Bci.vp:CorelVentura 7.0

A Health Maintenance Organization Serving: the Chicago, Rockford, Springfield and Downstate Illinois areas Service Area: Enrollment in this plan is limited; see page 9 for requirements.

Enrollment Code: 3B1 Self Only

3B2 Self and Family

Visit the OPM website at http:// www. opm. gov/ insure BCI HMO, Inc.

RI 73- 152

1999

BCI HMO, Inc.

BCI HMO, Inc., 300 E. Randolph, Chicago, Illinois 60601 has entered into a contract (CS 2008) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called BCI HMO, Inc. or the Plan.

This brochure is the official statement of benefits on which yu can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page 23 of this brochure.

Table of Contents Page Inspector General Advisory on Fraud ..................................................................................................... 3 General Information.................................................................................................................................. 3- 6

Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spousecoverage; Temporary continuation of coverage; and Conversion to individual coverage); Certificate of Creditable Coverage

Facts about this Plan.................................................................................................................................. 7- 9

Information you have a right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Experimental/ investigational determinations; Other considerations; The Plans service areas

General Limitations................................................................................................................................... 10- 11

Important notice; Circumstances beyond Plan control; Other sources of benefits

General Exclusions..................................................................................................................................... 11 Benefits........................................................................................................................................................ 12- 18

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits, Mental Conditions/ SubstanceAbuse Benefits; Prescription Drug Benefits

Other Benefits............................................................................................................................................. 19

Dental care; Vision care

Non- FEHB Benefits ................................................................................................................................... 20 How to Obtain Benefits ............................................................................................................................. 21- 22 How BCI HMO, Inc. Changes January 1999.......................................................................................... 23 Summary of Benefits.................................................................................................................................. 24

Inspector General Advisory: Stop Health Care Fraud!

Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD. This could result in CRIMINAL PENALTIES. Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital or pharmacy, charged your plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:

Call the provider and ask for an explanation - sometimes the problem is a simple error.

If the provider does not resolve the matter, or if you remain concerned, call your plan at 1- 800/ 892- 2803 and explain the situation.

If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300

The Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, N. W., Room 6400 Washington, D. C. 20415 The inappropriate use of membership identification cards, e. g., to obtain services for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.

General Information Confidentiality Medical and other information provided to the Plan, including claim files, is kept confidential

and will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan, coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions;

3) by OPM to review a disputed claim orperform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.

If you are a new member Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you

receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number 912/ 757- 3030 to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.

If you are a new member of this Plan, benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 15. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 4.

FEHB plans may not refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.

General Information continued

If you are hospitalized If you change plans or options, benefits under your prior plan or option cease on the effective

date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.

Your responsibility It is your responsibility to be informed about your health benefits. Your employing office or

retirement system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.

Things to keep in mind

The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if you changed plans or plan options, see If you are a new member above. In both cases, however, the Plans new rates are effective the first day of the enrollees first full pay period that begins on or after January 1 (January 1 for all annuitants).

Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.

The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.

An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits.

You will not be informed by your employing office (or your retirement system) or your Plan when a family member loses eligibility.

You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.

An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive benefits under any other FEHB Program.

Report additions and deletions (including divorces) of covered family members to the Plan promptly.

If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.

General Information continued

Things to keep in mind (continued) Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may

enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.

You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.

Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).

Coverage after enrollment ends

When an employees enrollment terminates because of separation from Federal service or when a family member is no longer eligible for coverage under an employee or annuitant enrollment, and the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free 31- day extension of coverage. The employee or family member may also be eligible for one of the following:

Former spouse coverage When a Federal employee or annuitant divorces, the former spouse may be eligible to elect

coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employees employing office (personnel office) or retirees retirement system to get more facts about electing coverage.

Temporary continuation of coverage (TCC)

If you are an employee whose enrollment is terminated because you separate from service, you may be eligible to temporarily continue your health benefits coverage under the FEHB Program in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you would be eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.

Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another free 31- day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.

Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31- day extension of coverage when they may convert to nongroup coverage.

NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.

General Information continued

Notification and election requirements

Separating employees 61 days after an employees enrollment terminates because of separation from service, his or her employing office must notify the employee of the opportunity to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.

Children You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.

Former spouses You or your former spouse must notify the employing office or retirement system or the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.

The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.

Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60- day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.

Conversion to individual coverage

When none of the above choices are available or chosen when coverage as an employee or family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.

