UPMC Health Plan http:// www.
upmchealthplan. com
2002
Serving: Allegheny, Beaver, Bedford, Blair, Butler, Cambria, Crawford,
Erie, Fayette, Lawrence, McKean, Mercer, Venango, Washington
And
Westmoreland
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 6 for requirements.
Enrollment codes for this Plan:
8W1 Self Only 8W2 Self and Family
RI 73-797
For changes in benefits
see page 7.
A Health Maintenance Organization
. 1
1 Page
2 3
2002 UPMC Health Plan 2
Table of Contents
Table of Contents
Introduction………………………………………………………………….
........................................................................................
4
Plain Language
.......................................................................................................................................................................................
4
Inspector General Advisory…………………………………………………………………………………………………………….. 4
Section 1. Facts about this HMO plan
...................................................................................................................................................
6
How we pay providers
..........................................................................................................................................................
6
Who provides my health
care?..............................................................................................................................................
6
Your
Rights...........................................................................................................................................................................
6
Service
Area..........................................................................................................................................................................
7
Section 2. How we change for 2002
......................................................................................................................................................
7
Program-wide changes
..........................................................................................................................................................
7
Changes to this
Plan..............................................................................................................................................................
8
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........................................................................................................................................
9
Services requiring our prior
approval....................................................................................................................................
9
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 .................................... 12
(b) Surgical and
anesthesia services provided by physicians and other health care
professionals................................. 12
(c) Services provided by a
hospital or other facility, and ambulance
services............................................................... 12
(d) Emergency services/ accidents
..................................................................................................................................
12
(e) Mental health and substance abuse benefits
.............................................................................................................
12
(f) Prescription drug
benefits.........................................................................................................................................
12
(g) Special features
.......................................................................................................................................................
12
Flexible benefits option 2
2 Page 3 4
2002 UPMC Health
Plan 3 Table of Contents
(h) Dental
benefits..........................................................................................................................................................
12
(i) Non-FEHB benefits available to Plan
members.......................................................................................................
12
Section 6. General exclusions --things we don't
cover........................................................................................................................
44
Section 7. Filing a claim for covered services
.....................................................................................................................................
45
Section 8. The disputed claims
process................................................................................................................................................
46
Section 9. Coordinating benefits with other coverage
........................................................................................................................
48
When you have…
Other health coverage
....................................................................................................................................................
48
Original
Medicare..........................................................................................................................................................
48
Medicare managed care plan
........................................................................................................................................
50
TRICARE/ Workers' Compensation/ Medicaid
...................................................................................................................
50
Other Government
agencies................................................................................................................................................
51
When others are responsible for
injuries.............................................................................................................................
51
Section 10. Definitions of terms we use in this
brochure......................................................................................................................
52
Section 11. FEHB facts
........................................................................................................................................................................
53
Coverage
information........................................................................................................................................................
53
No pre-existing condition limitation
.........................................................................................................................
53
Where you get information about enrolling in the FEHB Program
.......................................................................... 53
Types of coverage available for you and your
family...............................................................................................
53 When benefits and premiums start
.................................................................................................................................
54
Your medical and claims records are confidential
....................................................................................................
54
When you
retire........................................................................................................................................................
54
When you lose benefits
.....................................................................................................................................................
54
When FEHB coverage ends
......................................................................................................................................
54
Spouse equity
coverage............................................................................................................................................
54
Temporary Continuation of Coverage (TCC)
..........................................................................................................
54
Converting to individual coverage
...........................................................................................................................
55
Getting a Certificate of Group Health Plan
Coverage..............................................................................................
55
Long term care insurance is coming later in 2002
................................................................................................................................
56 Index
.........................................................................................................................................................................................
57
Summary of benefits
.............................................................................................................................................................................
58
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 UPMC Health Plan 4 Introduction/ Plain Language/ Advisory
Introduction
UPMC Health Plan One Chatham Center
112
Washington Place Pittsburgh, PA 15219
This brochure describes the benefits of UPMC Health Plan under our contract
(CS 2856) 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, 2002, unless those benefits are also shown in
this brochure.
OPM negotiates benefits and rates with each plan annually.
Benefit changes are effective January 1, 2002 and changes are summarized on page
7. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member;
"we" means UPMC Health Plan..
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions about how to
improve the structure of this brochure,
let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the
office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900
E Street, NW Washington, DC 20415-3650.
Inspector General Advisory
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 1-888-876-2756 and
explain the situation. If we do
not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Stop health care fraud! 4
4 Page 5 6
2002 UPMC Health
Plan 5 Introduction/ Plain Language/ Advisory
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. 5
5 Page 6 7
2002 UPMC Health Plan 6 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.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. 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.
