per visit .15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 30 copay to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan .13
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per generic prescription unit or refill and a 15 copay per brand name
prescription unit or refill .15
Dental care Accidental injury benefit you pay nothing .16
Vision care One refraction Under 22 once every 12 months Over 22 once every 24 months You pay nothing per visit .16
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UPMC Health Plan 2000
2000 Rate Information Non Postal rates apply to most non Postal Employees 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 rates 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
High Self 8W1 54.40 18.13 117.86 39.29 64.37 8.16 64.37 8.16 High Family 8W2 161.21 53.74 349.30 116.43 190.77 24.18 190.77 24.18
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