Pages 1--49 from Cimarron Health Plan

Enrollment codes for this Plan:
PX1 Self Only
PX2 Self and Family


 
     

6
(formerly QualMed Plans for Health)
http:// www. cimarronhealthplan. com
2001 1
1 Page 2 3
Table of Contents Page
Introduction ..................................................................................................................................... 4
Plain language ..................................................................................................................................... 4
Section 1 — Facts about this HMO Plan ............................................................................................... 4
How we pay providers ......................................................................................... 5
Who provides my healthcare ............................................................................................ 5
Patients' Bill of Rights ...................................................................................................... 5
Service Area ...................................................................................................................... 5
Section 2 — How we change for 2001 .................................................................................................. 5
Program-wide changes ...................................................................................................... 5
Changes to this Plan .......................................................................................................... 6
Section 3 — How to get care................................................................................................................. 6
Identification Cards ........................................................................................................... 6
Where you get covered care ............................................................................................. 7
°Plan Providers ............................................................................................................ 7
°Plan Facilities .............................................................................................................. 7
What you must do to get covered care ............................................................................. 7
°Primary care ............................................................................................................... 7
°Specialty care ............................................................................................................. 7
°Hospital care ............................................................................................................... 8
Circumstances beyond our control ...................................................................................... 9
Services requiring our prior approval .................................................................................. 9
Section 4 — Your costs for covered services .......................................................................................... 9
°Copayments .................................................................................................................. 9
°Deductible .................................................................................................................... 9
°Coinsurance .................................................................................................................. 9
Your out-of-pocket maximum ............................................................................................. 9
Section 5 — Benefits ............................................................................................................................. 10
Overview ........................................................................................................................... 10
(a) Medical services and supplies provided by physicians
and other health care professionals ..................................................................... 11
(b) Surgical and anesthesia services and supplies provided by physicians
.... and other health care professionals................................................................... 18
(c) Services provided by a hospital or other facility, and ambulance services ............. 22
(d) Emergency services/ accidents ................................................................................ 24
(e) Mental health and substance abuse benefits........................................................... 26
(f) Prescription drug benefits ...................................................................................... 28
(g) Special features ...................................................................................................... 30
(h) Dental benefits ....................................................................................................... 31
(i) Non-FEHB benefits available to Plan members ..................................................... 32

2001 Cimarron Health Plan 2 Table of Contents 2
2 Page 3 4
Section 6 — General exclusions – things we don't cover ..................................................................... 33
Section 7 — Filing a claim for covered services ................................................................................... 33
Section 8 — The disupted claims process ............................................................................................ 35
Section 9 — Coordinating benefits with other coverage ....................................................................... 36
When you have ....
°Other health coverage ................................................................................................. 36
°Original medicare ........................................................................................................ 36
°Medicare managed care .............................................................................................. 38
TRICARE/ Workers' Compensation/ Medicaid .................................................................. 38
Other Government agencies .............................................................................................. 39
When others are responsible for injuries ........................................................................... 39
Section 10— Definitions of terms we use in this brochure .................................................................... 39
Section 11— FEHB facts ...................................................................................................................... 41
Coverage information ....................................................................................................... 41
°No pre-existing condition limitation ........................................................................... 41
°Where you get information about enrolling in the FEHB Program ............................ 41
°Types of coverage available for you and your family ................................................ 41
°When benefits and premiums start ............................................................................ 42
°Your medical and claims records are confidential ...................................................... 42
°When you retire ......................................................................................................... 42
When you lose benefits .................................................................................................... 42
°When FEHB coverage ends ...................................................................................... 42
°Spouse equity coverage .................................................................................. 42
°Temporary Continuation of Coverage (TCC) ............................................................ 43
°Converting to individual coverage .............................................................................. 43
°Getting a Certificate of Group Health Plan Coverage ................................................. 43
Inspector General Advisory ................................................................................................................... 44
Index .................................................................................................................................... 45
Summary of benefits ............................................................................................................................. 47
Rates ....................................................................................................... ................. Back cover

2001 Cimarron Health Plan 3 Table of Contents 3
3 Page 4 5
Introduction
Cimarron Health Plan (formerly QualMed Plans for Health)
P. O. Box 3050
Albuquerque, NM 87190-3050

This brochure describes the benefits of Cimarron Health Plan under our contract (CS 2062) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is
the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,
and exclusions of this brochure.

If you are enrolled in this Plan, you are 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. You do not have a right
to benefits that were available before January 1, 2001, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 6. Rates are shown 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. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical
terms, we use common words. "You" means the enrollee or family member; "we" means Cimarron Health Plan.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare
this Plan with other FEHB plans, you will find that the brochures have the same format and similar information
to make comparisons easier.

If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.

Section 1. Facts about this HMO Plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations,
in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only
pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency
services from non-Plan providers, 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.

2001 Cimarron Health Plan 4 Section 1 4
4 Page 5 6
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure.
These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments
or coinsurance.

Who provides my healthcare
Cimarron Health Plan is an individual practice plan that provides care to members through an extensive list of
private practice doctors and other providers located conveniently throughout the entire State of New Mexico.
The doctor panel consists of over 2,400 primary care doctors and over 1,200 specialists.

Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's
Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website www. opm. gov/ insure lists the specific
types of information that we must make available to you. Some of the required information is listed below.

Find out about care management, which includes medical practice guidelines, disease management programs and how we determine if procedures are experimental or investigational.

If you want more information about us, call 800/ 365-0009, or write to Cimarron Health Plan, P. O. Box 3050,
Albuquerque, NM 87190-3050. You may also contact us by fax at 505/ 798-4558 or visit our website at
cimarronhealthplan. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area.
Our Service Area is the entire State of New Mexico.
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 also reimburse routine care received at Student Health Care
Centers at the out-of-area colleges or universities that your covered dependent children attend, less the office
visit copayment. 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.

Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays,
and day and visit limitations when you follow a treatment plan that we approve. Previously, we placed higher
patient cost sharing and shorter day or visit limitations on mental health and substance abuse services than we
did on services to treat physical illness, injury, or disease.

2001 Cimarron Health Plan 5 Section 2 5
5 Page 6 7
Many healthcare organizations have turned their attention this past year to improving quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our patient safety
activities by calling 800-365-0009, or checking our website at cimarronhealthplan. com. You can find out more
about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take these five steps:

Speak up if you have questions or concerns. Keep a list of all the medicines you take.
Make sure you get the results of any test or procedure. Talk with your doctor and health care team about your options if you need care.
Make sure you understand what will happen if you need surgery.
We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously,
the language referenced only women.
Changes to this Plan
Your share of the non-Postal premium will increase by 3.7% for Self Only or 3.7% for Self and Family.
Durable Medical Equipment, Orthopedic Devices, and Prosthetic Devices are no longer subject to a combined maximum Plan payment of $2,000 per calendar year. You pay 20% of covered charges.

Hospice Benefits are covered subject to a benefit maximum of 210 days per lifetime instead of a benefit maximum of $10,000 per lifetime.
Acupuncture is covered for up to 20 visits per calendar year. You pay 50% of covered charges. Previously, members paid $10 per visit and the benefit was limited to 60 days of coverage.
Contraceptive devices are no longer covered subject to a combined maximum Plan payment of $2,000 per calendar year. You pay $10 per visit and 50% of covered charges for the device.
Doctor's house calls are covered subject to a member copayment of $20 per visit instead of $15 per visit.
Preventive and diagnostic dental benefits are covered. You pay 50% instead of $40 per visit.
Kidney/ Pancreas transplants have been added to the list of covered organ/ tissue transplants.
We have expanded our service area to include all of the State of New Mexico.

Section 3. How to get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card,
use your copy of the Health Benefits Election Form, SF-2809, your
health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
(800) 365-0009 or (505) 342-4723.

2001 Cimarron Health Plan 6 Section 3 6
6 Page 7 8
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list
these in the provider directory, which we update periodically. The list is
also on our website.

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges
for most of your health care. Call Membership Services at
(800) 365-0009 or (505) 342-4723 to choose or change your
primary care physician.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or will request a referral from the Plan for you to see a
specialist.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, women may see their OB-Gyn physicans for female related
conditions without a referral. Services of providers who are not Plan
contracted providers are covered only when there has been a Plan
approved referral by your primary care doctor.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with the Plan to develop a treatment plan that allows you to see your specialist

for a certain number of visits without additional referrals. Your primary care physician will use our criteria
when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to 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.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we

can make arrangements for you to see someone else.

2001 Cimarron Health Plan 7 Section 3 7
7 Page 8 9
If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or

drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan, you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the
above circumstances, you can continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care.
This includes admission to a skilled nursing or other type
of facility.

If you are in the hospital when your enrollment in our Plan
begins, call our Customer Service Department immediately
at (800) 365-0009 or (505) 342-4723. If you are new to
the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan
will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized
person.

2001 Cimarron Health Plan 8 Section 3 8
8 Page 9 10
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be
unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services requiring our
prior approval Your primary care physician has authority to refer you for some services. For certain services, however, your physician

must obtain approval from us. Before giving approval, we
consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

We call this review and approval process "prior authorization".
Your physician must obtain a prior authorization for services
such as hospitalization and outpatient surgery and procedures,
testing such as CT Scans and MRI's, and nuclear medicine.
Your physician will request this information directly from the
Plan. If care must be extended, your physician will request
additional visits or procedures from the Plan.

Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your primary care physician you pay
a copayment of $10 per office visit and when you visit an
emergency room you pay a $50 copayment.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits
for those services. We have no deductible.
NOTE: if you change plans during open season, you do not have
to start a new deductible under your old plan between January 1
and the effective date of your new plan. If you change plans at
another time during the year, you must begin a new deductible
under your new plan.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for
infertility services and 20% for durable medical equipment
and prosthetics.

Your out-of-pocket maximum After your out-of-pocket expenses total 200% of your annual premium in any calendar year, you do not have to pay any more
for covered services. However, copayments for the following
services do not count toward your out-of-pocket maximum,
and you must continue to pay copayments for these services:

2001 Cimarron Health Plan 9 Section 4 9
9 Page 10 11
Dental Services Prescription Drugs
Be sure to keep accurate records of your out-of-pocket
expenses, since you are responsible for informing us when
you reach the maximum.

Section 5. Benefits ... OVERVIEW (See page 6 for how our benefits changed this year and page 47 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. For more information about our benefits, contact us at (800) 365-0009
or (505) 342-4723, or at our website at cimarronhealthplan. com.

(a) Medical services and supplies provided by physicians and other health care professionals ............... 11-18
Diagnostic and treatment services Hearing services Lab, X-ray, and other diagnostic tests (testing, treatment, and supplies)
Preventive care, adult Vision services Preventive care, children (testing, treatment, and supplies)
Maternity care Foot care Family planning Orthopedic and prosthetic devices
Infertility services Durable medical equipment (DME) Allergy care Home health services
Treatment therapies Alternative treatments Rehabilitative therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............ 18-21
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants

(c) Services provided by a hospital or other facility, and ambulance service ........................................... 22-24
Inpatient hospital Extended care benefits/ skilled nursing care Outpatient hospital or ambulatory facility benefits
surgical center Hospice care
Ambulance

(d) Emergency services/ accidents ............................................................................................................. 24-26

Medical emergency Ambulance
(e) Mental health and substance abuse benefits .......................................................................................... 26-27
(f) Prescription drug benefits ................................................................................................................. 28-30
(g) Special features ..................................................................................................................................... 30
(h) Dental benefits ....................................................................................................................................... 31
(i) Non-FEHB benefits available to Plan members ................................................................................... 32
Summary of benefits ..................................................................................................................................... 47

2001 Cimarron Health Plan 10 Section 5 10
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Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they

are medically necessary.
Plan physicians must provide or arrange your care. We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also please read Section 9
about coordinating benefits with other coverage, including with Medicare.