Licensed through the PA Insurance Department
NCQA – First
review scheduled for 2002
Years in existence – four (4) years
Profit
status – Not-for-profit
Member rights and appeals/ grievance
Accessing
emergency care
Member cost sharing
If you want more information about
us, call 1-888-876-2756, or write to UPMC Health Plan Member Services, One
Chatham Center, 112 Washington Place, Pittsburgh, PA 15219. You may also contact
us by fax at (412) 454-7529 or visit our website at
www. upmchealthplan. 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 area is: Allegheny, Beaver, Bedford, Blair, Butler,
Cambria, Crawford, Erie, Fayette, Lawrence, McKean, Mercer, Venango, Washington,
and
Westmoreland.
Ordinarily, you must get your care from providers who
contract with us. If you receive care outside our service area, we will pay only
for emergency care benefits. We will not pay for any other health care services
out of our service area unless the services have prior
plan approval.
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
2002 UPMC Health Plan 7 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5 Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a clarification that does not
change
benefits.
Program-wide changes
We increased speech therapy benefits by removing the requirement that
services must be required to restore functional speech (Section 5( a)).
Changes to this Plan
Your share of the non-Postal premium will
increase by 15.0% for Self Only or 15.0% for Self and Family.
We no longer
limit total blood cholesterol tests to certain age groups.
We now cover
certain intestinal transplants. 7
7 Page 8 9
2002 UPMC Health
Plan 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 1-888-876-8756.
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. The list of providers in our
directories include Primary Care
Physicians, Specialists, Ancillary
Providers, Hospitals and Pharmacies.
Plan facilities Plan facilities
are hospitals and other facilities in our service area that we contract with to
provide covered services to our members. We list these in the provider
directory, which
we update periodically. The list is also on our website.
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.
Choose a PCP at the time of enrollment (women may also choose an OB/ GYN for all
female-related services). List the PCP
name and 4-digit practice number on
your enrollment form.
Primary care Your primary care physician can be
a family or general practitioner, internist, 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 any specialist in the UPMC
Health Plan network at anytime without a referral.
Simply choose a network
specialist, present your identification card at the time of your visit and you
will be charged slightly higher office visit copay. Any medically necessary
prescribed services ordered by the treating specialist are covered at 100%
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will work with your specialist and
UPMC Health Plan to develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals. Your
primary care
physician will use our criteria when creating your treatment
plan (the physician may have to get an authorization or approval beforehand).
What you must do to get covered care 8
8
Page 9 10
2002
UPMC Health Plan 9 Section 3
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 1-888-876-2756. 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.
Your primary care physician
has authority to refer you for most services. For certain services, however,
your physician must obtain approval from us. Before giving approval,
we
consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
Services requiring our prior approval 9
9
Page 10 11
2002
UPMC Health Plan 10 Section 3
We call this review and approval
process. Your physician must obtain approval for medically necessary conditions
such as: experimental, out-of-network, or any non-covered
benefit that is
considered medically necessary.
Your treating physician will contact UPMC
Health Plan to coordinate your services. UPMC Health Plan will let you and your
treating physician know the decision. Should
you disagree with the decision,
you may file a complaint with UPMC Health Plan Member Services. 10
10 Page 11 12
2002 UPMC Health Plan 11 Section 4
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, facility,
pharmacy, etc., 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.
Deductible We do not have a deductible
Coinsurance We do
not have coinsurance.
We do not have an out-of-pocket maximum Your out-of-pocket maximum 11
11 Page 12 13
2002 UPMC Health Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our
benefits changed this year and page 58 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 1-888-876-2756 or
at our website at www. upmchealthplan. com.
(a) Medical services and
supplies provided by physicians and other health care
professionals........................................................ 13-24
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 Physical
and occupational therapies
Speech therapy 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
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................................ 25-29
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
30-32
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents
.................................................................................................................................................
33-34 Medical emergency Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................................
35-36
(f) Prescription drug benefits
........................................................................................................................................................
37-40
(g) Special features
.............................................................................................................................................................................
41 Flexible benefits option
Women select a network OB/ GYN in addition to a PCP and self-refer for all
female-related services.
Members may self-refer to any network chiropractor.
Emergency and urgent care travel assistance through Assist America.
(h)
Dental benefits
..............................................................................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
............................................................................................................................
43
Summary of benefits
.............................................................................................................................................................................
