The Beacon Health Plans 2001

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............................................................................................................................... 10

Copayments.......................................................................................................................................................... 10

Deductible............................................................................................................................................................. 10

Coinsurance.......................................................................................................................................................... 10

Your out-of-pocket maximum.................................................................................................................................... 10

Section 5. Benefits................................................................................. 11

Overview...................................................................................................................................................................... 11

(a) Medical services and supplies provided by physicians and other health care professionals........... 12

(b) Surgical and anesthesia services provided by physicians and other health care professionals....... 22

(c) Services provided by a hospital or other facility, and ambulance services........................................... 26

(d) Emergency services/accidents..................................................................................................................... 29

(e) Mental health and substance abuse benefits............................................................................................ 31

(f) Prescription drug benefits............................................................................................................................. 33

(g) Special features............................................................................................................................................... 35

(h) Non-FEHB benefits available to Plan members.......................................................................................... 37

Section 6. General exclusions -- things we don't cover........................................................................................................... 38

Section 7. Filing a claim for covered services............................................................................................................................ 39

Section 8. The disputed claims process..................................................................................................................................... 40

Section 9. Coordinating benefits with other coverage............................................................................................................. 42

When you have

Other health coverage.......................................................................................................................................... 42

Original Medicare................................................................................................................................................. 42

Medicare managed care plan.............................................................................................................................. 45

TRICARE/Workers' Compensation/Medicaid....................................................................................................... 45

Other Government agencies...................................................................................................................................... 46

When others are responsible for injuries................................................................................................................ 46

Section 10. Definitions of terms we use in this brochure........................................................................................................ 47

Section 11. FEHB facts.................................................................................................................................................................. 49

Coverage information........................................................................................................................................... 49

No pre-existing condition limitation.......................................................................................................... 49

Where you get information about enrolling in the FEHB Program....................................................... 49

Types of coverage available for you and your family............................................................................ 49

When benefits and premiums start............................................................................................................ 50

Your medical and claims records are confidential................................................................................... 50

When you retire........................................................................................................................................... 50

When you lose benefits....................................................................................................................................... 50

When FEHB coverage ends....................................................................................................................... 50

Spouse equity coverage............................................................................................................................. 50

Temporary Continuation of Coverage (TCC).......................................................................................... 50

Enrolling in TCC........................................................................................................................................... 50

Converting to individual coverage........................................................................................................... 51

Getting a Certificate of Group Health Plan Coverage............................................................................. 51

Inspector General advisory: Stop health care fraud!......................................................................................... 51

Index ................................................................................................................................................................................... 52

Summary of benefits....................................................................................................................................................................... 54

Rates..Back cover

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 plans 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. Our providers compensation include but are not limited to base payment methods (e.g., capitation, fee schedule) and additional financial incentives (e.g., bonus, withhold, etc.).

Patients Bill of Rights

OPM requires that all FEHB Plans comply with the Patients Bill of Rights, recommended by the Presidents Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information about us, ournetworks, providers, and facilities. OPMs 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.

Accreditation Status Accredited by the Accreditation Association for Ambulatory Health Care, Inc.

Years in existence 4 years

Profit status For Profit

Beacon Health Plans is compliant with State and Federal licensing, certification and fiscal solvency requirements.

For more information on items listed below call us:

Medical records confidentiality

Provider credentials

Experimental / Investigational medical treatment approval processes

Customer satisfaction measures

Referral utilization review procedures and processes

Clinical protocols and practice guidelines

Disease management programs

Formulary drug inclusion and exception process

Detailed information about networks and providers (e.g., education, location, languages spoken, compensation)

If you want more information about us, call 1-800/850-0979, or write to Beacon Health Plans, P.O. Box 14-9080, Coral Gables, FL 33114-9080. You may also contact us by fax at 305/774-2619 or visit our website at www.beaconhealth.com.

Service Area

To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our Service Areas are; Dade, Broward and Palm Beach counties.

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 away from our service area, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

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 1-800-850-0979.

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.Our members receive services from an integrated network of private practice physicians, specialists, ancillary providers, pharmacies and hospitals. All participating providers must meet our contracting and credentialling criteria prior to inclusion in the plan. You must choose a primary care physician from the plans participating provider directory. Primary care physicians include Internal Medicine, Pediatrics, and others. Please check the section in the directory for primary care physicians in your area. Any necessary care will be coordinated by the primary care physician including but not limited to referrals to specialist, ordering diagnostic testing and admission to a hospital. However, a woman may see her gynecologist without having to obtain a referral.