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $10 per visit
In a physician's office

Professional services of physicians
In an urgent care center $25 per visit
During a hospital stay Nothing
In a skilled nursing facility Nothing
Initial examination of a newborn child covered under
a family enrollment $10 per visit

Office medical consultations $10 per visit
Second surgical opinion $10 per visit
At home $20 per visit

Diagnostic and treatment services — Continued on next page

2001 Cimarron Health Plan 11 Section 5( a) 11
11 Page 12 13
Lab, X-ray and other diagnotic Tests You pay
Tests, such as:
Blood tests Nothing if you receive these
Urinalysis services during your office visit;
Non-routine pap tests otherwise, $10 per visit.
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Preventive care, adult
Routine screenings, such as: $10 per visit
Blood lead level
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening
Prostate Specific Antigen (PSA test)
Routine pap test and mammogram

Not covered: Physical exams required for obtaining or continuing All charges
employment or insurance, attending schools or camp, or travel.

Routine Immunizations such as: $10 per visit
Tetanus-diphtheria (Td) booster
Influenza/ Pneumococcal vaccines

2001 Cimarron Health Plan 12 Section 5( a) 12
12 Page 13 14
2001 Cimarron Health Plan 13 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the $10 per visit American Academy of Pediatrics
Examinations, such as: $10 per visit
Eye exams through age 17 to determine the need for vision correction

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)

Well-child care charges for routine examinations, immunizations and care (through age 22)

Maternity care
Complete maternity (obstetrical) care, such as: $10 per visit
Prenatal care
Delivery
Postnatal care — Note: Here are some things to keep in mind:
You need to precertify your normal delivery; see page 22 for other circumstances, such as extended stays for you or

your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will

extend your inpatient stay if medically necesary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover

other care of an infant who requires non-routine treatment only
if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits

(Section 5c) and Surgery benefits (Section 5b).

Family planning
Voluntary sterilization $10 per visit
Surgically implanted contraceptives 50% of charges
Injectable contraceptive drugs $10 per visit
Intrauterine devices (IUDs) 50% of charges

Not covered: reversal of voluntary surgical sterilization. All charges. 13
13 Page 14 15
2001 Cimarron Health Plan 14 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as: 50% of charges
Artificial insemination
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

Fertility drugs
Note: We cover injectable fertility drugs under medical benefits
and oral fertility drugs under the prescription drug benefit.

Not covered: All charges
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded ART procedures Cost of donor sperm.

Allergy care
Testing and treatment $10 per visit
Allergy injection $3 per visit and
$10 office visit copay

Allergy serum Nothing

Treatment therapies
Chemotherapy and radiation therapy $10 per visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 20.

Respiratory and inhalation therapy
Dialysis -Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic therapy

Growth hormone therapy (GHT) when prior authorization received by Plan from Plan physician — Covered under
medical benefits. 14
14 Page 15 16
2001 Cimarron Health Plan 15 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy: $10 per visit
Covered for two consecutive months per condition for the services of each of the following (Therapy may be extended

upon recommendation of the participating provider in
consultation with us):

qualified physical therapists; speech therapists; and

occupational therapists.
Note: We only cover therapy to restore bodily function or speech
when there has been a total or partial loss of bodily function or
functional speech due to illness or injury. Cardiac rehabilitation
following a heart transplant, bypass surgery or a myocardial
infarction, is provided for up to 36 sessions per cardiac event.

Not covered: All charges
long-term rehabilitative therapy
exercise programs

Hearing services (testing, treatment, and supplies)
Initial hearing evaluation $10 per visit
Hearing testing for children through age 17 (see Preventive care, children)

Not covered: All charges
all other hearing testing hearing aids, testing and examinations for them.

Vision services (testing, treatment, and supplies)
Eye exam to determine the need for vision correction for $10 per visit children through age 17 (see preventive care)

Not covered: All charges
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery 15
15 Page 16 17
2001 Cimarron Health Plan 16 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a $10 per visit
metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on
podiatric shoe inserts.

Not covered: All charges
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of

conditions of the foot, except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot

(unless the treatment is by open cutting surgery).

Orthopedic and prosthetic devices
Artificial limbs and eyes 20% of charges when prior authorized by the Plan
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices
as hospital benefits; see Section 5 (c ) for payment information.
See 5 (b) for coverage of the surgery to insert the device.

Not covered: All charges
orthopedic and corrective shoes arch supports

foot orthotics heel pads and heel cups
lumbosacral supports corsets, trusses, elastic stockings, support hose,

and other supportive devices.

Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, 20% of charges
of durable medical equipment prescribed by your Plan physician,
such as oxygen and dialysis equipment. Under this benefit,
we also cover:

hospital beds;
standard wheelchairs;
crutches;

Durable medical equipment (DME) — Continued on next page 16
16 Page 17 18
2001 Cimarron Health Plan 17 Section 5( a)
Durable medical equipment (DME) continued You pay
walkers;
blood glucose monitors; and
insulin pumps.
oxygen

Note: Durable medical equipment must be prior authorized
by the Plan.

Not covered: All charges
Motorized wheel chairs.

Home health services
Home health care ordered by a Plan physician and provided Nothing; no dollar or day limitation by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Not covered: All charges
nursing care requested by, or for the convenience of, the patient or the patient's family;

nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving
oral medication.