58 12
12 Page 13
14
2002 UPMC Health Plan 13 Section 5( a)
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 physician's office
$10 per office visit
$10 per visit to your primary care physician
$10
per visit to a specialist if referred by your PCP
$30 per visit to a
specialist if self-referred
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
$10 per office visit
At home Nothing
Diagnostic and treatment services --continued on next
page 13
13 Page
14 15
2002 UPMC Health Plan 14
Section 5( a)
Diagnostic and treatment services (continued)
You pay
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
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Colorectal Cancer Screening,
including
Fecal occult blood test
Sigmoidoscopy, screening – every five years
starting at age 50
Nothing.
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing
Routine pap test
Note: The office visit is covered if pap test
is received on the same day; see Diagnosis and Treatment, above.
Nothing
Preventive Care -Adult --continued on next page 14
14 Page 15 16
2002 UPMC Health Plan 15 Section 5( a)
Preventive care, adult (continued) You pay
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, 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
Nothing
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing.
Well-child care charges for routine examinations, immunizations and care
(under age 22)
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 ( under age 22)
Nothing. 15
15 Page
16 17
2002 UPMC Health Plan 16
Section 5( a)
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 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
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).
Nothing.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant) }
Injectable
contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription
drug benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges. 16
16 Page 17 18
2002 UPMC
Health Plan 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI) intracervical
insemination (ICI)
intrauterine insemination (IUI)
$10 per office visit
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization embryo transfer, gamete GIFT
and zygote ZIFT
Zygote transfer Services and supplies related to excluded ART
procedures
Cost of donor sperm
Cost of donor egg
Fertility
drugs
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges. 17
17 Page 18 19
2002 UPMC Health Plan 18 Section 5( a)
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 28.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment. Your Primary Care Physician will coordinate this
process for you.. 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.
Nothing. 18
18 Page
19 20
2002 UPMC Health Plan 19
Section 5( a)
Physical and occupational therapies
60
visits per condition for the services of each of the following:
qualified
physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury. }
Cardiac rehabilitation following a heart transplant, bypass surgery
or a
myocardial infarction, is provided without limitations.
$10 per visit
$10 per outpatient visit
Nothing per visit during
covered inpatient
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
60 visits per condition $10 per visit 19
19 Page 20 21
2002 UPMC Health Plan 20 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental
injury
Hearing testing for children through age 17 (see Preventive care,
children)
Nothing.
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
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
Eye exam to determine the need for vision correction for children up to age
22 (see Preventive care, children)
Annual eye refractions
Under 22 –
once every twelve (12) months
Over 22 – once every twenty-four (24) months
Nothing.
Not covered:
Eyeglasses or contact lenses and, after age 22,
examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges. 20
20 Page 21 22
2002 UPMC
Health Plan 21 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.
$25 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, 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.
Nothing
Orthopedic and prosthetic devices-Continued on next page 21
21 Page 22 23
2002 UPMC Health Plan 22 Section 5( a)
Orthopedic and prosthetic devices (Continued) You pay
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 provided less than 3 years after the last one we
covered
All charges.
Durable medical equipment (DME)
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 1-888-860-2273 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.
Not covered: Motorized wheel chairs
Repair, replacement
or duplication for health services except when necessitated due to a change in
the Member's medical condition.
All charges. 22
22 Page 23 24
2002 UPMC Health Plan 23 Section 5( a)
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 patient's family; Home healthcare primarily for
personal assistance that does not
include a medical component and is not
diagnostic, therapeutic, or rehabilitative.
All charges.
Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
Chiropractic Services
Limit of 25 visits per calendar year
No PCP
referral required
$10 per office visit
Not covered:
Acupuncture services
Naturopathic
services
Hypnotherapy
Biofeedback
All charges. 23
23 Page 24 25
2002 UPMC
Health Plan 24 Section 5( a)
Educational classes and programs
You pay
Coverage is limited to:
Diabetes self-management
$10 per office visit 24
24 Page 25 26
2002 UPMC Health Plan 25 Section 5( b)
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.).
I M
P O
R T
A N
T
Benefit Description You pay …
Surgical procedures
A
comprehensive range of services, such as: Operative procedures
Treatment of fractures, including casting Normal pre-and post-operative care
by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures 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.
$10 per office visit. Nothing for hospital visits.
Surgical procedures continued on next page. 25
25 Page 26 27
2002 UPMC Health Plan 26 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization
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
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
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 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.
Nothing.
Reconstructive surgery --continued on next page 26
26 Page 27 28
2002 UPMC Health Plan 27 Section 5( b)
Reconstructive surgery (continued) You pay
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
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.
Treatment of TMJ.
