Pages 1--50 from Aultcare HMO

Serving: Stark, Carroll, Holmes, Tuscarawas and Wayne counties in Ohio
Enrollment in this Plan is limited; see page 5 for requirements.

Enrollment codes for this Plan:
3A1 Self Only 3A2 Self and Family

RI 73-699

For changes in benefits
see page 7 1
1 Page 2 3
2001 AultCare HMO Table of Contents 2
Table of Contents
Introduction…………………………………………………………………................................................................. 4
Plain Language……………………………………………………………… ............................................................... 4
Section 1. Facts about this HMO plan .......................................................................................... ................................. 5
How we pay providers .................................................................................................................................. 5
Patients' Bill of Rights .................................................................................................................................. 5
Service Area.................................................................................................................................................. 6
Section 2. How we change for 2001……………………………………….................................................................. 7
Program-wide changes.................................................................................................................................. 7
Changes to this Plan...................................................................................................................................... 7
Section 3. How you get care …………... ...................................................................................................................... 8
Identification cards........................................................................................................................................ 8
Where you get covered care.......................................................................................................................... 8

· Plan providers ......................................................................................................................................... 8
· Plan facilities .......................................................................................................................................... 8
What you must do to get covered care.......................................................................................... ................ 8

· Primary care............................................................................................................................................ 8
· Specialty care.......................................................................................................................................... 8
· Hospital care ........................................................................................................................................... 9
Circumstances beyond our control.............................................................................................. ................ 10
Services requiring our prior approval ......................................................................................... ................ 10
Section 4. Your costs for covered services .................................................................................... .............................. 11

· Copayments .......................................................................................................................................... 11
· Deductible............................................................................................................................................. 11
· Coinsurance .......................................................................................................................................... 11
Your out-of-pocket maximum .................................................................................................... ................ 11
Section 5. Benefits…………………………………………………………............................................................... 12
Overview..................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals.............. 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals .......... 20
(c) Services provided by a hospital or other facility, and ambulance services ........................................ 23
(d) Emergency services/ accidents............................................................................................... .............. 25
(e) Mental health and substance abuse benefits ................................................................................. ...... 27
(f) Prescription drug benefits ................................................................................................. .................. 29
(g) Special features ................................................................................................................................... 31
(h) Dental benefits .................................................................................................................................... 32
(i) Non-FEHB benefits available to Plan members ................................................................................. 33
Section 6. General exclusions --things we don't cover .............................................................................................. 34 2
2 Page 3 4
2001 AultCare HMO Table of Contents 3
Section 7. Filing a claim for covered services ............................................................................................................. 35
Section 8. The disputed claims process........................................................................................................................ 36
Section 9. Coordinating benefits with other coverage ................................................................................................ 38
When you have…

·Other health coverage ............................................................................................................................ 38
·What is Medicare................................................................................................................................... 38
·The Original Medicare Plan................................................................................................................... 38
· Medicare managed care plan ................................................................................................................ 40
TRICARE/ Workers' Compensation/ Medicaid........................................................................................ .... 40
Other Government agencies........................................................................................................................ 41
When others are responsible for injuries...................................................................................... ............... 41
Section 10. Definitions of terms we use in this brochure ............................................................................................ 42
Section 11. FEHB facts ................................................................................................................................................ 44
Coverage information................................................................................................................................ 44

· No pre-existing condition limitation .......................................................................................... ....... 44
· Where you get information about enrolling in the FEHB Program.................................................. 44
· Types of coverage available for you and your family ...................................................................... 44
· When benefits and premiums start.............................................................................................. ...... 45
· Your medical and claims records are confidential............................................................................ 45
· When you retire................................................................................................................................ 45
When you lose benefits ............................................................................................................................. 45

· When FEHB coverage ends ....................................................................................................... ....... 45
· Spouse equity coverage.................................................................................................................... 45
· Temporary Continuation of Coverage (TCC).................................................................................. 45
· Converting to individual coverage............................................................................................ ....... 46
· Getting a Certificate of Group Health Plan Coverage ..................................................................... 46

Inspector General advisory............................................................................................................................................ 46
Index ................................................................................................................................................................. 47
Summary of benefits ..................................................................................................................................................... 49
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2001 AultCare HMO 4 Introduction/ Plain Language
Introduction
AultCare HMO 2600 Sixth Street SW
Canton, Ohio 44710
This brochure describes the benefits of AultCare HMO under our contract (CS2723) 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 7. 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 AultCare HMO.