Certificate of Creditable Coverage

Under Federal law, if you are no longer covered by this Plan, you should automatically receive a Certificate of Group Health Plan Coverage from the Plan. This certificate, along with any certificates you receive from other FEHB plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non- FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.

Facts about this Plan

This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services.

Your decision to join an HMO should be based on your preference for the plan's benefits and delivery system, not because a particular provider is in the plan's network. You cannot change plans because a provider leaves the HMO.

Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits, physicals, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.

Information you have a right to know All carriers in the FEHB Program must provide certain information to you. If you did not receive

information about this Plan, you can obtain it by calling the Carrier at 800/ 892- 2803, or you may write the Carrier at Bue Cross Blue Shield of Illinois, P. O. Box 1364, Chicago, Illinois 60690- 1364.

Information that must be available to you includes: Disenrollment rates for 1997; Compliance with State and Federal licensing or certification requirements and the dates met. Accreditations by recognized accrediting agencies and the dates received; Carriers type of corporate form and years in existence; Whether the carrier meets State, Federal and accreditation requirement for fiscal solvency, confidentiality and transfer of medical records.

Who provides care to Plan members? BCI HMO, Inc. is a mixed- model health plan offering both the group practice and individual

practice (IPA) modes of delivery. BCI HMO, Inc. physician groups are conveniently located throughout the Chicago metropolitan, Northwest Indiana and Downstate Illinois areas. The IPA model offers doctors practicing out of their own offices. It may be necessary to travel to another location to receive ancillary services. The group model offers doctors practicing out of one location, with the capability of performing the more common ancillary services on- site. Each family member may select their own Medical Group or IPA; and each family member must select their own individual primary care doctor. Subscribers can change Medical Groups by contacting Member Services at 1- 800/ 892- 2803. Hospital care will be provided at facilities your primary care doctor deems appropriate.

Role of a primary care doctor The first and most important decision each member must make is the selection of a primary care

doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Medical Group before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when there has been a referral by the members primary care doctor.

In addition to choosing a Primary Care Physician, female members have the option of selecting a Womans Principal Health Care Provider, a doctor specializing in obstetrics and gynecology. The female member may choose an obstetrician/ gynecologist who is in her Primary Care Physicians Medical Group or from another medical group within the Plans network. As a Primary Care Physician, the obstetrician/ gynecologist can provide OB/ GYN services as well as treatment for conditions not related to OB/ GYN. The OB/ GYN has the option to refer the member back to her PCP for non- related OB/ GYN services. A woman may see her Plan gynecologist for her annual routine examination without referral.

Choosing your doctor The Plans provider directory lists primary care doctors (generally family practitioners,

pediatricians, and internists) with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at 1- 800/ 892- 2803. You can also find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Facts about this Plan continued

Choosing your doctor (continued) Whether you are already a Plan member or are considering enrolling in this Plan, you should

review the Plans provider directory. If you are interested in receiving care from a specific provider, you should call the provider to verify his/ her continued participation in the Plan. If you enroll, you will be asked to let the Plan know which Primary Care Doctor( s) youve selected for you and each member of your family by sending a selection form to the Plan.

In the event a member is receiving services from a doctor who terminates a participation agreement, the Plan will provide payment for covered services until the Plan can make reasonable and medically appropriate provisions for the assumption of such services by a participating doctor.

Referrals for specialty care Except in a medical emergency, or when a primary care doctor has designated another doctor to

see patients when he or she is unavailable, you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if specialists or consultants are required beyond those participating in the Plan, the primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow- up care must be provided or arranged by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If additional services or visits are suggested by the consultant, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance. If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you for you to be seen by another participating doctor.

For new members If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you prior to your joining the Plan is now your Plan primary care doctor, you need only call to explain that you now belong to this Plan and ask that a referral form be sent to the specialist for your next appointment.

If you are selecting a new primary care doctor, you must schedule an appointment so the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.

Hospital care If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.

Out- of- pocket maximum Copayments are required for a few benefits. However, copayments will not be required for the

remainder of the calendar year after your out- of- pocket expenses for services provided or arranged by the Plan reaches $1,969.76 per Self Only enrollment or $4,968.86 per Self and Family enrollment. This copayment maximum does not include costs of prescription drugs.

You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out- of- pocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.

Deductible carryover If you changed to this Plan during open season from a plan with a deductible and the effective date

of the change was after January 1, any expenses that would have applied to that plans deductible will be covered by your old plan if they are for care you received in January before the effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective January 1.