$10 per office visit
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. 27
27 Page 28 29
2002 UPMC Health Plan 28 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
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas National Transplant Program (NTP) – UPMC Health Plan utilizes
the top transplant centers in Western Pennsylvania. Should care not be
available in Western Pennsylvania, UPMC Health Plan will
arrange for
services out of the area.
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. 28
28 Page 29 30
2002 UPMC
Health Plan 29 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
Nothing. 29
29 Page
30 31
2002 UPMC Health Plan 30
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 Sections 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
Inpatient hospital continued on next page. 30
30 Page 31 32
2002 UPMC Health Plan 31 Section 5( c)
Inpatient hospital (continued) You pay
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
(Note: calendar year
deductible applies.)
Nothing
Not covered: Custodial care
Non-covered facilities, such
as nursing homes, schools Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
All charges.
Outpatient hospital or ambulatory surgical center
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. 31
31 Page
32 33
2002 UPMC Health Plan 32
Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
Extended care benefit: No dollar or day limit
The plan provides a comprehensive range of benefits with no dollar or day
limit when full-time skilled nursing care is necessary and
confinement in a
skilled nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan. You pay
nothing. All necessary services are
covered, including:
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 All charges.
Hospice care
Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the direction
of a Plan doctor who certifies that the patient is in the terminal
stages of
illness, with a life expectancy of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate and ordered and authorized by a Plan doctor. Nothing 32
32 Page 33 34
2002 UPMC Health Plan 33 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.
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
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies
because, if not treated promptly, they might become more serious; examples
include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what they all have in
common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
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 immediately to
the nearest hospital emergency room. Be sure to tell the emergency personnel
that you are a Plan member so they can notify the Plan –
Member Services
1-888-876-2756. You or a family member must notify the Plan within 48 hours
unless it was not reasonable to do so. It is your responsibility to ensure that
the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your admission, unless it was not reasonably
possible to notify the Plan within that time. If you are hospitalized in
non-Plan
facilities, and a Plan doctor believes care can be better provided
in a Plan hospital, you will be transferred when medically feasible with any
ambulance charges covered in full. Benefits are available for care from non-Plan
providers in 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-Par
providers must be approved by the Plan or Provided by the Plan providers.
Emergencies outside our service area:
Benefits are available for
any medically necessary health service that is immediately required because of
injury or unforeseen illness. If you need to be hospitalized, the Plan must be
notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the
Plan within that time (Member Services 1-888-876-2756). If a Plan doctor
believes care can be better provided in a Plan hospital, you would be
transferred when medically
feasible with any ambulance charges covered in
full. 33
33 Page
34 35
2002 UPMC Health Plan 34
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
$30 copayment per visit (waived if admitted).
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
$30 copayment per visit (waived if admitted).
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, including air ambulance.
See 5( c) for non-emergency service.
Nothing. 34
34 Page 35 36
2002UPMC Health Plan 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for similar benefits for other
illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We do not have a calendar year
deductible.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. 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 visit.
Mental health and substance abuse benefits -continued on next page 35
35 Page 36 37
2002UPMC Health Plan 36 Section 5( e)
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, half-way house,
residential treatment, 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 plan's 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
obtain a treatment plan and follow all of the following authorization processes:
Self-referral to network providers: Call 1-888-251-0083. Providers are also
listed in the UPMC Health Plan directory under Behavioral Health.
Outpatient
care – unlimited outpatient visits to Plan doctors, consultants or other
psychiatric personnel each calendar year; you pay $10 copay for each covered
visit.
Inpatient care – unlimited days of hospitalization each calendar year
for Hospital Services provided for Behavioral Health service Inpatient treatment
by a Hospital or Facility provider.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 36
36 Page
37 38
2002 UPMC Health Plan 37
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.
We have no calendar year deductible.
Certain medications may require
prior authorization with UPMC Health Plan doctors the first time they are
prescribed. Your physician will coordinate this process through your Plan for
you.
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 37
37
Page 38 39
2002
UPMC Health Plan 38 Section 5( f)
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 must fill the prescription at a plan pharmacy or by
mail for a maintenance medication.
We use a formulary. UPMC Health Plan doctors and pharmacists have
developed the First Choice Pharmacy Plan for commonly used medications. First
Choice is designed to identify equally effective – but
lower cost –
medications and to recommend them as "first-choice" medications to doctors and
their patients. By using First Choice medications, you and your doctor have
access to high quality and effective medications
that help manage
prescription drug costs and keep your copayments low.
If you require for the
first time a medication that is listed in the "Drug Categories" column, your
doctor will prescribe the "First Choice" medication (please refer to the
Pharmacy Program brochure in your UPMC
Health Plan enrollment packet). If a First Choice medication is not
successful in treating your condition or you have tried a First Choice drug
in the past and it did not work for you, your doctor must contact UPMC
Health Plan to arrange for coverage for a different medication.
