RI73-689 BROCHURE

Bluegrass Family Health A Health Maintenance Organization

Serving: Central and Eastern Kentucky

Enrollment in this Plan is limited; see page 10 for requirements.

Enrollment Codes: 2B 1 Self Only 2B2 Self and Family

Visit the OPM website at http:// www. opm. gov/ insure and this Plans website at http:// www. bgfh. com

Authorized for distribution by the:

United States Office of Personnel Management

ti 1 l

Federal Employees Health Benefits Program

RI 73- 689

mily Health

Bluegrass Family Health, Inc., 65 1 Perimeter Drive, Suite 300, Lexington, Kentucky, 405 17, has entered into a contract (CS2728) 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 the Plan or Bluegrass Family Health.

This brochure is the official statement of benefits on which you 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 27 of this brochure.

Table of Contents Page Inspector General Advisory of Fraud ,..................................................,............................................... 3

General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..*................................ 3

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 Spouse Coverage; Temporary Continuation of Coverage; Conversion to Individual Coverage; and Certificate of Creditable Coverage)

Facts About This Plan ,........................,..............,...................,.............................,.....,....................,........ 8

Information you should have a right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; Authorizations; For New Members; Hospital Care; Out- of- Pocket Maximum; Deductible Carryover; Submit claims Promptly; Experimental/ Investigational Determinations; Other considerations; The Plans Service Area.

General Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... 11

Important Notice; Circumstances Beyond Plan Control; Other Sources of Benefits

General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............ 13 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... 13

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... 22

Dental Care

Point of Service Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..*......................... 22 Non- FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... 25 How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... 26 How Bluegrass Family Health Changes January 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... 29 1999 Rate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 32

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 l- 800-

787- 2680 or 606- 269- 4475 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 or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by 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 make 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 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,

General Information continued

you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on pages 18- 19 or when you self- refer for point of service (POS) benefits as described on page 22. 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 below.

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.

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 date 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 92 d 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 a 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 on page 3. 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.

General Information continued Things to l A member with Self Only coverage who is expecting a baby or the addition of a

keep in child may change to a Self and Family enrollment up to 60 days after the birth or

mind 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

continued 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 or POS 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 plan.

. 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 re- enroll 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.

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 l- 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).

General Information continued Coverage after enrollment ends

l Former spouse coverage

l Temporary continuation of coverage (TW

0 Notification and election requirements

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 3 1 - day extension of coverage. The employee or family member may also be eligible for one of the following:

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.

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 are 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 3 1 -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. Or if you use your TCC until it expires, you are entitled to another free 3 1 -day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 3 1 -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 3 l- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 3 l- 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 32 d 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.

Separating employees- Within 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,

0 Conversion to individual coverage

0 Certificate of creditable coverage General Information continued

the child reaches age 22 or marries.

Former spouses- You or your former spouse must notify the employing office or retirement system of 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 or 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 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.

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 non- payment 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 covert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 3 1 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 3 1 -day free extension of coverage that follows the event that terminated coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.

Under Federal law, if you lose coverage under the FEHB program, you should automatically receive a certificate of Group health plan coverage from the last FEHB plan to cover you. 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), that offers a point of service, or POS, product. Whenever you need services, you may choose to obtain them from your personal doctor within the Plans provider network or go outside the network for treatment. Within the Plans network you are required to select a personal doctor who will provide or arrange for your care and you will pay minimal amounts for comprehensive benefits. There are no claim forms when Plan doctors are used. When you choose a non- Plan doctor or other non- Plan providers under the POS option, you will pay a substantial portion of the charges and the benefits available may be less comprehensive. See page 22 for more information.

Your decision to join an HMO should be based on your preference for the plans benefits and delivery system, not because a particular provider is in the plans 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 606- 269- 4475, or you may write the Carrier at: 65 1 Perimeter Drive, #300, Lexington, Kentucky 405 17. You may also contact the Carrier by fax at 606- 269- 5044, at its website at http: l/ www. bgfh. com, or by email at jhunter@ bgfh. com.

Information that must be made available to you includes: . Disenrollment rates for 1997. . Compliance with State and Federal licensing and certification requirements and the

dates met. If noncompliant, the reason for noncompliance. . Accreditations by recognized accrediting agencies and dates received. . Carriers type of corporate firm and years in existence. . Whether the carrier meets State, Federal and accreditation requirements for fiscal

solvency, confidentiality and transfer of medical records.