We list Plan providers in the provider directory, which we update periodically.

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

to get covered care 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, general 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 a gynecologist for an annual well woman visit, podiatrists (limited visits allowed annually), chiropractors (limited visits allowed annually), and dermatologists (limited visits allowed annually) 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 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 1-800/850-0979. 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 Your primary care physician has authority to refer you for most services.

prior approval For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process obtaining a referral. Your physician must obtain a referral before sending you to a specialist (other than those identified that do not require referrals), diagnostic services, outpatient services, inpatient services, extensive treatment plans and any other service that we consider medically necessary.

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 when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing per admission.

Deductible We do not have a deductible.

NOTE: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Coinsurance We do not have coinsurance.

Your out-of-pocket maximum After your copayments total $1,500 per person or $3,000 per family

for copayments enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments for the following services do not count toward your out-of-pocket maximum, and you must continue to pay copayments for these services:

Prescription drugs.

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
	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 physicians must provide or arrange your care. We have no calendar year deductible. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.		I M P O R T A N T
Benefit Description			You pay
Diagnostic and treatment services
Professional services of physicians In physicians office			$10 per visit
Professional services of physicians In an urgent care center During a hospital stay In a skilled nursing facility Initial examination of a newborn child covered under a family enrollment Office medical consultations Second surgical opinion			$10 per visit
At home			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
Preventive care, adult
Routine screenings, such as: Annual physical examination Blood lead level One annually Total Blood Cholesterol once every three years, ages 19 through 64 Colorectal Cancer Screening, including Fecal occult blood test			$10 per visit
Sigmoidoscopy, screening every five years starting at age 50			$10 per visit
Prostate Specific Antigen (PSA test) one annually for men age 40 and older			$10 per visit
Routine pap test			$10 per 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			$10 per visit
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.			All charges.
Routine Immunizations, limited to: Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations) Influenza/Pneumococcal vaccines, annually, age 65 and over			$10 per visit
Preventive care, children			You pay
Childhood immunizations recommended by the American Academy of Pediatrics			$10 per visit
Preventive care, children (Continued)			You pay
Examinations, such as: Eye exams through age 17 to determine the need for vision correction. Ear exams through age 17 to determine the need for hearing correction Examinations done on the day of immunizations ( through age 22) Well-child care charges for routine examinations, immunizations and care (through age 22)			$10 per visit

Maternity care	You pay
Complete maternity (obstetrical) care, such as: Prenatal care Delivery Postnatal care Note: Here are some things to keep in mind: You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary. We cover routine nursery care of the newborn child during the covered portion of the mothers 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).	Nothing
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) Diaphragms	$10 per visit
Not covered: reversal of voluntary surgical sterilization, genetic counseling,	All charges.
Infertility services	You pay
Diagnosis and treatment of infertility, such as: Artificial insemination: intravaginal insemination (IVI) intracervical insemination (ICI) intrauterine insemination (IUI)	$10 per 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 Fertility drugs	All charges.
Allergy care
Testing and treatment Allergy injection	$10 per visit
Allergy serum	Nothing
Not covered: provocative food testing and sublingual allergy desensitization	All charges.
Treatment therapies	You pay
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 24. 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. Your doctor must call for preauthorization. We will ask your doctor to submit information that establishes that the GHT is medically necessary. We must authorize GHT before you begin treatment. 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 visit

Rehabilitative therapies	You pay
Physical therapy, occupational therapy and speech therapy -- 60 visits per condition for the services of each of the following: qualified physical therapists; speech therapists; and occupational therapists. Note: We only cover therapy to restore bodily function or speech when there has been a total or partial loss of bodily function or functional speech due to illness or injury. Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 10 sessions	Nothing
Not covered: long-term rehabilitative therapy exercise programs	All charges.
Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 (see Preventive care, children)	$10 per visit
Not covered: all other hearing testing hearing aids, testing and examinations for them	All charges.