If
you have any questions, please talk with your doctor, call UPMC Health Plan
Member Services at 1-888-876-2756, or visit our website at www. upmchealthplan.
com.
These are the dispensing limitations. Prescription drugs prescribed by
a Plan or referral doctor and obtained at a Plan participating pharmacy will be
dispensed for up to a 30-day supply or one commercially
prepared unit (i.
e., one inhaler, one vial insulin); or prescriptions obtained through the Plan
participating mail order pharmacy will be dispensed for up to a 90-day supply
for Plan approved medications. Medications will
be dispensed based upon FDA
guidelines.
$5 copayment per prescription unit or refill for generic drugs.
$15 copayment for brand name drugs when generic substitution is not
permissible.
The 90-day mail order program, through RX Partners, is for
maintenance medications that you take on a regular, long-term basis. You will
receive a 90-day supply of your medication for two copayments ($ 10
generic and $30 brand-name). These "maintenance drugs" may include
medications to reduce blood pressure or treat respiratory conditions, asthma,
diabetes, arthritis or high cholesterol. To verify if your
medications can
be dispensed through the mail order program, please contact RX Partners at
1-877-7UPMC-RX (1-877-787-6279). Some medications are prohibited from being sent
through the mail.
Refills using the Mail Order program – to avoid running out of your
prescription medication, re-order when you have a 10-to 14-day supply remaining.
For refills, you may re-order either by mail, by phone, or online.
Should
you request a refill too early, RX Partners will contact you to explain when
your refill will be mailed to you.
Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a corresponding brand name drug.
Generic drugs are less expensive than brand name drugs;
therefore, you may
reduce your out-of-pocket costs by choosing to use a generic drug.
When
you have to file a claim. Members who pay out of pocket for a prescription
will be reimbursed, simply by completing a prescription reimbursement form.
Members will be reimbursed 100% minus the
applicable copayment. Please contact Member Services at 1-888-876-2756 to
request a prescription reimbursement form. 38
38
Page 39 40
2002
UPMC Health Plan 39 Section 5( f)
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 or
through our mail order
program: Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except those listed
as Not covered.
Insulin Disposable needles and syringes for the
administration of covered
medications Drugs for sexual dysfunction (see
Prior authorization below)
Contraceptive drugs and devices
Prior
authorization for drugs treating sexual dysfunction will be coordinated by your
PCP.
Retail
Generic: $5 copayment
Brand-name: $15 copayment
Mail Order
Generic: $10 copayment
Brand-name: $30 copayment
Note: If there is no generic equivalent available, you will still have to pay
the
brand name copay.
Covered medications and supplies --continued on next page 39
39 Page 40 41
2002 UPMC Health Plan 40 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.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no generic available, your
physician may prescribe a
name brand drug from 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 1-888-876-2756.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
Medical
supplies such as dressings and antiseptics
Smoking cessation drugs
and medications (nicotine patches and nicotine gums)
Drugs available without a prescription or for which there is a
nonprescription equivalent available.
Food supplements and other
nutritional and over-the-counter electrolyte supplements except as required to
treat phenylketonuria
(PKU)
All charges. 40
40 Page 41 42
2002 UPMC
Health Plan 41 Section 5( g)
Section 5 (g). Special Features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Direct Access to Network Specialists Members may self-refer at anytime
to any network specialist for a $30 office visit copayment per visit. Prescribed
services ordered by the treating specialist (i. e. x-rays, labs) are covered at
100%.
Direct Access for Women to their OB/ GYN Women may choose a
network OB/ GYN in addition to their PCP. Women may self-refer for all
female-related services directly to their selected OB/ GYN – a referral from the
PCP is never needed. Should female members want to
change their selected OB/
GYN, simply call Member Services at 1-888-876-2756 and the change will be made
over the phone.
Direct Access to Network Chiropractors Members may go directly to any
network chiropractor without a referral from the PCP. Visit requires a $10
copayment. There is a limit of 24 visits per calendar year.
Travel benefit/ services overseas UPMC Health Plan provides an
additional service for emergencies outside the Service area called Assist
America. Any time you need care when traveling more than 100 miles from home,
Assist America can help to direct you to the
closest, most appropriate
medical facility. Assist America will then notify the Plan, fulfilling your
obligation to do so within 48 hours. This service is
available 24 hours per
day, 365 days per year for urgent or emergency care while outside the Service
Area. Please call Assist America in the USA at 1-
800-872-1414 and outside
the USA at 301-656-4152 41
41 Page 42 43
2002 UPMC
Health Plan 42 Section 5( j)
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 have no calendar year
deductible.