Who provides Bluegrass Family Health is a not- for- profit, Individual Practice Prepayment (IPP) model

care to plan HMO in Lexington, Kentucky. The Plans provider network includes 45 participating

members? hospitals and approximately 500 primary care physicians and over 1600 specialists.

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

primary care primary care doctor. The decision is important since it is through this doctor that all

doctor health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorization from the plan before

referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when you have been referred by your primary care doctor or when you use POS benefits, with the following exception: women may receive an annual gynecological examination from a participating gynecologist without a referral.

Choosing your doctor

The Plans provider directory lists primary care doctors (family practitioners, general 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 Customer Service Department at 606- 269- 4475 or l- 800- 787- 2680; you can also find out

Facts About this Plan continued

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 or POS 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. If you enroll, you will be asked to complete a primary care doctor selection form and send it directly to the plan, indicating the name of the primary care doctor( s) selected for you and each member of your family. If you need help choosing a doctor, call the Plan. Members may change their doctor selection by notifying the Plan 30 days in advance. If you are receiving services form a doctor who leaves the Plan, the Plan will assist you in selecting another participating physician.

Referrals speciality

for care

Except in a medical emergency, or when a primary care doctor has designated another doctor to see his or her patients, or when you choose to use the Plans POS benefits, 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.

Authorizations If you have a chronic, complex or serious medical condition that causes you to see a Plan specialist frequently, 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. The treatment plan will permit you to visit your specialist without the need to obtain further referrals. The plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your Plan doctor must obtain the Plans determination of medical necessity before you may be hospitalized, referred for specialty care, or obtain follow- up care from a specialist.

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 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.

/ ?

Facts About this Plan continued

Out- of- pocket maximum

Deductible carryover

Submit claims promptly

Experimental/ investigational determinations

Other considerations

The Plans service area

Copayments are required for most 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 reach $1,500 per Self Only enrollment or $3,000 per Self and Family enrollment. This copayment maximum does not include charges for prescription drugs, non- covered services, or any amounts not paid because a maximum limit has been reached. There is no out- of pocket maximum for the charges you pay when you use POS benefits, as described on page 22.

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 expense that would have applied to that plans deducible will be covered by your old plan if they are for care you got 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.

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 3 1 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.

The Plans Chief Medical Officer and the Director of Quality Improvement and Utilization determine what procedures and services are experimental/ investigational using FDA guidelines and Hayes Technology, an outside consultant.

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 service area for this Plan, where Plan providers and facilities are located, is described below. You must live or work in the service area to enroll in this Plan.

The service area for this Plan includes the following counties in Kentucky: Adair, Anderson, Bath, Bell, Bourbon, Boyle, Bracken, Breath&, Casey, Clark, Clay, Estill, Fayette, Fleming, Floyd, Franklin, Garrard, Grant, Green, Harlan, Harrison, Jackson, Jessamine, Johnson, Knott, Knox, Laurel, Lee, Leslie, Letcher, Lincoln, Madison, Magoffin, Marion, Mason, McCreary, Menifee, Mercer, Montgomery, Morgan, Nicholas, Owen, Owsley, Pendleton, Perry, Pike, Powell, Pulaski, Robertson, Rockcastle, Rowan, Scott, Taylor, Washington, Whitley, Wolfe, and Woodford. Benefits for care outside the service area are limited to emergency services, as described on pages 18- 19, and to services covered under POS benefits, as described on page 22.

If you or a covered family member move outside the service 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.

General Limitations Important Notice

Circumstances beyond Plan control

Other sources of benefits

Medicare Group health insurance and automobile insurance

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.

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.

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.

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 which coverage is primary. However, this Plan will not cover services, except those for emergencies, unless you use Plan providers or the services are covered under this Plans POS benefits. You must tell your Plan that you or your family member 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.

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 lessor 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

General Limitations continued

the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given to this Plan to obtain information about benefits or services available from the coverage, or to recover over payments from other coverages.