Submit claims promptly When you are required to submit a claim to this Plan for covered expenses, submit your claim

promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Facts about this Plan continued

Experimental/ Investigational determinations

A drug, device or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U. S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished.

Other considerations Plan providers will follow generally accepted medical practice in prescribing any course of

treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.

The Plans Service Areas The service area for this Plan, where Plan providers and facilities are located, is described below.

You must live in the service area to enroll in the Plan. Benefits for care outside the service area are limited to emergency services, as described on page 15.

If you or a covered family member move outside the Enrollment Area, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.

Service Area: Services from Plan providers are available only in the following counties:

The Illinois counties of Boone, Cass, Christian, Cook, DeKalb, DuPage, Franklin, Hamilton, Jackson, JoDaviess, Kane, Kankakee, Lake, Lee, Logan, Macoupin, Mason, McHenry, Menard, Montgomery, Morgan, Ogle, Perry, Randolph, Saline, Sangamon, Stephenson, White, Whiteside, Will, Williamson and Winnebago; and the Indiana county of Lake.

General Limitations Important notice Although a specific service may be listed as a benefit, it will be covered for you only if, in the

judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.

Circumstances beyond Plan control

In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant number of Plan providers, complete or partial destruction of facilities, or other circumstances beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plan will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel.

Other sources of benefits This section applies when you or your family members are entitled to benefits from a source other

than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.

Medicare If you or a covered family member is enrolled in this Plan and Medicare Part A, and/ or Part B, the Plan will coordinate benefits according to Medicares determination of or Parts A and B of Medicare, benefits will be coordinated with Medicare according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, unless you use Plan providers. You must tell your Plan that you or your family memeber is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.

Group health insurance and automobile insurance

This coordination of benefits (double coverage) provision applies when a person covered by this Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the payment of medical and hospital costs under no- fault or other automobile insurance that pays benefits without regard to fault. Information about the other coverage must be disclosed to this Plan.

When there is double coverage for covered benefits, other than emergency services from non- Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary plan.

One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full, or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners. When benefits are payable under automobile insurance, including no- fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

CHAMPUS If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

Medicaid If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. 10

General Limitations continued

Workers Compensation The Plan will not pay for services required as the result of occupational disease or injury for which

any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers compensation (under section 8103 of title 5, U. S. C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers compensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP (or the agency).

DVA facilities, DoD facilities, and Indian Health Service

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from the Plan for certain services and supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.

Other Government agencies The Plan will not provide benefits for services and supplies paid for directly or indirectly by any

other local, State, or Federal Government agency.

Liability insurance and third party actions

If a covered person is sick or injured as a result of the act or omission of another person or party, the Plan requires that it be reimbursed for the benefits provided in an amount not to exceed the amount of the recovery, or that it be subrogated to the persons rights to the extent of the benefits received under this Plan, including the right to bring suit in the persons name. If you need more information about subrogation, the Plan will provide you with its subrogation procedures.

General Exclusions

All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your illness or condition. The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see

Emergency Benefits)

Expenses incurred while not covered by this Plan

Services furnished or billed by a provider or facility barred from the FEHB Program

Services not required according to accepted standards of medical, dental, or psychiatric practice

Procedures, treatments, drugs or devices that are experimental or investigational

Procedures, services and supplies related to sex transformations; and

Procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Medical and Surgical Benefits What is covered A comprehensive range of preventive, diagnostic and treatment services is provided by Plan

doctors and other Plan providers. This includes all necessary office visits; you pay a $10 office visit copay, but no additional copay for laboratory tests and X- rays; $10 per visit after regular office hours. Within the Service Area, house calls will be provided if in the judgement of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctors house call or for home visits by nurses and health aides.

The following services are included:

Preventive care, including well- baby care and periodic check- ups

Mammograms are covered as follows: for women age 35 through age 39, one mammogram during these five years; for women age 40 through 49, one mammogram every one or two years; for women age 50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness.

Routine immunizations and boosters

Consultations by specialists

Diagnostic procedures, including laboratory tests and X- rays

Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and postnatal care by a Plan doctor. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment.