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. 4
4 Page 5 6
2001 AultCare HMO 5 Section 1
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.

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.

AultCare HMO is an IPA model HMO, whereby the HMO has individual agreements with select physicians who have
agreed to provide care for AultCare HMO enrollees. Each family member must select a primary care doctor who
coordinates care for the HMO enrollee. There are approximately 251 primary care physicians from which to choose
and nearly 642 specialists in our network.

The first and most important decision each member must make is the selection of a primary care doctor. The decision
is important since it is through this doctor that all other health services, particularly those of specialists, are obtained.
It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before
referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only
when there has been a referral by the member's primary care doctor with the following exception( s): a woman may
see her Plan gynecologist for her annual routine examination without a referral.

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.

If you want more information about us, call 330-438-6360, or write to AultCare HMO, 2600 Sixth Street SW, Canton,
Ohio 44710. You may also contact us by fax at 330-580-5527 or visit our website at www. aultman. com. 5
5 Page 6 7
2001 AultCare HMO 6 Section 1
Service Area
To enroll with us, you must live in or work in our service area. This is where our providers practice. Our service area
is:

· Stark; · Carroll;

· Holmes; · Tuscarawas;
· Wayne Counties in Ohio.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live out of the area, (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 6
6 Page 7 8
2001 AultCare HMO 7 Section 2
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 copayments 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.

· Many healthcare organizations have turned their attention this past year to improving healthcare 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 330-438-6360, or checking our website at www. aultman. 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 hospital 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 6.3% for Self Only or 13.0% for Self and Family. · Ear exams through age 17 to determine the need for hearing correction.
· Home Health Care will be covered at 100% with no visit limitation. · Your Mental Health and Substance Abuse outpatient benefit will be covered at 100% after $10 copayment. The
Mental Health and Substance Abuse inpatient benefit will be covered at 100%.
· You may purchase a 90 day supply of maintenance drugs at retail. 7
7 Page 8 9
2001 AultCare HMO 8 Section 3
Section 3. How you 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
330-438-6360.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments 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.

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.

·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 give you a referral 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, you may see your obstetrician/ gynecologist once yearly
without a referral.
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 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 8
8 Page 9 10
2001 AultCare HMO 9 Section 3
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.

· 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 330-438-6360. 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 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.
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 most services.
For certain services, however, your physician must obtain approval from 9
9 Page 10 11
2001 AultCare HMO 10 Section 3
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 precertification.
Precertification is required for all non-AultCare admissions and all Home
Health Care programs. You must notify the AultCare Utilization
Management Department prior to any planned non-AultCare admissions
or to any Home Health Care program.

Other services requiring precertification include:

· Partial hospitalization programs provided out-of-network; · Intensive out patient programs provided out-of-network;
· Rehabilitation facility admissions; · Skilled nursing facility admissions;
· Hospice care; · Therapies, including physical, occupational, speech, cognitive and
growth hormone;
· Mental Health and Substance Abuse; and · Certain drugs. 10
10 Page 11 12
2001 AultCare HMO Section 5 11
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.

·Deductible We do not have a deductible.
·Coinsurance We do not have coinsurance.

Your out-of-pocket maximum for coinsurance and copayments We do not have an out-of-pocket maximum. 11
11 Page 12 13
2001 AultCare HMO Section 5 12
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 49 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. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 330-438-6360 or at our website at www. aultman. com.

(a) Medical services and supplies provided by physicians and other health care professionals…………………. 13-19
· Diagnostic and treatment services · Lab, X-ray, and other diagnostic tests
· Preventive care, adult · Preventive care, children
· Maternity care · Family planning
· Infertility services · Allergy care
· Treatment therapies

· Rehabilitative therapies · Hearing services (testing, treatment, and
supplies)
· Vision services (testing, treatment, and supplies) · Foot care

· Orthopedic and prosthetic devices · Durable medical equipment (DME)
· Home health services · Alternative treatments

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................ 20-22
· Surgical procedures · Reconstructive surgery · Oral and maxillofacial surgery · Organ/ tissue transplants
· Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services...................................................... 23-24