We cover hospitalization for dental procedures only when a
nondental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient; we do not cover the dental procedure unless
it is
described below.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
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. 42
42 Page 43 44
2002 UPMC Health Plan 43 Section 5( j)
Section 5 (j). 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.
Dental Discount Program – All new and current members will be
automatically enrolled in a comprehensive Dental Discount Program through Doral
Dental USA. Members will receive preventive services (which include cleanings,
exams and x-rays) at NO CHARGE. In addition, other dental services
(fillings, root canals, crowns and even orthodontics) are provided at fees that
are 30% to 45% lower than usual and customary charges.
Simply choose a participating Doral dentist and present your UPMC Health Plan
identification card at the time of service to receive your dental benefits
(there is no additional enrollment form or ID card needed). A complete
participating dentist list and description of your benefits is included in
your UPMC Health Plan enrollment packet.
Wellness Programs – UPMC
Health Plan, together with UPMC Health System, offers a variety of health
promotion and wellness classes (most free of charge) for conditions such as
diabetes, childbirth, cancer support groups and
smoking cessation. The
classes are taught by trained professionals and are held at convenient locations
throughout the area. Descriptions of classes can be found in the Healthy Living
Rewards brochure. To get information and
details on registration, call
1-800-533-UPMC (8762).
One-to-One Program – The One-to-One Program
was designed to recognize and address the unique health care needs of women.
Offered in partnership with Magee-Womens Hospital, this innovative program
provides
comprehensive, prevention-focused health care services, including
gynecology, gynecologic oncology, assisted reproduction, a neo-natal intensive
care unit as well as a comprehensive maternity program for all pregnant women
enrolled as members in UPMC Health Plan. For more information, or to
participate in the One-to-One Program, please contact UPMC Health Plan Member
Services at 1-888-876-2756.
Healthy Living Rewards – The Healthy Living Rewards program offers
value – added savings to UPMC Health Plan members. As a member, you are eligible
to receive discounts on products and services that promote healthy
lifestyles, such as fitness clubs, sporting goods stores and health food
stores. Show your UPMC Health Plan identification card at the time of purchase
to receive your savings. The discounts apply to services where insurance
coverage may not exist. A listing of participating vendors can be obtained
by calling UPMC Health Plan Member Services at 1-888-876-2756. 43
43 Page 44 45
2002 UPMC Health Plan 44 Section 6
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; or
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. 44
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45 46
2002 UPMC Health Plan 45
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 and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will file on the UB-92 form.
For claims
questions and assistance, call us at 1-888-876-2756.
When you must file a
claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim
form that includes the information shown below. Bills and receipts should be
itemized and show:
Covered member's name and ID number;
Name and
address of 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:
UPMC Health Plan Claims Department
P. O. Box 2999
Pittsburgh, PA
15230-2999
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. 45
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46 47
2002 UPMC Health Plan 46
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
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: UPMC Health Plan, Member
Services, One Chatham Center, 112 Washington Place, Pittsburgh, PA 15219; 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 request— go 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, 1900 E Street, NW, Washington, DC 20415-3630. 46
46 Page 47 48
2002 UPMC Health Plan 47 Section 8
The Disputed Claims process (Continued)
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 include 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 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 or from the year in
which you were denied precertification or prior approval. 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 1-888-876-2756 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. 47
47
Page 48 49
2002
UPMC Health Plan 48 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. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if
you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare + Choice is the term used to describe
the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed
care plan
you have.
The Original Medicare Plan (Original Medicare) is
available everywhere in the United States. It is the way everyone used to get
Medicare benefits and is the way most people
get their Medicare Part A and
Part B benefits now. You may go to any doctor, specialist, or hospital that
accepts Medicare. The Original Medicare Plan pays its share and you pay
your
share. Some things are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, 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.
We will not waive any
of our copayments.
(Primary payer chart begins on next page.)
The Original Medicare Plan (Part A or Part B) 48
48 Page 49 50
2002 UPMC Health Plan 49 Section 9
The following chart illustrates whether the Original Medicare Plan
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) Areanactiveemployee with
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability), !
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, or !
c) Are a former spouse of an annuitant,
or !
d) Are a former spouse of an active employee !
If your Plan physician does not participate in Medicare, you will have to
file a claim with Medicare. 49
49 Page 50 51
2002 UPMC Health Plan 50 Section 9
Claims process when
you have the Original Medicare Plan --You probably will never have to file a
claim form when you have both our Plan and the Original Medicare Plan.