CHAMPUS Medicaid Workers Compensation

DVA facilities, DOD facilities, and Indian Health Service

Other government agencies

Liability insurance and third party actions

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 pre- paid plan, special limitations on your CHAMPUS coverage apply; your primary care provider must authorize all care unless you use a non- Plan provider for POS benefits as described on page 22. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. 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 8 103 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 law. If medical benefits provided under such law 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).

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.

The Plan will not provide benefits for services and supplies paid for directly or indirectly by any other local, State, or Federal Government agency.

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 the 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 and the Plan agrees, as discussed under Authorizations on page 9. The following are excluded:

. Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (See Emergency Benefits) or eligible self- referred benefits (see POS 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, drugs 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.

Medical and Surgical Benefits in Network 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. Within the Service Area, house calls will be provided if, in the judgment of the Plan doctor, such care is necessary and appropriate; you pay a $10 copay for a doctors house call; nothing for home visits by nurses and health aides.

The following services are included and are subject to the office visit copay unless stated otherwise:

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 year; 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

Bone density testing for women age 35 and older Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and x- rays Ambulatory/ hospital outpatient surgery; you pay a $75 copay per visit 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 cesarean delivery. Inpatient stays will be extended if medically necessary. If enrollment in

Medical and Surgical Benefits in Network continued

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 including Norplant implantations.

Diagnosis and treatment of diseases of the eye Allergy testing and treatment, including testing and treatment materials (such as allergy serum) for office visits for injections only; you pay $5

The insertion of internal prosthetic devices, such as pacemakers and artificial joints Cornea, heart, heart/ lung, pancreas, kidney 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 on non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer, multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors, Transplants are covered when approved by the Plan. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan.

Cochlear implants for members diagnosed with profound hearing impairments 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.

Dialysis Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Durable medical equipment including, but not limited to: wheelchairs, hospital beds, and apnea monitors. The rental/ purchase of the equipment includes any necessary fittings, adjustments and delivery/ installation of the durable medical equipment. Items that are not considered durable medical equipment include, but are not limited to : adjustments made to vehicles, air purifiers, ramps, stair glides and whirlpool baths. You pay 20% of charges.

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

Medical and Surgical Benefits in Network continued

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

. Prosthetic devices, such as artificial limbs and lenses following cataract removal, and orthopedic devices, such as braces and orthotics are covered for the purchase, necessary adjustments, repairs, and replacement of devices and supplies which replace all or part of an absent body part (including contiguous tissue) or replace all or part of the function of a permanently inoperative or malfunctioning body part; you pay 20% of charges. Over- the- counter foot devices are not covered.

. Diabetes equipment, supplies, outpatient self- management training and education including medical nutrition therapy, and all medications for the treatment of insulin dependent diabetics, insulin using diabetics, gestational diabetics, and noninsulin using diabetics. This includes blood glucose monitors and testing strips, insulin syringes, injection aids, insulin infusion devices, oral agents for controlling sugar, and medically necessary insulin pumps and appurtenances.

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 and excision of tumors and cysts. Surgical treatment for Temporomandibular Joint Disorder (TMJ), including dental appliances, is covered for services included in a treatment plan authorized by the Plan prior to surgery.

All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered.

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, occupational, cardiac rehabilitation, and chiropractic) is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can be expected within two months; you pay a $20 copay per outpatient session. Speech therapy is limited to treatment of 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.

Diagnosis and treatment of infertility is covered; you pay a $10 copay. The following types of artificial insemination are covered: intravaginal insemination (IVI) and intracervical insemination (ICI); you pay 50% of charges. Cost of donor sperm is not covered. Fertility drugs are not 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 not covered.

Sterilizations are covered; you pay a $100 copay for a tubal ligation or a $50 copay for a vasectomy.

Therapeutic, respite and rehabilitative care for autism is covered for members ages 2 through 2 1 for up to a $500 maximum Plan payment per child per month.

Medical and Surgical Benefits in Network continued

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 school or camp, or travel

Reversal of voluntary, surgically- induced sterility Surgery primarily for cosmetic purposes Transplants not listed as covered Blood and blood derivatives not replaced by the member Hearing aids Long- term rehabilitative therapy Homemaker services Acupuncture

Hospital/ Extended Care Benefits in Network What is covered

Hospital Care

Extended Care

Hospice Care Ambulance Service

Limited Benefits

Inpatient Dental Procedures

Acute Inpatient

What is not covered

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 a $100 copay per admission. 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.