· Inpatient hospital · Outpatient hospital or ambulatory surgical
center
· Extended care benefits/ skilled nursing care facility benefits
· Hospice care · Ambulance

(d) Emergency services/ accidents ............................................................................................... ........................... 25-26
· Medical emergency · Ambulance

(e) Mental health and substance abuse benefits ................................................................................. .................... 27-28
(f) Prescription drug benefits ................................................................................................. ................................ 29-30
(g) Special features ...................................................................................................................................................... 31

· Aultman Healthline · I Can Cope
· Common Ground
(h) Dental benefits ....................................................................................................................................................... 32
(i) Non-FEHB benefits available to Plan members.................................................................................................... 33

Summary of benefits ..................................................................................................................................................... 49 12
12 Page 13 14
2001 AultCare HMO 13 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
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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.
· 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.

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Benefit Description You pay
Diagnostic and treatment services

Professional services of physicians
· In physician's office

$10 per office visit

Professional services of physicians
· In an urgent care center
· During a hospital stay
· Initial examination of a newborn child covered under a family enrollment

· Office medical consultations
· Second surgical opinion

$10 per office visit

· In a skilled nursing facility Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap tests
· Pathology
· X-rays
· Non-routine Mammograms
· Cat Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG

Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit 13
13 Page 14 15
2001 AultCare HMO 14 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
· Blood lead level – One annually
· Total Blood Cholesterol
· Colorectal Cancer Screening, including
·· Fecal occult blood test
·· Sigmoidoscopy, screening

$10 per office visit

Prostate Specific Antigen (PSA test) $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and treatment services, above.

$10 per office visit

Routine mammogram –covered for women age 35 and older, as
follows:

· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age 65 and older, one every two consecutive calendar years

Nothing

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

Routine Immunizations Nothing

Preventive care, children
· Childhood immunizations recommended by the American Academy of Pediatrics

· Ear exams through age 17 to determine the need for hearing correction
· Well-child care charges for routine examinations, immunizations and care

$10 per office visit

Maternity care
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:

· You do not need to precertify your normal delivery.
· You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

Nothing 14
14 Page 15 16
2001 AultCare HMO 15 Section 5( a)
Maternity care (Continued) You Pay
your inpatient stay if medically necessary.
· 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).

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
· Voluntary sterilization
· Surgically implanted contraceptives
· Injectable contraceptive drugs
· Intrauterine devices (IUDs)

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling, elective abortion
All charges.

Infertility services
Diagnosis and treatment of infertility, such as:
· 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.

$10 per office visit

Not covered:
· 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

All charges. 15
15 Page 16 17
2001 AultCare HMO 16 Section 5( a)
Allergy care You pay
· Testing and treatment
· Allergy injection
· Allergy serum

Nothing

Not covered: provocative food testing and sublingual allergy
desensitization
All charges.

Treatment therapies
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 22.

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

· Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment.
Call 330-438-6360 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

$10 per office visit

Rehabilitative therapies
Physical therapy, occupational therapy and speech therapy --
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.

$10 per office visit 16
16 Page 17 18
2001 AultCare HMO 17 Section 5( a)
Rehabilitative therapies (Continued) You pay
Not covered:
· long-term rehabilitative therapy
· exercise programs
· cardiac rehabilitation Phase III

All charges.

Hearing services (testing, treatment, and supplies)
· First hearing aid and testing only when necessitated by accidental injury

· Hearing testing for children through age 17 (see Preventive care, children)

$10 per office visit

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

Vision services (testing, treatment, and supplies)
In addition to the medical and surgical benefits provided for diagnosis
and treatment of diseases of the eye, annual eye refractions (to provide a
written lens prescription) may be obtained from Plan providers.

$10 per office visit

· One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)

$10 per office visit

Coverage includes:
· one complete refractory eye examination by a Plan provider every 24 months; and

· one set of prescribed frames with a $55 maximum Plan payment; or
· one set of single vision lenses with a $35 maximum Plan payment; or
· one set of bi-focal lenses with a $55 maximum Plan payment; or
· one set of tri-focal lenses with a $150 maximum Plan payment; or
· one set of prescribed contact lenses with a $150 maximum Plan payment.