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 1-888-876-2756 or
visit us online at www. upmchealthplan. com.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --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 provide all the benefits that Original
Medicare covers. 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 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. If you enroll in a Medicare managed care plan,
tell us. We will need to know whether you are in the Original
Medicare Plan
or in a Medicare managed care plan so we can correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in 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's service area.
If you do not have one or both
Parts of Medicare, you can still be covered under the FEHB Program. We will not
require you to enroll in Medicare Part B and, if you can't
get premium-free
Part A, we will not ask you to enroll in it.
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 illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
If you do not enroll in Medicare Part A or Part B 50
50 Page 51 52
2002 UPMC Health Plan 51 Section 9
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 care. 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 for injuries medical or hospital 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. 51
51 Page
52 53
2002 UPMC Health Plan 52
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.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Custodial care, rest cures, domiciliary or
convalescent care is not covered.
Experimental or Investigational services are any treatment, service,
procedure, facility, equipment, drug, device or supply (intervention) which is
not determined by the Plan or
its designated agent to be a proven treatment.
Group health coverage The Group, including the Employers, who are
party to the Group Agreement with UPMC Health Plan.
Medical necessity Services or supplier provided by a Plan Hospital,
Facility/ Other Provider, or Professional Provider that UPMC Health Plan
determines are:
a. Appropriate for the symptoms and diagnosis or treatment
of the Member's condition; and
b. Provided in accordance with standards of
good medical practice and consistent in type, frequency and duration of
treatment with scientifically based guidelines of
medical, research, or
health care coverage organizations or governmental agencies that are accepted by
UPMC Health Plan; and
c. Not provided only as a convenience.
Plan allowance Plan allowance is the amount we use to determine our
payment to our Plan providers for covered services. Plan providers accept the
plan allowance as payment in full.
Us/ We Us and we refer to UPMC Health Plan.
You You refers
to the enrollee and each covered family member.
Experimental or investigational services 52
52 Page 53 54
2002UPMC Health Plan 53 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 about enrolling in the retirement office 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 up to 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. 53
53 Page
54 55
2002UPMC Health Plan 54
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you joined this Plan premiums start during
Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell you the
effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following records are confidential
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 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.
Temporary continuation of coverage (TCC) If you leave Federal service,
or if you lose coverage because you no longer qualify as a
family member,
you may be eligible for Temporary Continuation of Coverage (TCC). For example,
you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child
and you turn 22 or marry, etc.
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 54
54
Page 55 56
2002UPMC Health Plan 55 Section 11
and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure. It
explains what you have to do to enroll.
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 The Health Insurance Portability Group
Health Plan Coverage and Accountability Act of 1996 (HIPAA) is a Federal law
that offers limited Federal
protections for health coverage availability and
continuity to people who lose employer group coverage. If you leave the FEHB
Program, we will give you a Certificate of Group
Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this certificate
when getting health insurance or other health care coverage. Your
new plan
must reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as you
enroll within
63 days of losing coverage under this Plan. If you have been
enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request
a certificate from those plans.
For
more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the FEHB web site
(www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked question. These highlight
HIPAA rules, such as the requirement that Federal employees must
exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies you
can
contact for more information. 55
55 Page 56 57
2002 UPMC Health Plan 56 Long Term Care Insurance
Long
Term Care Insurance Is Coming Later in 2002!
The Office of Personnel
Management (OPM) will sponsor a high-quality long term care insurance program
effective in October 2002. As part of its educational effort, OPM asks you to
consider these questions:
It's insurance to help pay for long term care
services you may need if you can't take care of yourself because of an extended
illness or injury, or an age-related disease
such as Alzheimer's. LTC
insurance can provide broad, flexible benefits for nursing home care, care in an
assisted living facility, care in your home, adult day care, hospice care,
and more. LTC insurance can supplement care provided by family members, reducing
the
burden you place on them.
Welcome to the club! 76% of Americans
believe they will never need long term care, but the facts are that
about
half of them will. And it's not just the old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a
serious
accident, a stroke, or developing multiple sclerosis, etc. We hope you will
never need long term care, but everyone should have a plan just in
case.
Many people now consider long term care insurance to be vital to their financial
and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's
before inflation! Long term care can easily exhaust your savings.
Long term care insurance can
protect your savings.
Not FEHB. Look
at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB
brochure. Health plans don't cover custodial care or a stay in an assisted
living facility or a continuing need for a home health aide to help you get
in and out of bed and with other activities of daily living. Limited stays in
skilled nursing
facilities can be covered in some circumstances. Medicare
only covers skilled nursing home care (the highest level of nursing care)
after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for
those who meet their state's poverty guidelines, but has restrictions on covered
services and where they can be received. Long term
care insurance can
provide choices of care and preserve your independence.