The Plan provides a comprehensive range of benefits, limited to 30 days per calendar year 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 a $150 copay per admission. 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. 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. You pay nothing.

Benefits are provided for ground ambulance transportation ordered or authorized by a Plan doctor. You pay a $50 copay per trip.

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.

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 20 for non- medical substance abuse benefits.

. Personal comfort items, such as telephones and television . Blood and blood derivatives not replaced by the member . Custodial care, rest cures, domiciliary or convalescent care.

Emergency Benefits What is a medical emergency ?

A medical emergency is the sudden and unexpected onset of a condition or an injury you believe endangers your life or could result in serious injury or disability and 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, or a family member should notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized in a non- Plan facility, 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 Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

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

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

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

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

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

Emergencies outside the service area

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 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 except as covered under POS benefits.

Emergency Benefits continued

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

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

What is Covered . Emergency care at a doctors office

. Emergency care as an outpatient or inpatient at a hospital, including doctors; services . Ambulance service if approved by the Plan . Elective care or nonemergency care except as covered under POS benefits . Emergency care provided outside the service area if the need for care could have

been foreseen before departing the service area except as covered under POS benefits. . Medical and hospital costs resulting from a normal full- term delivery of a baby

outside the service area, except as covered under POS 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, 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 26.

Mental Condition/ Substance Abuse Mental Conditions

What is covered

To the extend 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:

Outpatient Care

Inpatient Care

What is not covered

Substance Abuse

What is covered

. Diagnostic evaluation . Psychological Testing . Psychiatric treatment (including individual and group therapy) . Hospitalization (including inpatient professional services)

Up to 40 outpatient visits to Plan doctors, consultants, or other psychiatric personnel each calendar year; you pay a $20 copay ($ 10 per group session) for each covered visit; all charges thereafter.

Up to 30 days of hospitalization each calendar year; you pay a $100 copay per admission; all charges thereafter. Inpatient days may be exchanged for outpatient day treatment at the rate of two treatment days for each inpatient day.

. 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 that is not medically necessary to determine the appropriate

treatment of a short- term psychiatric condition. 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 providers for treatment each calendar year; you pay a

$20 copay ($ 10 per group session) for each covered visit; all charges thereafter.

Inpatient Care

Up to 30 days per calendar year in a substance abuse rehabilitation (intermediate care) program in an alcohol or drug rehabilitation center approved by the Plan; you pay a $150 copay per admission. Benefits are limited to one admission per 6 months.

What is not covered

Treatment that is not authorized by the Plan. 20

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 3 l- day supply. You pay a $7 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not permissible. When generic substitution is permissible (i. e. a generic drug is available and the prescribing doctor does not require the use of a name brand drug), but you request the name brand drug, you pay the price difference between the generic and name brand drug as well as the $7 copay per prescription unit or refill.

Covered medications and accessories include:

. Drugs for which a prescription is required by Federal law . Oral and injectable contraceptive drugs; contraceptive diaphragms and IUDs . Insulin; a copay charge applies to each vial . Disposable needles and syringes and other diabetic supplies necessary for the

treatment of diabetes

Additional Benefits

Limited Benefits

Implanted time- release medications, such as Norplant, are covered under the Medical and Surgical Benefits on page 13. For Nor- plant and other internally implanted time- release medication, you pay a $10 office visit. There is no charge when the device is implanted during a covered hospitalization.

Intravenous fluids and medications for home use are covered under the Medical and Surgical Benefits.

. Drugs to treat sexual dysfunction are limited. Contact the Plan for dose limits at l- 800/ 787- 2680. You pay 50% of charges up to the dosage limits and all charges above that.

. What is not covered

Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Contraceptive devices (except diaphragms and IUDs) Drugs for cosmetic purposes Drugs to enhance athletic performance Smoking cessation drugs and medication, including nicotine patches Fertility drugs

Other Benefits in Network Dental Care Accidental injury benefit 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 and must occur on or after your effective date. You pay nothing.