Voluntary sterilization and family planning services

Diagnosis and treatment of infertility is covered; you pay a $10 office visit copay. The following types of artificial insemination are covered: intravaginal insemination (IVI); intracervical insemination (ICI); and intrauterine insemination (IUI) as determined by the Center for Human Reproduction; you pay a $10 office visit copay; cost of donor sperm is not covered. Fertility drugs are covered under the Prescription Drug Benefit. Other assisted reproductive technology (ART) procedures that enable a woman with otherwise untreatable infertility to become pregnant through other artificial conception procedures such as in vitro fertilization and embryo transfer are covered.

Diagnosis and treatment of diseases of the eye

Allergy testing and treatment, including test and treatment materials (such as allergy serum)

The insertion of internal prosthetic devices, such as pacemakers and artificial joints, including the cost of the device.

Cornea, heart, kidney single/ double lung, heart/ lung, pancreas, and liver transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors, and breast cancer, multiple myeloma and epithelial ovarian cancer upon approval by the Plans Medical Director. Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan.

Women who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure, as determined by the Primary Care Physician.

Dialysis

Chiropractic services, upon approval of the Plans Medical Group

Chemotherapy, radiation therapy, and inhalation therapy

Surgical treatment of morbid obesity

Orthopedic devices, such as braces; foot orthotics

Prosthetic devices, such as artificial limbs and lenses following cataract removal 12

Medical and Surgical Benefits continued

What is covered

(continued) Durable medical equipment, such as wheelchairs, hospital beds and ventilators. Benefits will be provided for the purchase of durable medical equipment (in lieu of renting equipment) upon

approval by the Plan.

Home health services of nurses and health aides, including intravenous fluids and medications when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers.

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures, surgical removal of bony impacted teeth, and excision of tumors and cysts. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance and if the condition can reasonably be expected to be corrected by such surgery.

Short- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected within two months. You pay nothing per outpatient sessions. Speech therapy is not limited to certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided in a Plan approved facility for up to two months; you pay nothing.

What is not covered Physical examinations that are not necessary for medical reasons, such as those required for

obtaining or continuing employment or insurance, attending camp, or travel

Reversal of voluntary, surgically- induced sterility

Surgery primarily for cosmetic purposes

Transplants not listed as covered

Hearing aids

Long- term rehabilitative therapy

Homemaker services 13

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Hospital/ Extended Care Benefits What is covered

Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing. All necessary services are covered, including:

Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care

Specialized care units, such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay nothing. All necessary services are covered, including:

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.

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care, and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor.

Limited benefits Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a

need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.

Acute inpatient detoxification Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis,

treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 17 for nonmedical substance abuse benefits.

What is not Personal comfort items, such as telephone and television

covered Custodial care, rest cures, domiciliary or convalescent care

Private duty nursing in the home 14

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Emergency Benefits What is a medical emergency?

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

Emergencies within the 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 to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

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

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

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

Plan pays... Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers.

You pay... $50 per hospital emergency room or urgent care center visit for emergency care services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency care copay is waived.

Emergencies outside the 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 possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

Plan pays... Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

You pay... Nothing for an emergency room or urgent care center visit for emergency services that are covered benefits of this Plan.

What is covered Emergency care at a doctors office or an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors services

Ambulance service approved by the Plan

What is not Elective care or nonemergency care

covered Emergency care provided outside the Service Area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full- term delivery of a baby outside the Service Area

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Emergency Benefits Filing claims for non- Plan providers

With your authorization, the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 21.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Mental Conditions/ Substance Abuse Benefits Mental Conditions

What is covered To the extent shown below, the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions, including the treatment of mental illness or disorders:

Diagnostic evaluation

Psychological testing

Psychiatric treatment (including individual and group therapy)

Hospitalization (including inpatient professional services)

Outpatient care Up to 20 outpatient visits to Plan doctors, consultants, or other psychiatric personnel each calendar

year; every two visits of outpatient group treatment is counted as one visit to the 20 outpatient visit limit; you pay the lesser of 50% of charges or a $20 copay for each covered visit all charges thereafter.

Inpatient care Up to 30 days of hospitalization each calendar year. Every two days of partial hospital psychiatric

treatment (day treatment) is counted as one day toward the available thirty inpatient day limit; you pay nothing for the first 30 days all charges thereafter.

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not

subject to significant improvement through relatively short- term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate

Psychological testing when not medically necessary to determine the appropriate treatment of a short- term psychiatric condition

Substance Abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the

medical, non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition, and, to the extent shown below, the services necessary for diagnosis and treatment.