Alternative treatments
Acupuncture -by a contracted Plan provider for: anesthesia, 50% of charges per visit
pain relief; limited to 20 visits per calendar year.

Chiropractic care -acute care only for subluxation of the 50% of charges per visit
spinal column, limited to 20 visits per calendar year.

Not covered: All charges
naturopathic services
hypnotherapy
biofeedback. 17
17 Page 18 19




















2001 Cimarron Health Plan 18 Section 5( a)

Educational classes and programs You pay
Programs such as:
Weight control, stress management, workplace ergonomics No charge are routinely offered at plan offices or at the worksite at client

request.
Prenatal education class and Child safety class with free infant car seat is available to all member mothers who deliver children

on the Plan.
Bike safety class with free bike helmet available to all member children ages 4-18.

Other programs such as weight management, stress reduction, No charge ergonomics, back injury, etc. are available and can be designed
to fit the particular needs of the group.

Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they

are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for

charges associated with the facility charge (i. e. hospital, surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF MOST SURGICAL PROCEDURES. Please refer to the precertification information

shown in Section 3 or call us at (800) 365-0009 to identify which
surgeries require precertification.

Benefit Description You pay

Surgical procedures
Treatment of fractures, including casting $10 per visit in physician's office;
Normal pre-and post-operative care by the surgeon nothing per inpatient hospital
Correction of amblyopia and strabismus admission

Surgical procedures continued on next page. 18
18 Page 19 20
2001 Cimarron Health Plan 19 Section 5( b)
Surgical procedures (Continued) You pay
Endoscopy procedure $10 per visit in physician's office;
Biopsy procedure nothing per inpatient hospital
Removal of tumors and cysts admission
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity — a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards.
Insertion of internal prosthetic devices. See 5( a) -Orthopedic braces and prosthetic devices for device coverage information.

Voluntary sterilization
Norplant (a surgically implanted contraceptive) and intrauterine 50% of charges devices (IUDs) Note: Devices are covered under 5( a).

Treatment of burns $10 per visit in physician's office; nothing per inpatient hospital
admission

Not covered: All charges
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.

Reconstructive surgery
Surgery to correct a functional defect $10 per visit in physician's office; nothing per hospital admission
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.
Examples of congenital anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth marks; webbed fingers;
and webbed toes.

All stages of breast reconstruction surgery following a Nothing mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas; breast prostheses and surgical bras and replacements
(see Prosthetic devices) — Note: If you need a mastectomy,
you may choose to have the procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after
the procedure.

Reconstructive surgery continued on next page. 19
19 Page 20 21
2001 Cimarron Health Plan 20 Section 5( b)
Reconstructive surgery continued You pay
Not covered: All charges
Cosmetic surgery -any surgical procedure (or any portion of a procedure) performed primarily to improve physical

appearance through change in bodily form, except repair
of accidental injury

Surgeries related to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, limited to: $10 per visit;
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Dental work related to the treatment of TMJ

Organ/ tissue transplants
Limited to: $10 per visit;
Cornea nothing for inpatient services
Heart

Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single -Double
Pancreas
Allogeneic (donor) bone marrow transplants

Reconstructive surgery continued on next page.

nothing for inpatient services 20
20 Page 21 22
2001 Cimarron Health Plan 21 Section 5( b)
Organ/ tissue transplants continued You pay
Autologous bone marrow transplants (autologous stem cell $10 per visit; and peripheral stem cell support) for the following conditions: nothing for inpatient services
acute lymphocytic or non-lymphocytic leukemia; advanced
Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma;
advanced neuroblastoma; aplastic anemia; Wiskott-Aldrich
Syndrome; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors

All transplants require the prior approval of the Cimarron Transplant Committee — Note: We cover related medical

and hospital expenses of the donor when we cover the recipient.
Not covered: All charges
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in
Hospital (inpatient) Nothing

Professional services provided in
Hospital outpatient department Nothing
Skilled nursing facility Nothing
Ambulatory surgical center Nothing
Office $10 per visit 21
21 Page 22 23




















2001 Cimarron Health Plan 22 Section 5( c)

Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they

are medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your

surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Section 5( a) or (b).

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

Benefit Description You pay
Inpatient hospital
Room and board, such as Nothing
ward, semiprivate, or intensive care accommodations; general nursing care; and

meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
perating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Inpatient hospital continued on next page. 22
22 Page 23 24
2001 Cimarron Health Plan 23 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered: All charges
Custodial care Non-covered facilities, such as nursing homes,

extended care facilities, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: -We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

Not covered: All charges
blood and blood derivatives not replaced by the member

Extended care benefits/ skilled nursing care facility benefits
We cover up to 30 days per calendar year when full-time skilled Nothing
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. 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.

Not covered: custodial care All charges 23
23 Page 24 25




















2001 Cimarron Health Plan 24 Section 5( d)

Hospice care You pay
Supportive and palliative care for a terminally ill family member is Nothing
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. Maximum benefit is 210 days
per member per lifetime.

Not covered: Independent nursing, homemaker services All charges

Ambulance
Local professional ambulance service when medically appropriate $50 ground ambulance per trip,
$100 air ambulance per trip

Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you 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 we may determine are medical emergencies -what they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: For true life or limb threatening emergencies: Call 911 and go to the nearest facility. For other emergent or urgent situations go to a Plan contracted facility or call the Plan's

Healthline at (800) 564-8596. 24
24 Page 25 26
2001 Cimarron Health Plan 25 Section 5( d)
Emergency services/ acidents continued
Emergencies outside our service area: Life or limb threatening emergencies or medically necessary urgent care: Go to an emergency facility or doctors office or call the Plan's Healthline at (800) 564-8596 for
assistance.
You or a family member must notify the Plan at (800) 365-0009 within 48 hours, unless it was not reasonably
possible to do so.

You must return to your primary care physician for all follow-up care. Do not return to the Emergency Room.