Employees will
get more information from their agencies during the LTC open enrollment period
in the late summer/ early fall of 2002.
Retirees will receive information at
home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can
learn more about the program on our web site at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I'm healthy. I won't need long
term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage?
How can I find out more about the program NOW? 56
56 Page 57 58
2002 UPMC Health Plan 57 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury
42 Allergy tests 17
Allogenetic (donor) bone marrow transplant 28 Ambulance
32
Anesthesia 29 Autologous bone marrow transplant 28
Biopsies 25
Blood and blood plasma 31
Breast cancer screening 15 Casts 31
Changes for 2002 7 Chemotherapy 18
Childbirth 16 Chiropractic 23
Cholesterol tests 14 Claims 45
Coinsurance 11 Colorectal cancer
screening 14
Congenital anomalies 26 Contraceptive devices and drugs 39
Coordination of benefits 48 Covered charges 52
Covered providers 8
Crutches 22
Deductible 11 Definitions 52
Dental care 42
Diagnostic services 13
Disputed claims review 46 Donor expenses
(transplants) 28
Dressings 31 Durable medical equipment (DME) 22
Educational classes and programs 24 Effective date of enrollment 54
Emergency 33 Experimental or investigational 52
Eyeglasses 20 Family
planning 16
Fecal occult blood test 14 General Exclusions 44
Hearing
services 20 Home health services 23
Hospice care 32 Home nursing care 23
Hospital 30 Immunizations 15
Infertility 17 Inhospital physician
care 13
Inpatient Hospital Benefits 30 Insulin 39
Laboratory and
pathological services 14
Machine diagnostic tests 14 Magnetic
Resonance Imagings
(MRIs) 14 Mail Order Prescription Drugs 39
Mammograms
15 Maternity Benefits 16
Medicaid 51 Medically necessary 52
Medicare 48
Mental Conditions/ Substance
Abuse Benefits 35 Neurological testing
14
Newborn care 16 Non-FEHB Benefits 43
Nursery charges 16
Obstetrical care 16
Occupational therapy 19 Ocular injury 20
Office visits 13 Oral and maxillofacial surgery 27
Orthopedic devices 21
Out-of-pocket expenses 11
Outpatient facility care 31 Oxygen 22
Pap test 14 Physical examination 15
Physical therapy 19 Physician
13
Preventive care, adult 14 Preventive care, children 15
Prescription
drugs 37 Preventive services 14
Prostate cancer screening 14 Prosthetic
devices 21
Psychologist 35 Psychotherapy 35
Radiation therapy 18
Renal dialysis 18
Room and board 30 Skilled nursing facility care 32
Smoking cessation 24 Speech therapy 19
Splints 31 Sterilization
procedures 16
Subrogation 51 Substance abuse 35
Surgery 25 Anesthesia 29
Oral 27 Outpatient 25
Reconstructive 26 Syringes 39
Temporary
continuation of coverage 54
Transplants 28 Treatment therapies 18
Vision services 20 Well child care 15
Wheelchairs 22
Workers' compensation 50
X-rays 14 57
57
Page 58 59
2002
UPMC Health Plan 58 Summary
Summary of benefits for the UPMC
Health Plan – 2002
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; $10 specialist (referred)/$ 30
self-referred 13
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing.
Nothing.
30
31
Emergency benefits:
In-area..............................................................................................
Out-of-area
......................................................................................
$30 copay (waived if admitted)
$30 copay (waived if admitted)
33
33
Mental health and substance abuse
treatment...................................... Regular cost sharing. 35
Prescription drugs
.................................................................................
Retail: $5 generic/$ 15 brand-name
Mail Order: $10 generic/$ 30 brand-name
37
Dental Care
.......................................................................................
Dental Discount Program 43
Vision Care
.......................................................................................
Nothing for routine eye exam. Once every 24 months for over age 22/ Once every
12 months
for under age 22.
20
Special features:
1. Direct Access to Network Specialists
2. Direct
Access to Selected OB/ GYN for Women
3. Assist America (Out-of-Area Travel
Assistance)
41 58
58 Page
59 60
2002 UPMC Health Plan 59
Summary 59
59 Page
60
2002 UPMC Health Plan
2002 Rate Information
for UPMC Health Plan
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, 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 who are not career postal
employees. 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
High Option
Self Only 8W1 $70.14 $23.38 $151.97 $50.66 $83.00 $10.52
High Option
Self and Family 8W2 $ 178. 92 $59.64 $387.66 $129.22 $211.
72 $26.84 60