$10 per office visit

Not covered:
· Eye exercises and orthoptics

· Radial keratotomy and other refractive surgery
· Eye exams from an optometrist

All charges. 17
17 Page 18 19
2001 AultCare HMO 18 Section 5( a)
Foot care You Pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

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

$10 per office visit

Not covered:
· 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)

All charges.

Orthopedic and prosthetic devices
· Artificial limbs and eyes; stump hose
· Externally worn breast prostheses and surgical bras (two per calendar year), including necessary replacements, following a

mastectomy
· Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.

· 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.

· Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Not covered:
· 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

All charges. 18
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2001 AultCare HMO 19 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

· hospital beds;
· wheelchairs;
· crutches;
· walkers;
· blood glucose monitors; and
· insulin pumps.

Note: Call us at 330-438-6360 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Nothing

Home health services
· Home health care ordered by a Plan physician and provided 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.

Nothing

Not covered:
· 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.

All charges.

Alternative treatments
Not covered:
· naturopathic services · hypnotherapy

· biofeedback · massotherapy
· acupuncture

All charges. 19
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2001 AultCare HMO 20 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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T

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.
· 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 (i. e. hospital,

surgical center, etc.).
· YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require

precertification and identify which surgeries require precertification.

I M
P O
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A N
T

Benefit Description You pay
Surgical procedures

· Treatment of fractures, including casting · Normal pre-and post-operative care by the surgeon

· Correction of amblyopia and strabismus · Endoscopy procedure
· Biopsy procedure · Removal of tumors and cysts
· 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; eligible
members must be age 18 or over

· Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces and prosthetic devices for device coverage information.

$10 per office visit; nothing for
hospital visits

· Voluntary sterilization · Norplant (a surgically implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered under 5( a).
· Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing for
hospital visits

Not covered:
· Reversal of voluntary sterilization · Routine treatment of conditions of the foot; see Foot care. All charges. 20
20 Page 21 22
2001 AultCare HMO 21 Section 5( b)
Reconstructive surgery You pay
· Surgery to correct a functional defect
· 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.

$10 per office visit; nothing for
hospital visits

· All stages of breast reconstruction surgery following a 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.

Not covered:
· 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

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
· 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.

$10 per office visit; nothing for
hospital visits

Not covered:
· Oral implants and transplants · Procedures that involve the teeth or their supporting structures

(such as the periodontal membrane, gingiva, and alveolar bone)

All charges. 21
21 Page 22 23
2001 AultCare HMO 22 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single –Double
· Pancreas
· Allogeneic (donor) bone marrow transplants

· Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.

Nothing

Not covered:
· Donor screening tests and donor search expenses, except those performed for the actual donor

· Implants of artificial organs
· Transplants not listed as covered

All charges

Anesthesia
Professional services provided in –

· Hospital (inpatient)
Nothing

Professional services provided in –
· Hospital outpatient department · Skilled nursing facility
· Ambulatory surgical center · Office

Nothing 22
22 Page 23 24
2001 AultCare HMO 23 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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.

· 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.

I M
P O
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
· 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.

Nothing

Other hospital services and supplies, such as:
· Operating, recovery, maternity, and other treatment rooms · Prescribed drugs and medicines

· Diagnostic laboratory tests and X-rays · Administration of blood and blood products
· 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

Nothing

Not covered:
· Custodial care · Personal comfort items, such as telephone, television, barber

services, guest meals and beds
· Private nursing care

All charges. 23
23 Page 24 25
2001 AultCare HMO 24 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
· Operating, recovery, and other treatment rooms · 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.

Nothing

Not covered: blood and blood derivatives if replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
The Plan provides a comprehensive range of benefits, with no day or
dollar limit when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan. 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

Nothing

Not covered: custodial care, rest cures, domiciliary or convalescent
care
All charges

Hospice care
· Supportive and palliative care

· Inpatient and outpatient care
· Family counseling
Note: limited to life expectancy of six (6) months or less

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when medically appropriate Nothing 24
24 Page 25 26
2001 AultCare HMO 25 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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.

· 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.