Vision services (testing, treatment, and supplies)	You pay
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 visit
Eye exam to determine the need for vision correction for children through age 17 (see preventive care)	$10 per visit
Not covered: Eyeglasses or contact lenses and, after age 17, examinations for them Eye exercises and orthoptics Radial keratotomy and other refractive surgery	All charges.
Foot care
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 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	You pay
Artificial limbs and eyes; stump hose Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: 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. Braces	$10 per visit
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 prosthetic replacements, unless determined by the members PCP to be medically necessary	All charges.
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 (semi-electric); lcanes wheelchairs (standard) lcommode chairs crutches; ltrapezes walkers; ltraction equipment blood glucose monitors;lnebulizers insulin pumps ostomy supplies lLSO & TSLO braces Note: Call us at 1-800/850-0979 as soon as your Plan physician prescribes this equipment.	Nothing
Not covered: Motorized wheelchairs Any other item not listed above	All charges.
Home health services	You pay
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 patients family; Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.	All charges.
Alternative treatments
Chiropractic services	$10 per visit
Not covered: Accupucture services Naturopathic services Hypnotherapy Biofeedback	All charges.
Educational classes and programs
Coverage is limited to: Diabetes self-management	$10 per visit

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
	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 physicians must provide or arrange your care. We have no calendar year deductible. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.). YOUR DOCTOR 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 R T 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 and prosthetic devices for device coverage information.			Nothing

Surgical procedures continued on next page.

Surgical procedures (Continued)	You pay
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.	Nothing
Not covered: Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care. Cost of a penile implanted device	All charges.
Reconstructive surgery
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 members 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.	Nothing
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.	Nothing
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 Surgeries related to sex transformation	All charges
Oral and maxillofacial surgery	You pay
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.	Nothing
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.
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 National Transplant Program (NTP) - We currently participate with specific Centers of Excellence that provide an optimal setting and have the best medical outcomes possible for these types of services. 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 Plans medical director in accordance with the Plans 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	You pay
Professional services provided in Hospital (inpatient)	Nothing
Professional services provided in Hospital outpatient department Skilled nursing facility Ambulatory surgical center Office	$10 per visit

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).		I M P O R T 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 Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services Take-home items Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.			Nothing
Not covered: Custodial care Non-covered facilities, such as nursing homes, extended care facilities, schools Personal comfort items, such as telephone, television, barber services, guest meals and beds Private nursing care Blood or blood derivatives not replaced by the member			All charges.
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 not replaced by the member			All charges
Extended care benefits/skilled nursing care facility benefits
Extended care benefit and Skilled Nursing Facility (SNF) benefits: We cover a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered, including: Bed, board and general nursing care Drugs, biologicals, supplies, equipment ordinarily provided by the skilled nursing facility when prescribed by a Plan doctor.			Nothing
Not covered: custodial care			All charges
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility. Services include: Inpatient Care Outpatient Care Family Counseling NOTE: - These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stage of illness, with a life expectancy of approximately six months or less.			Nothing
Not covered: Independent nursing, homemaker services			All charges
Ambulance			You pay
Local professional ambulance service when medically appropriate			Nothing

Section 5 (d). Emergency services/accidents

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We have no calendar year deductible.

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

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:

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., 911) 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 us. You or a family member must notify us within 48 hours, unless it was not reasonably possible to do so. It is your responsibility to ensure that we have been timely notified. Call us at 1-800-850-0979.

Emergencies within and outside our service area:

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

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

To be covered by this Plan any follow-up care recommended by non-Plan providers must be approved by us or provided by Plan providers.

We pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

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	$10 per visit $50 per visit; however, if the emergency results in admission to a hospital, the copay is waived. $50 per visit; however, if the emergency results in admission to a hospital, the copay is waived.
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	$50 per visit; however, if the emergency results in admission to a hospital, the copay is waived.
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 Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area	All charges.
Ambulance
Professional ambulance service when medically appropriate. See 5(c) for non-emergency service.	Nothing
Not covered: air ambulance	All charges.

Section 5 (e). Mental health and substance abuse benefits
	I M P O R T 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. YOUR PLAN DOCTOR 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 illnesses or conditions.
Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers Medication management			$10 per visit

Mental health and substance abuse benefits - Continued on next page

Mental health and substance abuse benefits (Continued)

You pay

Diagnostic tests

Nothing

Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.

NOTE: OPM will base its review of disputes about treatment plans on the treatment plans clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

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

Your primary care physician will obtain a referral for you to see a specialist in this area. You may also call us at 1-800/850-0979 for assistance with obtaining a Provider Directory and Inpatient and Outpatient Treatment Plan approval procedures.

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 conditions:

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

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

Limitation We may limit your benefits if you do not follow your treatment plan.