Point of Service (POS) Benefits Facts about this At your option, you may choose to obtain benefits covered by this Plan from non- Plan

Plans POS Option doctors and hospitals whenever you need care, except for the benefits listed below under What is not covered. Benefits not covered under Point of Service must either be

received from or arranged by Plan doctors to be covered. When you obtain covered non- emergency medical treatment from a non- Plan doctor without a referral from a Plan doctor, you are subject to the deductibles, coinsurance and maximum benefit stated below.

As a member of a POS plan, you have benefits for both Plan and non- Plan doctors, except for the benefits listed below under What is not covered. You pay a higher copayment or coinsurance amount if you self- refer to Plan doctors for covered services. You pay

deductibles and higher coinsurance when you obtain covered services from non- P& doctors, except life- threatening emergencies.

You will always pay higher copayments and coinsurance when you see non- Plan or Plan providers without Primary Care Physician referral.

What is Covered The following is a Schedule of Benefits for the POS Plan

22 Service InPlan/ Self- Referral

Member Pays Non- Plan

Provider Member Pays

Provider Office Visits (primary care and specialists)

Diagnostic Procedures $25 Copay per visit

$25 Copay per visit 30% of charges after

Deductible 30% of charges after Deductible

Obstetrical Care $25 Copay per visit 30% of charges after Deductible

Voluntary Sterilization and family planning $25 Copay per visit 30% of charges after Deductible

Allergy Serum and Injections $7 Copay per injection 30% of charges after Deductible

Prosthetic Devices 25% Coinsurance 30% coinsurance after Deductible

Ambulatory/ Hospital Outpatient Surgery $100 Copay 30% coinsurance after Deductible

Durable Medical Equipment 25% Coinsurance 30% coinsurance after Deductible

Point of Service (POS) Benefits continued

Short- Term Rehabilitative Therapy (speech, physical, occupation, chiropractic and cardiac rehab) (visit limits apply)

$30 Copay 30% of charges after Deductible

Inpatient Hospital Care $200 Copay per admission 30% of charges after Deductible

Extended Care (limits apply) $200 Copay per admission 30% of charges after Deductible

Ambulance $50 copay per use 30% of charges after Deductible

Hospital Emergency Room (true emergencies are always payable as in- Plan benefits)

$50 copay( waived if admitted) 30% of charges after Deductible

Mental Health/ Inpatient (Limits apply)

Mental Health/ Outpatient (Limits apply)

Substance Abuse/ Inpatient (Limits apply)

Substance Abuse/ Outpatient (Limits apply)

Prescription Drugs $200 copay per admission

$30 copay per visit $200 copay per admission $30 copay per visit $15 copay13 1 -day supply

30% of charges after Deductible

Precertification Deductible

The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. You Plan doctor must obtain the Plans determination of medical necessity before you may be hospitalized, referred for specialty care, or obtain follow- up care from a specialist. If your Plan provider pre- authorizes services with non- Plan doctors, benefits may be paid at the HMO benefit level. If you are using your POS benefits or seeing non- Plan providers and receiving services that require authorization, you are responsible for verifying pre- certification requirements. To verify Precertification you may call l- 800- 787- 2680. If you receive covered services that require authorization but have not been authorized, you pay a Precertification penalty of $500. SERVICES THAT ARE NOT MEDICALLY NECESSARY, ARE NOT COVERED.

The Deductible applies to all covered services received from non- Plan providers except for hospital emergency treatment. The Deductible must be satisfied each Plan Year

before benefits are paid. The Deductible does not apply to the out- of- pocket limit. The Family Deductible is satisfied when one Covered Person satisfies an Individual Deductible in a Plan Year, and the remaining Covered Persons together satisfy an amount equal to one Individual Deductible in a Plan Year. You pay no Deductible for services received from a Plan doctor. You pay a $700 Deductible for Self Only enrollment, and you pay $1,400 for Self and Family Enrollment for services received from non- Plan doctors.

i I

Point of Service (POS) Benefits continued

Coinsurance Maximum lifetime benefit

Annual out- of- pocket limit

Hospital/ extended care

Emergency benefits

Other Benefits Mental conditions/ substance abuse benefits

What is not covered

Coinsurance is calculated based on eligible expenses for services provided. You pay

30% of charges for most services received from non- Plan doctors. Coinsurance is subject to reasonable and customary limits. You are responsible for all charges that exceed the reasonable and customary limit.