Benefit Description You pay

Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, $50 per visit including doctors' services.

Note: Hospital emergency care copay waived if you are
admitted to the hospital.

Not covered: Elective care or non-emergency care All charges

Emergency outside our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, $50 per visit including doctors' services.

Note: Hospital emergency care copay waived if you are
admitted to the hospital.

Not covered: All charges
Elective care or non-emergency 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

Emergency services continued on next page. 25
25 Page 26 27




















2001 Cimarron Health Plan 26 Section 5( e)

Ambulance You pay
Professional ambulance service when medically appropriate. $50 per trip for ground ambulance,
See 5( c) for non-emergency service. $100 per trip for air ambulance

Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will
achieve "parity" with other benefits. This means that we will provide mental health
and substance abuse benefits differently than in the past. When you get our approval
for services and follow a treatment plan we approve, cost-sharing and limitations for
Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES FROM ASPEN BEHAVIORAL HEALTH SERVICES AT (505) 342-2474 OR

(888)-91-ASPEN. See the instructions after the benefits description below.

Benefit Description You pay

Mental health and substance abuse benefits
Diagnostic and treatment services recommended by an Aspen Your cost sharing responsibilities
Behavioral Health Services provider and contained in a treatment are no greater than for other
plan that Aspen approves. The treatment plan may include services, illness or conditions.
drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when Aspen Behavioral Health
Services determines the care is clinically appropriate to treat your
condition and only when you receive the care as part of a treatment
plan that they approve.

Mental health and substance abuse benefits continued on next page. 26
26 Page 27 28
2001 Cimarron Health Plan 27 Section 5( e)
Mental health and substance abuse benefits continued You pay
Professional services, including individual or group therapy $10 per visit
by providers such as psychiatrists, psychologists, or clinical
social workers

Medication management

Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive
outpatient treatment.

Not covered: Services not approved by Aspen Behavioral All charges
Health Services.

Note: OPM will base its review of disputes about treatment
plans on the treatment plan's clinical appropriateness.
OPM will generally not order us to pay or provide one

clinically appropriate treatment plan in favor of another.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

Call Aspen Behavioral Health Services at (505) 342-2474 or
(888)-91-ASPEN. You do not need a referral from your Primary Care
Physician (PCP) or Specialist for an evaluation for behavioral health
services, however, you must call the number( s) above to access the
services.

Special transitional benefit If a mental health or substance abuse professional provider is treating you
under our plan as of January 1, 2001, you will be eligible for continued
coverage with your provider for up to 90 days under the following
condition:

If your mental health or substance abuse professional provider with whom
you are currently in treatment leaves the plan at our request for other than
cause.

If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day

period ends before January 1 and this transitional benefit does not apply.

Limitation We may limit your benefits if you do not follow your treatment plan. 27
27 Page 28 29




















Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician must write the prescription.
Where you can obtain them. You may fill the prescription at a participating pharmacy, by internet, or by mail.

We use a formulary. A formulary is a listing of drugs that a plan customarily uses. Unless your physician indicates "dispense as written", your prescription will be filled with an available generic
and/ or formulary drug. If your physician specifies that the prescription must be dispensed as written,
you will receive the drug as prescribed.

These are the dispensing limitations. Retail prescriptions will be dispensed for a 30-day supply or manufacturer's standard trade package. Maintenance drugs may be ordered by mail order. You
will receive a 90-day supply for two copayments. Be sure to have your doctor specify that the
prescription is for a 90-day supply. If you do not have a mail order envelope, contact Customer Service
at (800) 365-0009 or (505) 342-4723. You may also order mail order drugs on the internet at the
Website: merckmedco. com. If there is no generic equivalent of your drug, you will still be required
to pay the name brand copayment.

When you have to file a claim. Under normal circumstances, you should not have to file a claim. If this becomes necessary, call Customer Service at (800) 365-0009 or (505) 342-4723.

2001 Cimarron Health Plan 28 Section 5( f) 28
28 Page 29 30
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed Retail Pharmacy
by a Plan physician and obtained from a Plan pharmacy or $5 per generic,
through our mail order program: $8 per name brand drug

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 or 100 unit dose, whichever is less, or manufacturer's Mail Order
standard package size, including inhalers. If a generic substitution $10 per generic mail order
is permissible, but you request the name brand drug, you will pay (90-day) prescription,
the price difference between the generic and name brand drug $16 per name brand (mail order)
as well as the brand name copay per prescription unit or refill. mail order prescription
Drugs are prescribed by Plan doctors and dispensed in accordance
with the Plan's drug formulary. The Plan's drug formulary is based
upon effectiveness and cost. Nonformulary drugs will be covered
when prescribed by a Plan doctor. Covered medications and
accessories include:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase.

Full range of FDA-approved drugs, prescriptions, and devices for birth control. Contraceptive devices, including implanted
devices and implantable drugs such as Norplant are covered
under Medical and Surgical Benefits as a Limited benefit.

Compounded dermatological preparations
Nitroglycerin, Phenobarbital, or Thyroid U. S. P.
Insulin, with a copay charge applied to every two vials
Fertility drugs are covered under Infertility benefits (see page 14)

Intravenous fluids and medications for home use, implants and some injectible drugs, are covered under Medical and
Surgical Benefits.
Disposable needles and syringes needed to inject covered prescribed medication for up to a 30 day supply or 100 units.

Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent,
glucose monitors and acetone test tablets.
Appetite suppressants when prescribed for morbid obesity
Drugs for sexual dysfunction, with prior authorization from the Plan. 50% of covered charges

Growth hormones are available with prior authorization from the Plan. 20% of covered charges

Prescription drug benefits continued on next page.