Outpatient care Up to 20 outpatient visits to Plan doctors, consultants, or other psychiatric personnel each calendar

Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation (intermediate care) program in

an alcohol detoxification or rehabilitation center approved by the Plan. Every two days of partial hospitalization (day treatment) is counted as one day toward the 30- day inpatient limit; you pay

nothing during the benefit period all charges thereafter.

What is not covered Treatment that is not authorized by the Plan.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be

dispensed for up to a 34- day supply or 100 unit supply, whichever is less, or one commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin). In lieu of name brand drugs, generic drugs will be dispensed when substitution is permissible. You pay a $5 copay per generic or brand name drug per prescription unit or refill. You pay a $50 copay per prescription or refill for self- injectable drugs (other than insulin and infertility drugs). Nonformulary drugs will be covered when prescribed by a Plan doctor.

If purchased at a non- participating pharmacy you pay appropriate copay as indicated above plus 25% of the amount that would have been paid at a participating pharmacy, plus any difference between the participating and non- participating pharmacys charge.

Experimental or investigational definition

An FDA- approved drug, device or biological product (for use other than its intended purposes and labeled indications), or medical treatment or procedure is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol( s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment procedure.

FDA- approved drugs, devices, or biological products used for their intended purposes and labeled indications and those that have received FDA approval subject to post marketing approval clinical trials, and devices classified by the FDA as Category B Non- experimental/ Investigational Devices are not considered experimental or investigational.

Covered medications Drugs for which a prescription is required by law

and accessories Insulin

include: Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedicts solution or equivalent and acetone test tablets

Medical and surgical supplies, dressings, cast and splints. You pay nothing.

Disposable needles and syringes needed for injecting covered prescribed medication

Intravenous fluids and medications for home use

Smoking cessation drugs and medication, including nicotine patches

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent

available

Vitamins and nutritional substances that can be purchased without a prescription

Contraceptive drugs (except by mail order) and devices

Drugs for cosmetic purposes

Drugs to enhance athletic performance

Implanted time- release medications, such as Norplant.

Mail order drugs Benefits are provided for drugs purchased from a participating mail order prescription drug provider, including maintenance drugs, certain contraceptive drugs and nicotine patches. You pay a $5 copay per generic or brand name drug per prescription unit or refill; a $10 copay per prescription unit or refill for covered contraceptive drugs and nicotine patches. One copayment covers up to a 90- day supply of medication.

Contact your Medical Group or the Plan at 1- 800/ 892- 2803 for mail order forms and complete program details.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Other Benefits Dental care

Accidental injury benefit Restorative services and supplies necessary to promptly repair (but not replace) sound natural

teeth are covered. The need for these services must result from an accidental injury occurring while the member is covered under the FEHB Program. You pay nothing.

Vision care What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of

the eye, annual eye refractions (to include a written lens prescription for eyeglasses) may be obtained from Plan providers. You pay nothing. A 20% discount on lenses and frames, or contact lenses is provided when BCI Plan providers are used. Members must call 1- 800- 321- EYES to receive this benefit.

What is not Eye exercises

covered Lenses and frames, or contact lenses (including fitting), except provided above by Plan providers.

Non- FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members who are members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium; any charges for these services do not count toward any FEHB deductibles, out- of- pocket maximum, copay charges, etc. These benefits are not subject to the FEHB disputed claims procedures.

Away From Home Care Using the nationwide network of Blue Cross HMOs, Away From Home Care provides you and your dependents health care coverage when traveling throughout the United States (in participating service areas). For more details, call Member Services at 800/ 892- 2803.

Guest Membership HMO Members who are away from home for 90 days or more are eligible to become a Guest Member at an affiliated Blue Cross HMO near their travel destination. This is an added benefit value for anyone on extended out- of- town business, attending school out- of- state, as well as families living apart. For additional information, call Member Services at 800/ 892- 2803.

Urgent Care This program that will help ease the pain of an unexpected injury or illness while members are travelling out- of- state. Access to urgent care is possible via a 24 hour, toll free service number 800- 4HMO USA.

Benefits on this page are not part of the FEHB contract

How to Obtain Benefits Questions If you have a question concerning Plan benefits or how to arrange for care, contact the Plans

Membership Services Office at 1- 800/ 892- 2803, TDD 312/ 938- 7010; or you may write to the Plan at BCI HMO, Inc., 300 E. Randolph Street, Chicago, Illinois 60601.

Disputed claims Plan reconsideration If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing, and

within six months of the date of denial, to reconsider its denial before you request a review by OPM. OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan should state why, based on specific benefits provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.

Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.

OPM Review If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plans actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plans letter affirming its initial denial.

You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.

This right is available only to you or the executor of a deceased claimants estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review.

Your written request for an OPM review should state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.

Your request must include the following information or it will be returned by OPM:

A copy of your letter to the Plan requesting reconsideration;

A copy of the Plans reconsideration decision (If the Plan failed to respond, provide instead (a) the date of your request to the Plan, or (b) the dates the Plan requested and you provided additional information to the Plan);

Copies of documents that support your claim (such as doctors letters, operative reports, bills, medical records, Explanation of Benefit forms, etc.); and

Your daytime phone number. 21

How to Obtain Benefits (continued)

OPM Review Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy Act.

Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division II P. O. Box 436, Washington, DC 20044.

You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plans decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plans benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Plans denial of the benefit. The recovery in such a suit is limited to the amount of benefits indispute.

Privacy Act Statement If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.

How BCI HMO, Inc. Changes January 1999

Do not rely on this page; it is not an official statement of benefits.

Program- Wide Changes Several changes have been made to comply with the Presidents mandate to implement the

recommendations of the Patient Bill of Rights. Women may see their Plan gynecologist for their annual routine examination without a referral from their primary care doctor.

The diagnosis, evaluation, and medical management of certain mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any cost for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits. Office visits for the medical aspects of treatment do not count toward the 20 outpatient Mental Conditions visit limit.

Changes to this Plan The Illinois counties of Coles, Jefferson and Lawrence and the Indiana county of Porter are not longer included in the service area.

Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights.

Female members have the option of choosing a Primary Care Physician and a Womens Health Care Provider, OB/ GYN, who may also choose to act as a Primary Care Physician. See page 7.

If you have a chronic, complex, or serious medical condition that causes you to frequently see a Plan specialist, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist without the need to obtain further referrals.

A medical emergency is defined as 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.

The medical management of mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits.

A definition of experimental or investigatinal has been added and includes information on biological products.

Summary of Benefits for BCI HMO, Inc.- 1999

Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated, subject to the limitations and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit.

Includes in- hospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, intensive care and complete maternity care. You pay

nothing .................................................................................................................................... 14

Extended Care All necessary services. You pay nothing ............................................................................... 14

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient

care per year. You pay nothing .............................................................................................. 17

Substance Abuse Up to 30 days per year in a substance abuse treatment program. You pay nothing .............. 17

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury,

including specialists care; preventive care, including well- baby care, periodic checkups and routine immunizations; laboratory tests and X- rays; complete maternity care.

You pay a $10 copay per office visit; nothing per house call by a doctor............................. 12

Home Health Care All necessary visits by nurses and health aides. You pay nothing......................................... 13

Mental Conditions Up to 20 outpatient visits per year. You pay the lesser of a $20 copay or 50% of charges

per visit ................................................................................................................................... 17

Substance Abuse Up to 20 outpatient visits per year. You pay the lesser of a $20 copay or 50% of charges

per visit ................................................................................................................................... 17

Emergency care Reasonable charges for services and supplies required because of a medical emergency.

You pay a $50 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan.......................................................................... 15- 16

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay a $5 copay per prescription unit or refill; $50 copay for certain self- injectable drugs .................. 18

Mail order drugs You pay a $5 copay per generic or brand name drug per prescription or refill; a $10 copay for covered contraceptive drugs and nicotine patches ................................................. 18

Dental care Accidental injury benefit; you pay nothing............................................................................ 19

Vision care One refraction annually; you pay nothing.............................................................................. 19

Out- of- pocket maximum Copayments are required for a few benefits; however, after your out- of- pocket expenses reach a maximum of $1,969.76 per Self Only or $4,968.86 per Self and Family enrollment per calendar year, covered benefits will be provided at 100%. This copay maximum does not include costs of prescription drugs......................................... 8

1999 Rate Information for BCI HMO, Inc. 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 most career U. S. Postal Service employees, but do not apply to non- career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any postal employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.

High Option Self Only 3B1 $72.06 $156.13 $84.98

High Option Self and Family 3B2 $160.39 $347.51 $183.29

Non- Postal Premium Postal Premium Biweekly Monthly Biweekly Type of Govt Govt USPS Enrollment Code Share Share Share

Your Share

$33.12 $104.92

$71.76 $227.33

$20.20 $82.02