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 licensed physician must write the prescription. Where you can obtain them. You may fill the prescription at a participating pharmacy or by mail for a maintenance medication. We use a formulary. A formulary means a specific list of drug products, including their strengths and appropriate dosage that are available for use by Members. These are the dispensing limitations.Prescription drugs prescribed by a Plan doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply. The $5 co-pay covers only generic drugs if the generic is available. If a generic drug is not available, and you are dispensed a brand name drug, you are only responsible for the $5 co-pay amount. If a generic drug is available and a more expensive brand name drug is dispensed at your request or the Plan doctors request, you must pay the $15 co-pay amount and the difference between the brand name drug and the generic drug cost. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary. Non-formulary drugs will be covered when prescribed by a Plan doctor and authorized by us. It is the prescribing doctors responsibility to obtain the Plans authorization. The Mail Service Pharmacy benefit allows you to obtain covered prescriptions (up to a 90-day supply) used to treat chronic or long-term health conditions (e.g., high blood pressure or diabetes) through our mail order program. Please call us at 1-800-850-0979 for a supply of the prescription mail order form. Refills: Orders placed more than 2 weeks before the refill date may be returned unfilled with a request to re-submit them at a later date. Prescription Expiration: Most prescriptions, including refills, have an expiration date from the date they are written. After the expiration date, regardless of whether you are vial label still shows refills remaining, you must obtain a new prescription from your doctor. When you have to file a claim.If you are required to pay for your prescriptions, submit itemized bills and your receipts to us along with an explanation of the services and the identification information from your ID CARD. Payment will be sent to you, unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which the denial(s) was based. If you disagree with our decision, you may request reconsideration in accordance with the disputed claims procedure described on Section 8.
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 physicians prescription for their purchase, except as excluded below. Insulin; a copay applies to each vial Disposable needles and syringes for the administration of covered medications Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedicts solution or equivalent, glucose monitors and acetone test tablets Contraceptive drugs and devices			$5 copay per prescription unit or refill for generic drugs $15 copay per prescription unit or refill for name brand drugs Note: If there is no generic drug available and you are dispensed a name brand drug, you will only have to pay the $5 copay for a generic drug. Note: If there is a generic equivalent available and a name brand drug is dispensed, you will still have to pay the name brand copay of $15 and the difference between the name brand drug and the generic drug cost.
Drugs for sexual dysfunction require prior authorization. They are limited and you must call us at 1/800-850-0979 for dose limits.			$15 copay per prescription unit or refill
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic. We administer an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-800/850-0979.
Covered medications and supplies (continued)			You pay
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 Fertility drugs Smoking cessation drugs and medication			All Charges

Section 5 (g). Special Features
Feature	Description
24 hour nurse line	For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800/850-0979 and talk with a registered nurse who will discuss treatment options and answer your health questions.
Services for deaf and hearing impaired	We have telephone lines within our customer service units that are designated for our hearing impaired members. That number is 1-888-397-2844.
High risk pregnancies	We have a special high risk pre-natal program with a designated case manager who monitors the high risk pregnancies closely with the physician and the member directly.
Centers of excellence for transplants	We currently refer specific transplant cases to the U.R.N. Centers of Excellence. These Centers of Excellence provide the best medical outcomes possible for these types of medical services.
Accreditation	We have received accreditation from the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), for another term of 3 years. The term will expire on June 30, 2003. AAAHC was founded in 1979, and is dedicated to improving the quality of medical, surgical, and dental care to Americas patients. It maintains its dedication to this goal through its survey and accreditation process, standards Handbook, and educational programming. The AAAHC logo on an organizations informational materials provides proof of quality services and the organizations adherence to the highest standards for ambulatory health care.

Section 5 (h). Non-FEHB benefits available to Plan members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Vision care

Discounted Vision Benefit available to all Beacon Health Plans members at no additional cost. As a Beacon Health Plan member, you receive special prices on eye exams, contact lens exams and contact lenses at all For Eyes Optical and Vision Works locations.

Comprehensive Eye Examination...

Doctors of Optometry provide comprehensive eye examinations that include testing for near and distance vision in addition to assessing the overall health of the eyes.

Contact Lens Exam..

Includes Comprehensive eye exam, contact lens fitting and follow up care for soft, spherical daily wear contact lenses.

Extended wear and disposable contact lens exams are available for

Specialty contact lens exams for rigid gas permeable, toric and hard lenses is usual and customary less 20%.

Daily Wear Lenses..