2001 Cimarron Health Plan 29 Section 5( f) 29
29 Page 30 31
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription
drug program:

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive

a name brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as
Written for the name brand drug, you have to pay the difference
in cost between the name brand drug and the generic.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your

physician may prescribe a name brand drug from the Cimarron
Health Plan formulary list. If your physician believes that a
non-formulary drug is necessary for you, he must specifiy
"dispense as written" on the prescription. This list of formulary
drugs is a preferred list of drugs that we selected to meet patient
needs at a lower cost. To order a prescription drug formulary
brochure, call (800) 365-0009 or (505) 342-4723.

Not covered: All Charges
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs to aid in dieting, unless for morbid obesity
Drugs to aid in smoking cessation, including nicotine gum and patches

Section 5 (g). Special Features
Feature Description
Prenatal Program Member mothers are encouraged to attend one prenatal class and one infant safety class, after which they will each receive a free car
seat to encourage infant safety.
Child Safety Program Parents of children ages 4 through 18 are encouraged to bring them to a bicycle safety class that teaches safe riding. At the conclusion
of the class, all children are properly fitted for and receive a free
bicycle helmet to encourage child safety.

24-hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-564-8596 and talk with a registered nurse who will
discuss treatment options and answer your health questions.

2001 Cimarron Health Plan 30 Section 5( g) 30
30 Page 31 32
2001 Cimarron Health Plan 31 Section 5( h)
Section 5 (h) —Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they

are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health

of the patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly $10 per visit
repair (but not replace) sound natural teeth. The need for these
services must result from an accidental injury

Preventive dental benefits
Oral Examination 50% of charges
Prophylaxis (cleaning)
X-rays (bitewings, twice per year; and full mouth, once per 5 year period)

Flouride application
Sealants for enrolled dependents through age 15 for permanent molars, once per three year period per molar. These preventive

and diagnostic services are provided by participating Delta
Dental Advantage Plan dentists. This benefit is limited to
two visits per year.

















 31
31 Page 32 33
2001 Cimarron Health Plan 32 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
out-of-pocket maximums.

NEW!! DENTAL BENEFITS:
Provided by DELTA DENTAL PLAN OF NEW MEXICO

This comprehensive dental program is available as a buy-up option to the FEHB sponsored benefit on page 31.
This plan covers the following services:

BENEFIT YOUR COST
Preventive Exam, Cleaning and X-rays No charge
Basic Services 20% of charges
ajor Services 50% of charges
Child and Adult Orthodontia 50% of charges, $1,000 maximum benefit per person

For a complete listing of Delta Benefits and Providers, Call Delta Dental at
(505) 883-4777 or (800) 999-0968.

VISION BENEFITS:
(You are NOT required to pay any additional premium for this benefit.)

Your vision exam and eyewear purchase are covered by Cimarron Health Plan through the Vision Service Plan.
No referral is necessary, just call the provider and schedule your appointment. Your copayment for your
eye exam is $10. (Note: If an exam is done for contact lenses, an additional copayment applies.) You and
your covered family members may each have one exam every 12 months.

Eyewear is available in most Plan provider offices. If the Plan doctor of your choice does not offer eyewear,
you may take your prescription to one of the other participating provider locations. Each covered family
member will receive an initial provider discount of 20% for spectacle lenses and 15% for contact
lenses if the exam was received at that location, followed by an additional $55 Cimarron Health Plan
discount. You and your covered family members are allowed one purchase (spectacles or contact lenses)
each 24 months.

Remember! This benefit is for routine eye care. Medically necessary diagnostic eye care is available
by referral under your FEHB Medical and Surgical Benefits. Refer to the Medical directory for
those providers.

For a complete listing of the Vision Service Plan benefits and providers, please call
Cimarron Health Plan at (800) 365-0009 or (505) 342-4723. 32
32 Page 33 34
2001 Cimarron Health Plan 33 Section 6 and 7
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, disease, injury or condition and we agree, as discussed in What Services Require
Our Prior Approval on page 9.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or 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;

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

Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs
at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment
or coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes
these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.

Facilities will file on the UB-92 form. For claims questions and
assistance, call us at (800) 365-0009 or 505/ 342-4723.

When you must file a claim — such as for out-of-area care — submit it
on the HCFA-1500 or a claim form that includes the information shown
below.

Bills and receipts should be itemized and show:
Covered member's name and ID number; Name and address of physician or facility that provided the service

or supply;
Dates you received the services or supplies; Diagnosis;

Type of each service or supply; The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer —such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to: Cimarron Health Plan, Box 3050,
Albuquerque, NM 87190-3050 33
33 Page 34 35
Section 7. Filing a claim for covered services (continued)
Prescription drugs Call Customer Service at (800) 365-0009 or (505) 342-4723 for a Prescription Drug Reimbursement form.
Submit your claims to: PAID Prescriptions, P. O. Box 2187,
Lee's Summit, MO 64063-2187.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by 90 days following the date you received the
service, unless timely filing was prevented by administrative operations
of Government or legal incapacity, provided the claim was submitted as
soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision
on your claim or request for services, drugs, or supplies -including a request for prior authorization:

Step Description

Ask us in writing to reconsider our initial decision. Write to us at: Cimarron Health Plan, P. O. Box 3050
Albuquerque, NM 87190-3050.
You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Cimarron Health Plan, P. O. Box 3050, Albuquerque, NM 87190-3050.
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports,
bills, medical records, and explanation of benefits (EOB) forms.

 We have 30 days from the date we receive your request to:

(a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial — go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy
of our request-go to step 3.

 You or your provider must send the information so that we receive it within 60 days of our request.
We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

2001 Cimarron Health Plan 34 Section 8 34
34 Page 35 36
Section 8. The disputed claims process (continued)
 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us — if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information. Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts

Division III, P. O. Box 436, Washington, D. C. 20044-0436.
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply
to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must provide a copy of your specific written consent with the
review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline
because of reasons beyond your control.