I M
P O
R T
A N
T
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:
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you
are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or
go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a
Plan member so they can notify the Plan. You or a family member should notify the Plan unless it is not
reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day
following your admission, unless it is not reasonably possible to notify the Plan within that time. If you
are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers. 25
25 Page 26 27
2001 AultCare HMO 26 Section 5( d)
Benefit Description You pay
Emergency within our service area

· Emergency care at a doctor's office
· Emergency care at an urgent care center
· Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Nothing

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
· Emergency care at a doctor's office
· Emergency care at an urgent care center
· Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Nothing

Not covered:
· 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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing 26
26 Page 27 28
2001 AultCare HMO 27 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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A N
T

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.
· 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. See the instructions after the benefits description below.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are no
greater than for other illness
or conditions.

· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

· Medication management

$10 per office visit

· Diagnostic tests $10 per office visit
· Services provided by a hospital or other facility
· Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

Nothing 27
27 Page 28 29
2001 AultCare HMO 28 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Not covered: Services we have not approved.
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 of 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:
All non-AultCare admissions, partial hospitalization programs and
intensive out-patient programs require preauthorization. For
preauthorization, call 330-438-6360.

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, or

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. 28
28 Page 29 30
2001 AultCare HMO 29 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A
N T

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.
· 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.

I M
P O
R T
A
N T

There are important features you should be aware of. These include:
· Who can write your prescription. A plan physician or licensed dentist must write the prescription.
· Where you can obtain them. You may fill the prescription at a Plan pharmacy or a non-network pharmacy. We pay a higher level of benefits when you use a network pharmacy.

· These are the dispensing limitations. Prescriptions are filled up to a 34 day supply per copay. Maintenance drugs are dispensed up to a 90 day supply for one copay at retail.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

· Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as
excluded below.
· Insulin; a copayment applies to each 34 day supply. · Diabetic supplies, including insulin syringes, needles, glucose test

tablets and test tape, Benedict's solution or equivalent, and acetone
test tablets

· Disposable needles and syringes for the administration of covered medications

· Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
· Drugs for sexual dysfunction (see Prior authorization) · Contraceptive drugs and devices

$5 generic
$10 brand
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay. 29
29 Page 30 31
2001 AultCare HMO 30 Section 5( f)
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.

· Certain drugs require prior authorization where your physician will submit a letter of medical necessity. For a list of these drugs call
330-438-6360.

Not covered:
· Drugs and supplies for cosmetic purposes
· Vitamins, nutrients and food supplements that can be purchased without a prescription

· 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

All Charges 30
30 Page 31 32
2001 AultCare HMO 31 Section 5( g)
Section 5 (g). Special Features
Feature Description
Aultman Healthline For any of your health concerns, 7 days a week, you may call 1-800-569-4464 and talk with a registered nurse who will discuss
treatment options and answer your health questions.

I Can Cope Weekly cancer education sessions are presented by doctors, nurses and other professionals. The sessions are held by the Aultman Cancer
Center and co-sponsored by the American Cancer Society. For
information/ registration, you may call 330-438-6290. Free parking is
available.

Common Ground A cancer support group for cancer patients and their caregivers. It's led by an Aultman oncology social worker. For information,
call 330-438-6290. Free parking is available. 31
31 Page 32 33
2001 AultCare HMO 32 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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 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.

I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.

Nothing

Dental Benefits
· Oral exam (one per year)
· Prophylaxis or cleaning (one per year)
· Annual application of fluoride up to age 12
· Sealants
· X-rays, including bite wings (limited to once per year) and panoramic (limited to once every 5 years)

· Vitality test
· Oral cancer exam
· Study models
· Emergency treatment, limited to the relief of pain, bleeding, swelling or life threatening conditions

30%

Not covered: other dental services not shown as covered All Charges 32
32 Page 33 34
2001 AultCare HMO Section 6 33
Section 5 (i). Non-FEHB benefits available to Plan members
Feature Description
Aultman Aulternatives Aultman Aulternatives is committed to health promotion and disease prevention. Programs are offered to individuals and businesses
designed to help participants learn to control risk factors and make
healthier decisions. Weight management, healthy nutrition, teen
nutrition, smoking cessation and stress management programs are
developed and presented by medical professionals and are approved by
a physician steering committee. Day and evening sessions are
available for most classes. Call 330-363-6209 for fee and registration
information. 33
33 Page 34 35
2001 AultCare HMO Section 6 34
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.

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; or
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 34
34 Page 35 36
2001 AultCare HMO 35 Section 7
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.