There is no maximum lifetime benefit, The annual out- of- pocket is the maximum eligible expense that may be incurred by an individual or a family in a Plan Year. After the out- of- pocket limit is satisfied, the Plan pays 100% of eligible expenses for covered services. Expenses that apply to the out- of- pocket limit are copayments and coinsurance for covered services. Expenses that do not apply to the out- of- pocket limit include the Deductible, charges exceeding eligible expenses, all expenses for non- covered services, non- FEHB benefits and penalties for failure to obtain required pre- certitication and compliance with Plan delivery system rules. You pay a maximum of $1,500 out- of- pocket for Self Only Enrollment and you

pay $3,000 out- of- pocket for Self and Family Enrollment if you receive care from a Plan doctor. If care is not received from a Plan doctor, you pay $2,500 for Self Only Enrollment and you pay $5,000 for Self and Family Enrollment.

The Plan provides a comprehensive range of benefits with no dollar limit when you are hospitalized under the care of a Plan doctor. You pay a $200 copay per admission for hospitalizations or extended care not arranged by your primary care doctor. You pay a 30% coinsurance amount after any applicable Deductible when you are hospitalized in a non- Plan facility. This does not include any copayment or coinsurance that applies to doctors services.

Emergencies are always paid as an In- Plan benefit.

Inpatient Mental conditions and substance abuse benefits are covered. You pay a $200

copay per admission for each benefit for Plan doctors and you pay a 30% coinsurance amount after any applicable deductible for non- Plan doctors. This condition is limited to 30 days per Plan year and 1 admission per 6 months for each benefit.

Outpatient Mental conditions are covered. You pay a $30 copay per visit, limited to 40 visits per year for Plan doctors and you pay 30% of charges after any applicable Deductible, limited to 40 visits per year for non- Plan doctors.

Outpatient substance abuse benefits are covered. You pay a $30 copay per visit, limited to 20 visits per Plan year for Plan doctors and you pay 30% of charges after any applicable Deductible, limited to 20 visits per Plan year for non- Plan doctors.

In addition to the above not covered services, preventive care and transplant benefits are not covered when received from non- 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 of this Plan. The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles, POS maximum benefits, opt- out maximum benefits, or out- of- pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.

Concordia PLUS Dental Plan

At Bluegrass Family Health we know that dental health is an important part of your familys wellness. Therefore, Bluegrass Family Health is pleased to offer its members the opportunity to receive dental benefits through United Concordia. It is a comprehensive plan that emphasizes preventive and diagnostic care, generally by covering such services in full or with only a nominal copayment.

To enroll in this dental plan, you must be enrolled in Bluegrass Family Health and complete and sign the ConcordiaPLUS enrollment form, ConcordiaPLUS premiums are payable to United Concordia on an annual basis by check, Visa or Mastercard.

ConcordiaPLUS IIC covered services include preventive and diagnostic services such as, but not limited to, oral exams and bitewing x- rays. Restorative services include, but are not limited to, routine fillings, simple extraction and crowns.

This optional plan is available to Federal employees during the scheduled Federal open enrollment period for coverage effective January 1, 1999. Federal employees who do not enroll at this time will not be eligible for these dental benefits until the next open enrollment period. For more information regarding the ConcordiaPLUS dental health plan, please contact United Concordia at (800) 822- 3368.

This is not a contract. For a complete schedule of benefits, please see your ConcordiaPLUS Certificate of Coverage.

Bluegrass Family Health Health Helpers

As a Bluegrass Family Health member, you are eligible for Health Helper discounts of 10% to 25% on Optical, Wellness and Dental needs from the providers listed on the Health Helper page of the Plans provider director.

Optical Discounts

Optical services are not a covered benefit under the FEHB benefits program offered by Bluegrass Family Health. To accommodate those Members who need optical services, BFH Members may obtain services such as vision exams, glasses, and contact lenses at a discounted fee from the providers listed on the Health Helper page of the Plans provider directory.

Wellness Discounts

Bluegrass Family Health has made arrangements with businesses to give HMO Members a substantial discount on their fitness services. Welhress is a big part of our plan and Bluegrass Family Health has decided to do all we can to assist our Members in that area. All you need to do is show your ID Card and these discounts can be yours at the establishments listed on the Health Helper page of the Plans provider directory.