Extended Wear Lenses.

Disposable Lenses (6 packs-one week or two week wear)

Daily Disposable Lenses (30 pack of Acuvue one day).

Frequent Replacement Lenses (6 packs-one month to three month).

All other contact lenses (hard, Gas Permeable, Toric and others).

All Beacon Health Plan Members receive special package prices and discounts on eyeglass frames, lenses and optical accessories.

Eyeglass Package

Choose from special Fashion/Group A Frame Collection.

Frame and plastic single vision lenses..

Frame and plastic bifocal lenses (FT-35 or executive lenses).

Frame and plastic trifocal lenses (FT-25-35 or executive lenses).

Frame Prices:

All eyewear selected outside of the special Fashion/Group A Frame Collection will be available at a 20% discount off the listed retail price.

Lens only and Lens Options:

Refer to your Beacon Health Plans insert for more detailed information

Member Pays

$32.00

$60.00

$75.00

$35.00/pair

$39.00/pair

$19.00/each

$23.50/each

$29.00/each

Less 15%

$29.00

$49.00

$59.00

Section 7. Filing a claim for covered services

When you see Plan physicians, receive services at Plan hospitals and facilities, or fill 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 and In most cases, providers and facilities file claims for you. Physicians

Drug benefits 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 1-800/850-0979.

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 members name and ID number;

Name and address of the 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: Beacon Health Plans, P.O. Box 14-9080, Coral Gables, FL 33114-9080.

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.

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
1	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: 2511 Ponce de Leon Boulevard; 5^th Floor, Coral Gables, FL 33134; 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.
2	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 requestgo to step 3.
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.
4	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.
	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.
5	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.
6	If you do not agree with OPMs decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies. 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 1-800-850-0979 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 202/606-0755 between 8 a.m. and 5 p.m. eastern time.

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. Your care must continue to be authorized by your Plan PCP, or precertified as required.

We will not waive any of our copayments.

(Primary payer chart begins on next page.)
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you -- or your covered spouse -- are age 65 or over and	Then the primary payer is
	Original Medicare	This Plan
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when a) The position is excluded from FEHB, or..	..
b) The position is not excluded from FEHB .. Ask your employing office which of these applies to you.	..
4) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,	(for Part B services)	(for other services)
6) Are a former Federal employee receiving Workers Compensation and the Office of Workers Compensation Programs has determined that you are unable to return to duty,	(except for claims related to Workers Compensation.)
B. When you -- or a covered family member -- have Medicare based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and a) Are an annuitant, or	.
b) Are an active employee..	..	.

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare

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 1-800-850-0979.

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 waive our copayments for your FEHB coverage.

This Plan and another Plans Medicare managed care plan: You may enroll in another plans 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 plans 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 plans 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.

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.

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 dont determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for

for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or 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.

When benefits and The benefits in this brochure are effective on January 1. If you are new

premiums start to this Plan, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. Annuitants premiums begin on January 1.

Your medical and claims We will keep your medical and claims information confidential. Only

records are confidential the following will have access to it:

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

This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and subrogating claims;

Law enforcement officials when investigating and/or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;

Individuals involved in bona fide medical research or education that does not disclose your identity; or

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

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation of coverage (TCC).

When you lose benefits

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

Your enrollment ends, unless you cancel your enrollment, or

You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

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

coverage continue to get benefits under your former spouses 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-spouses 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.

Enrolling in TCC Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www.opm.gov/insure.

Converting to You may convert to an individual policy if:

individual coverage Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot convert;

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

You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you 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 1-800-850-0979 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.