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, hospital & drug 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 330-438-6360.

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 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: AultCare HMO
2600 Sixth Street SW
Canton, Ohio 44710

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year 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. 35
35 Page 36 37
2001 AultCare HMO 36 Section 8
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 preauthorization:

Step Description

 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: AultCare HMO, 2600 Sixth Street SW, Canton, Ohio 44710; and
(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.

 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 3,
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. 36
36 Page 37 38
2001 AultCare HMO 37 Section 8
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
330-438-6360 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 3 at 202-606-0737 between 8 a. m. and 5 p. m. eastern time. 37
37 Page 38 39
2001 AultCare HMO 38 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care 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-Stage 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 managed care plan 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.

(Primary payer chart begins on next page.) 38
38 Page 39 40
2001 AultCare HMO 39 Section 9
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
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability), 9

2) Are an annuitant, 9
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or 9

b) The position is not excluded from FEHB
Ask your employing office which of these applies to you.

9

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), 9

5) Are enrolled in Part B only, regardless of your employment status, 9 (for Part B
services)

9
(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,

9
(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, 9

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, 9

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, 9

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or 9
b) Are an active employee 9 39
39 Page 40 41
2001 AultCare HMO 40 Section 9
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 1-800-344-8858 or visit our
website at www. aultman. com.

· 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 and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do coordinate benefits.
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, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments.

Suspended FEHB coverage and a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare managed
care plan premium.) 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 managed care plan 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. 40
40 Page 41 42
2001 AultCare HMO 41 Section 9
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 agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

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. 41
41 Page 42 43
2001 AultCare HMO 42 Section 10
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 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. We do not have coinsurance.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided primarily for maintenance of the patient or which is designed essentially to assist the patient in meeting his activities of daily
living and which is not primarily provided for its therapeutic value in the
treatment of an illness, disease, bodily injury or condition.

Custodial care includes, but is not limited to, help in walking, bathing,
dressing, feeding, preparation of special diets and supervision over self-administration
of oral medications not requiring constant attention of
trained medical personnel.

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 do not have deductibles.

Experimental or investigational services The Plan's Utilization Management team gathers information from
various sources before making an independent evaluation to determine
medical appropriateness and/ or the experimental/ investigational nature of
new technology, i. e., the application of existing technology or new
medical procedures, drugs, or devices. The Plan's decision is made in
good faith, following a detailed factual background investigation of the
claim and proposed service and interpretation of the Plan provisions.
Sources the Plan may use include the Federal Drug Administration,
Medicare guidelines, published scientific articles, and related medical
society guidelines. If the plan decides that a service or supply is not
medically appropriate and/ or is experimental/ investigational, that service
or supply will not be eligible.

Group health coverage Coverage provided by the Company for the Plan participant and dependents, if applicable.
Medical necessity A service or supply given by a Provider that is required to diagnose or treat your condition, illness or injury and which we determine is:
· Appropriate with regard to standards of good medical practice;
· Not solely for the convenience of you or a provider; · The most appropriate supply or level or service which can
be safely provided to you. When applied to the care of an
Inpatient, this means that your medical symptoms or 42
42 Page 43 44
2001 AultCare HMO 43 Section 10
conditions require that the services cannot be safely
provided to you as an Outpatient.

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: a
Provider's charge is considered "Usual, Customary and Reasonable"
when it is comparable to the fee usually charged for the same or similar
service rendered by other Providers in the same geographical area whose
training, education, and professional standing is equivalent to that of the
Provider making the charge.

Us/ We Us and we refer to AultCare HMO
You You refers to the enrollee and each covered family member. 43
43 Page 44 45
2001 AultCare HMO 44 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 for whom your employing
or retirement 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. 44
44 Page 45 46
2001 AultCare HMO 45 Section 11
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 (TCC).

· Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage 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.

·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. 45
45 Page 46 47
2001 AultCare HMO 46 Section 11
·Converting to You may convert to a non-FEHB individual policy if: individual coverage
·· Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot
convert;
·· You decided not to receive coverage under TCC or the spouse equity law; or

·· You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you 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 Group Health Plan Coverage 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.

Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the
same service, or misrepresented any information, do the following:

· Call the provider and ask for an explanation. There may be an error. · If the provider does not resolve the matter, call us at 1-800-344-8858
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. 46
46 Page 47 48
2001 AultCare HMO 47 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury 32 Allergy tests 16
Alternative treatment 19 Ambulance 24
Anesthesia 22 Autologous bone marrow
transplant 22 Biopsies 20
Blood and blood plasma 24 Casts 23
Changes for 2001 7 Chemotherapy 16
Childbirth 14 Cholesterol tests 14
Claims 35 Coinsurance 11
Colorectal cancer screening 14 Congenital anomalies 20
Contraceptive devices and drugs 15, 29 Coordination of benefits 38
Covered charges 5 Covered providers 5
Crutches 19 Deductible 11
Definitions 42 Dental care 32
Diagnostic services 13 Disputed claims review 36
Donor expenses (transplants) 22 Dressings 23
Durable medical equipment (DME) 19
Effective date of enrollment 45 Emergency 25
Experimental or investigational 34, 42
Eyeglasses 17 Family planning 15
Fecal occult blood test 14 General Exclusions 34
Hearing services 17

Home health services 19 Hospice care 24
Home nursing care 19 Hospital 23
Immunizations 14 Infertility 15
In-hospital physician care 13 Inpatient Hospital Benefits 23
Insulin 29 Laboratory and pathological
services 13 Machine diagnostic tests 13
Magnetic Resonance Imagings (MRIs) 13
Maintenance Prescription Drugs 7, 29
Mammograms 14 Maternity Benefits 14
Medicaid 41 Medically necessary 42
Medicare 38 Members 44
Mental Conditions/ Substance Abuse Benefits 27
Newborn care 13 Non-FEHB Benefits 33
Nurse Nurse Anesthetist 23
Psychiatric Nurse 27 Nursery charges 15
Obstetrical care 14 Occupational therapy 16
Ocular injury 17 Office visits 11
Oral and maxillofacial surgery 21 Orthopedic devices 18
Out-of-pocket expenses 11 Outpatient facility care 24
Oxygen 19, 23 Pap test 14
Physical examination 14

Physical therapy 16 Physician 8
Precertification 10 Preventive care, adult 14
Preventive care, children 14 Prescription drugs 29
Preventive services 14 Prior approval 9
Prostate cancer screening 14 Prosthetic devices 18
Psychologist 27 Psychotherapy 27
Radiation therapy 16 Rehabilitation therapies 16
Renal dialysis 16 Room and board 23
Second surgical opinion 13 Skilled nursing facility care 24
Speech therapy 16 Splints 23
Sterilization procedures 15, 20
Subrogation 41 Substance abuse 27
Surgery 20
· Anesthesia 22 · Oral 21

· Outpatient 24 · Reconstructive 21
Syringes 29 Temporary continuation of
coverage 45 Transplants 22
Treatment therapies 16 Vision services 17
Well child care 14 Wheelchairs 19
Workers' Compensation 41 X-rays 13 47
47 Page 48 49
2001 AultCare HMO 48
NOTES: 48
48 Page 49 50
2001 AultCare HMO 49 Summary
Summary of benefits for the AultCare HMO -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.................. $10 per office visit 13

Services provided by a hospital:
· Inpatient .............................................................................................
· Outpatient...........................................................................................
Nothing

Nothing
23
24

Emergency benefits:
· In-area ..............................................................................................
· Out-of-area.......................................................................................
Nothing

Nothing
26
26

Mental health and substance abuse treatment....................................... Regular cost sharing 27
Prescription drugs.................................................................................. $5 generic, $10 brand 29
Dental care:
Accidental injury benefit…………………………………………
Preventive dental care……………………………………………
Nothing
30% 32 32

Vision care:
One exam every two years ..................................................... ……
Eyewear……………………………………………………………
$10 per office visit
Various payments
17

17

Special features:
· Aultman Healthline
· I Can Cope
· Common Ground

31 49
49 Page 50
2001 AultCare HMO 50 Rates
2001 Rate Information for
AultCare HMO

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to 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 Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

Fill in Location Here
Self Only 3A1 $75.38 $25.13 $163.33 $54.44 $89.20 $11.31

Self and Family 3A2 $195.82 $65.50 $424.28 $141.91 $231.17 $30.15 50

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