 OPM will review your disputed claim request and will use the information it collects from you and us to
decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

 If you do not agree with OPM's 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, drugs or supplies. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed
claim decision. This information will become part of the court record. You may not sue until you have
completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and
payment of benefits. The Federal court will base its review on the record that was before OPM when
OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800-365-0009 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time.

2001 Cimarron Health Plan 35 Section 8 35
35 Page 36 37
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you are covered or a family member is covered under
health coverage another group health plan or have automobile insurance that pays medical expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits
in full as the primary payer and the other plan pays a reduced benefit
as the secondary payer. We, like other insurers, determine which
coverage is primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in
this brochure.

When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance,
up to our regular benefit. We will not pay more than our allowance.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older Some people with disabilities, under 65 years of age

People with End-State-Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.

Part B (Medical Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare managed care plan
you have.

The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B benefits.
You may go to any doctor, specialist, or hospital that accepts Medicare.
Medicare pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.

When you are enrolled in this Plan and Original Medicare, you still
need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by the Plan PCP,
or precertified as required.

We will waive some copayments, coinsurance, and deductibles as follows:
We will coordinate benefits with Medicare as we coordinate benefits
with any other Plan.

(Primary payer chart begins on next page.)

2001 Cimarron Health Plan 36 Section 9 36
36 Page 37 38
Section 9. Coordinating benefits with other coverage (continued)
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us
if you or a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you — or your covered spouse — are age 65 or over and … Then the primary payer is…
Original Medicare This Plan
1) Are an active employee with the Federal government (including when you

or a family member are eligible for Medicaresolely because of a disability),

2) Are an annuitant, 
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or……………………………. 

b) The position is not excluded from FEHB……………………………

Ask your employing office which of these applies to you.

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your 
covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, 

(for Part B services) (for other
services)

6) Are a former Federal employee receiving Workers' Compensation and
the Office of Workers' Compensation Programs has determined that 
you are unable to return to duty, (except for claims
related to Workers'
Compensation.)

B. When you — or a covered family member — have Medicare
based on end stage renal disease (ESRD) and…

1) Are within the first 30 months of eligibility to receive Part A benefits

solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are still 
eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became 
primary for you under another provision,

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) And are an annuitant, or………………….……………………… 

b) Are an active employee…………………………………………

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare .
2001 Cimarron Health Plan 37 Section 9 37
37 Page 38 39
2001 Cimarron Health Plan 38 Section 9
Section 9. Coordinating benefits with other coverage (continued)
Claims process — You probably will never have to file a claim form when you have both our Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the balance of covered charges. You will not need

to do anything. To find out if you need to do something about filing your claims, call us at (800) 365-0009
or (505) 342-4723.

We waive some costs when you have Medicare — When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:

If you are enrolled in Medicare Part B, we will waive copayments and coinsurance for Medicare covered
medical services and supplies provided by physicians and other health care professionals.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are

health care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists,
or hospitals that are part of the plan. Medicare managed care plans
cover all Medicare Part A and B benefits. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed
care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or
at www. medicare. gov. If you enroll in a Medicare managed care plan, the
following options are available to you:

This Plan does not offer a Medicare managed care plan.
This Plan and another Plan's Medicare managed care plan:
You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary and you have utilized our
Plan providers and followed our Plan procedures , and we will waive
deductibles and copayments.

Suspended FEHB coverage and a Medicare managed care plan:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage and enroll in a Medicare managed care plan. For information
on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage
or move out of the Medicare+ Choice service area.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first.
See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage. 38
38 Page 39 40
2001 Cimarron Health Plan 39 Section 10
Section 9. Coordinating benefits with other coverage (continued)
Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar

Federal or State agency determines they must provide; or
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 OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government We do not cover services and supplies when a local, State,
agencies are responsible or Federal Government agency directly or indirectly pays for them.
for your care

When others are responsible When you receive money to compensate you for medical or hospital
for injuries care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, 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.

Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 9.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 9.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care or service that is designed primarily to assist in meeting the needs of an individual. This type of care is administered to the individual,

whether or not totally disabled. This care is given as assistance in daily
living. These activities may include bathing, dressing, feeding, special
diet preparations, walking assistance, and getting in and out of bed. It
also provides for the supervision over medication that can normally be
self-administered.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits

for those services. We have no deductibles. 39
39 Page 40 41
Section 10. Definitions of terms we use in this brochure (continued)
Experimental or
Investigational services The Plan's experimental/ investigational determination process is based upon authoritative information obtained from medical literature, medical

specialist opinion, and evidence from State and Federal government
agencies and research organizations, including FDA.

Medical necessity Care, services, or supplies that meet all of the following criteria, as determined by the Plan Medical Director:
(a) Is consistent with symptoms, diagnosis, treatment, and is non-Experimental
or under investigation;

(b) Is appropriate in keeping with standards of good medical practice;
(c) Is not solely for the convenience of the Member, Primary Care
Physician, or other health care Provider; and
(d) Is the appropriate level of service which can be safely provided
to the Member

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their
allowances in different ways. We determine our allowance as follows:
Reasonable and customary charges based upon the 90th percentile.

Note: Contracted Plan providers accept the plan allowance as payment
in full.

Us/ We Us and we refer to Cimarron Health Plan
You You refers to the enrollee and each covered family member.

2001 Cimarron Health Plan 40 Section 10 40
40 Page 41 42
2001 Cimarron Health Plan 41 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.

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.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or retire-ment

office authorizes coverage for. Under certain circumstances, you
may also continue 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 that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.

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, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 41
41 Page 42 43
2001 Cimarron Health Plan 42 Section 11
Section 11. FEHB facts (continued)
When benefits and The benefits in this brochure are effective on January 1. If you are new
premiums start to this Plan, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. Annuitants' premiums

begin on January 1.

Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;

This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

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

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

When you 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 (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may coverage not continue to get benefits under your former spouse's enrollment.
But, you may be eligible for your own FEHB coverage under the spouse
equity law. If you are recently divorced or are anticipating a divorce,
contact your ex-spouse's employing or retirement office to get RI 70-5,
the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices. 42
42 Page 43 44
2001 Cimarron Health Plan 43 Section 11
Section 11. FEHB facts (continued)
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 Temporary
Continuation of Coverage (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 or from www. opm. gov/ insure.

Converting to individual coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot

convert;
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. 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.

Getting 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. Your new plan must reduce
or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as
long as you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans. 43
43 Page 44 45
2001 Cimarron Health Plan 44 Section 11
Section 11. FEHB facts (continued)
Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the
same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.

If the provider does not resolve the matter, call us at 800-365-0009, or (505) 342-4723, and explain the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE— 202/ 418-3300 or write to:
The United States Office of Personnel Management,
Office of the Inspector General Fraud Hotline,
1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is
no longer enrolled in the Plan and tries to obtain benefits. Your
agency may also take administrative action against you. 44
44 Page 45 46
2001 Cimarron Health Plan 45 Index
Accidental injury 24
Allergy tests 14
Ambulance 24, 26
Anesthesia 21
Autologous bone marrow transplant
21
Biopsies 19
Blood and blood plasma 22,23
Breast cancer screening 12
Casts 18
Catastrophic protection 9
Changes for 2001 6
Chemotherapy 14
Childbirth 13
Cholesterol tests 12
Claims 38
Coinsurance 9
Colorectal cancer screening 12
Congenital anomalies 19
Contraceptive devices and drugs 13
Coordination of benefits 36
Covered charges 10
Covered providers 5, 7
Crutches 16
Definitions 39
Dental care 31, 32
Diagnostic services 11
Disputed claims review 34
Donor expenses (transplants) 20, 21
Dressings 22, 23
Durable medical equipment (DME)
16
Educational classes and programs 18
Effective date of enrollment 42
Emergency 24, 25
Experimental or investigational
33, 40
Eyeglasses 32

Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Family planning 13, 19
Fecal occult blood test 12
General Exclusions 33
Hearing services 15
Home health services 17
Hospice care 24
Home nursing care 17
Hospital 8, 22
Immunizations 12, 13
Infertility 14
Inhospital physician care 11
Inpatient Hospital Benefits 22
Insulin 29
Laboratory and pathological services
12
Magnetic Resonance Imagings
(MRIs) 12
Mail Order Prescription Drugs 29
Mammograms 12
Maternity Benefits 13
Medicaid 39
Medically necessary 40
Medicare 36, 37
Members 41
Mental Conditions/ Substance Abuse
Benefits 26
Neurological testing 27
Newborn care 13
Non-FEHB Benefits 32
Nursery charges 13
Obstetrical care 13
Occupational therapy 15
Office visits 11
Oral and maxillofacial surgery 20
Orthopedic devices 16
Out-of-pocket expenses 9
Outpatient facility care 23
Oxygen 17

Pap test 12
Physical examination 12
Physical therapy 15
Pre-admission testing 23
Precertification 22
Preventive care, adult 12
Preventive care, children 13
Prescription drugs 28
Preventive services 12, 13
Prior approval 9
Prostate cancer screening 12
Prosthetic devices 16, 19
Psychologist 27
Psychotherapy 27
Radiation therapy 14
Rehabilitation therapies 15
Renal dialysis 14
Room and board 22
Second surgical opinion 11
Skilled nursing facility care 23
Speech therapy 15
Sterilization procedures 13
Subrogation 39
Substance abuse 26
Surgery 18
Anesthesia 21 Oral 20

Outpatient 23 Reconstructive 19
Syringes 29
Temporary continuation of
coverage 43
Transplants 20
Treatment therapies 14
Vision services 13, 15, 18, 32
Well child care 13
Wheelchairs 16
Workers' compensation 39

X-rays 12 45
45 Page 46 47
NOTES
2001 Cimarron Health Plan 46 46
46 Page 47 48
Summary of benefits for Cimarron Health Plan -2001
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office Office visit copay:
$10 primary care; $10 specialist 11

Services provided by a hospital:
Inpatient Nothing 22
Outpatient Nothing 23

Emergency benefits:
In-area $25 per urgent care visit, 25
Out-of-area $50 per hospital emergency
room visit 25

Mental health and substance abuse treatment Regular cost sharing 26
Prescription drugs $5 generic, $8 name brand 28
Dental Care Accidental Injury: $10 per visit,
Preventive dental benefit: 50%
of charges (Also, see page 32
for non Federally sponsored
benefit) 31

Vision Care No benefit (See page 32 for
non-Federally sponsored benefit) 32

Special features: Free car seats to expectant Plan Members with prenatal classes, free bicycle
helmets to member children aged 4 years through 18 years with bicycle safety class 30

Protection against catastrophic costs Nothing after your
out-of-pocket (your
out-of-pocket maximum)
expenses total twice the
individual or family annual
premium amount
Some costs do not count
toward this protection 9

2001 Cimarron Health Plan 47 Summary of Benefits for CHP 2001 47
47 Page 48 49
2001 Cimarron Health Plan 48 Rate Information for CHP 2001
Rate Information for
CIMARRON HEALTH PLAN
(formerly QualMed Plans for Health)

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 career Postal Service employees. Most employees should refer to the FEHB Guide
for United States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB guides
are published for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service

Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal
employee organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share Share Share

The entire State of New Mexico
Self Only PX1 $59.83 $19.94 $129.63 $43.21 $70.80 $8.97
Self and Family PX2 $157.88 $52.63 $342.08 $114.03 $186.83 $23.68 48
48 Page 49
49

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