Accidental injury 29

Allergy tests 16

Allogeneic (donor) bone marrow

transplant XX

Alternative treatment 21

Ambulance 28

Anesthesia 25

Autologous bone marrow transplant 24

Biopsies 22

Birthing centers 26

Blood and blood plasma 26

Breast cancer screening 13

Carryover 10

Casts 20

Changes for 2001 7

Chemotherapy 17

Childbirth 15

Cholesterol tests 13

Circumcision 15

Claims 39

Coinsurance 10

Colorectal cancer screening 20

Congenital anomalies 23

Contraceptive devices and drugs 33

Coordination of benefits 42

Covered charges 8

Covered providers 8

Crutches 20

Deductible 10

Definitions 47

Dental care 36

Diagnostic services 12

Disputed claims review 40

Donor expenses (transplants) 24

Dressings 26

Durable medical equipment (DME) 20

Educational classes and programs 21

Effective date of enrollment 50

Emergency 29

Experimental or investigational 47

Eyeglasses 19, 37

Family planning 15

Fecal occult blood test 13

General Exclusions 38

Hearing services 18

Home health services 21

Hospice care 27

Home nursing care 21

Hospital 26

Immunizations 13

Infertility 15

Inhospital physician care 26

Inpatient Hospital Benefits 26

Insulin 33

Laboratory and pathological services 13

Machine diagnostic tests 12

Magnetic Resonance Imagings (MRIs) 12

Mail Order Prescription Drugs 33

Mammograms 13

Maternity Benefits 15

Medicaid 45

Medically necessary 45

Medicare 43, 45

Members 46

Mental Conditions/Substance Abuse Benefits 31

Neurological testing 12

Newborn care 15

Non-FEHB Benefits 37

Nurse

Licensed Practical Nurse 21

Nurse Anesthetist 25

Nurse Midwife 15

Nurse Practitioner 21

Psychiatric Nurse 31

Registered Nurse 25

Nursery charges 15

Obstetrical care 15

Occupational therapy 18

Ocular injury 19

Office visits 12

Oral and maxillofacial surgery 20

Orthopedic devices 20

Ostomy and catheter supplies 20

Out-of-pocket expenses 55

Outpatient facility care 27

Oxygen 20

Pap test 13

Physical examination 13

Physical therapy 18

Physician 8

Precertification 31

Preventive care, adult 13

Preventive care, children 14

Prescription drugs 33

Preventive services 13

Prior approval 10

Prostate cancer screening 13

Prosthetic devices 20

Psychologist 31

Psychotherapy 31

Radiation therapy 17

Rehabilitation therapies 18

Renal dialysis 20

Room and board 26

Second surgical opinion 12

Skilled nursing facility care 27

Smoking cessation 33

Speech therapy 17

Splints 26

Sterilization procedures 26

Subrogation 46

Substance abuse 31

Surgery 22

Anesthesia 25

Oral 24

Outpatient 27

Reconstructive 23

Syringes 33

Temporary continuation of coverage 50

Transplants 24

Treatment therapies 17

Vision services 19, 37

Well child care 13, 14

Wheelchairs 20

Workers compensation 45

X-rays 27

Summary of benefits for Beacon Health Plans- 2001

Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits	You Pay	Page
Medical services provided by physicians: Diagnostic and treatment services provided in the office...................	Office visit copay: $10 primary care; $10 specialist	12
Services provided by a hospital: Inpatient...................................................................................................... Outpatient...................................................................................................	Nothing Nothing	26 27
Emergency benefits: In-area......................................................................................................... Out-of-area.................................................................................................	$50 per visit $50 per visit	30 30
Mental health and substance abuse treatment........................................	Regular cost sharing	31
Prescription drugs.......................................................................................... Up to a 31-day supply per prescription unit or refill	$5 for generic drugs $15 for name brand drugs	33
Dental Care..................................................................................................	No benefit
Vision Care................................................................................................... One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery	$10 per visit	17
Special features: 24 hour nurse line; Services for deaf and hearing impaired; High risk pregnancies; Centers of excellence for transplants; Accreditation		35
Protection against catastrophic costs (your out-of-pocket maximum)..................................................................	Nothing after $1,500/Self Only or $3,000/Family enrollment per year Some costs do not count toward this protection	10

2001 Rate Information for

Beacon Health Plans

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

Govt

Share

Your

Share

Govt

Share

Your

Share

USPS

Share

Your

Share

Self Only

4K1

$65.24

$21.74

$141.35

$47.11

$77.19

$9.79

Self and Family

4K2

$183.92

$61.30

$398.48

$132.83

$217.63

$27.59

Diagnostic and treatment services

Lab, X-ray and other diagnostic tests

Preventive care, adult

Preventive care, children

Preventive care, children (Continued)

Not covered:

Naturopathic services

Hypnotherapy

Biofeedback

Educational classes and programs

Other hospital services and supplies, such as:

Outpatient hospital or ambulatory surgical center

You pay

Prescribed drugs and medicines

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

Hospice care

Section 5 (d). Emergency services/accidents

Mental health and substance abuse benefits

Mental health and substance abuse benefits (Continued)

You pay

Not covered: Services we have not approved.

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 conditions:

Limitation We may limit your benefits if you do not follow your treatment plan.

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,