Dental Discounts

Bluegrass Family Health Members can enjoy discounts on Dental services from certain dentists. Many dentists have agreed to supply preventive dental services at a discounted rate for orthodontic, restorative, surgical, and other dental needs. We, at Bluegrass Family Health, wish to assist our Members in any way we can to have the best possible treatment in all areas of your health and Health Helpers is how we are able to do this, Please refer to the list of dentists on the Health Helper page of the Plans provider directory.

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

Plans Customer Service Office at l- 800- 787- 2680 or 606- 269- 4475 or you may write to the Plan at: 65 1 Perimeter Drive, Suite 300, Lexington, Kentucky 405 17. You may also contact the Plan by fax at 606- 269- 5044, at its website at http:// www. bgth. com or by email at jhunter@ bgfh. com

Disputed Claims Review

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 the denial, to reconsider its denial before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.) 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 must state why, based on specific benetit 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 aftirm 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 afIirming 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 must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service 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.

How to Obtain Benefits continued

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, suchas doctors letters, operative

reports, bills, medical records, and explanation of benefit (EOB) forms; and . Your daytime phone number.

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 4, P- 0. 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 3 1 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 in dispute.

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 identifying 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 Bluegrass Family Health Plan 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. . 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 to allow an adequate number of direct access visits with that specialist, without the need to obtain further referrals (see page 9 for details). . A medical emergency is defined as the sudden and unexpected onset of a condition

How Bluegrass Family Health Plan Changes January 1999 continued

Changes to this Plan

. . .

. .

. . . . . . . . .

. . .

or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care (see page 18).

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. Office visits for the medical aspects of treatment do not count toward the 40 outpatient Mental Conditions visit limit.

The Plan has added a Point- of- Service option. You now have the choice of self referring to Plan doctors and non- Plan doctors under the POS options. (See page 22). The Plan has added a $100 copay per hospital admission. (See page 17). The Plan has added a $50 copay for ground ambulance transportation. (See page 17). Benefits for skilled nursing in an extended care facility have decreased to 30 days per calendar year with a $150 copay per admission. Therapeutic, respite and rehabilitative care for autism is covered for children ages 2 through 21, limited to $500 per month per child. (See page 15). Benefits for diabetes have expanded to include diabetic supplies and medical nutrition therapy. (See page 15). The Plan now covers cochlear implants for members diagnosed with profound hearing impairments. (See page 14). The Plan now covers bone density testing for women age 35 and older. (See page 13). The copay for outpatient short- term rehabilitative therapy has increased to $20 per session. Benefits for transplants have expanded to include lung, heart/ lung, and pancreas. (See page 14). Benefits for prosthetic devices and orthopedic devices have expanded to include coverage for repair and replacement. (See page 15). The Plan has added coverage for orthotics; the member pays 20% of charges. (See page 15). Benefits for inpatient Mental Conditions and Substance Abuse benefits have increased to two separate 30 days of hospitalization per each per calendar year. Substance abuse admissions are limited to one admission every six month period and is subject to a $150 copay per admission. (See page 20). The office visit copay for allergy injections have decreased to $5 per visit. (See page 14). Coverage of drugs for sexual dysfunction are shown under the Prescription Drug Benefit. (See page 21). The Plan has expanded its service area to include Johnson County, Kentucky.

Summary of Benefits for Bluegrass Family Health 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 AND SERVICES AVAILABLE AS POS BENEFITS, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Inpatient Care Hospital

Plan pays/ provides Page

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 a $100 copay per admission . . . . . . . . . . . . . . . . . . . . . . . 16

Extended Care All necessary services up to 30 days per calendar year. You pay a $150 copay per admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year. You pay a $100 copay per admission . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Substance Abuse Up to 30 days per year in a substance abuse treatment program. You

pay a $150 copay per admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 \

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury, including specialist care; preventive care, well- baby care, periodic check- ups and routine immunizations; laboratory tests and x- rays; complete maternity care, You pay a $10 copay per office visit and for a house call by a doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...*.. 13

Home Health Care

All necessary visits by nurses and health aides. You pay nothing . . . . . . . . . . . . . . . . . . . . 14 Mental Conditions Up to 40 outpatient visits per year. You pay a $20 copay per visit . . . . . . . . . . . . . . . . . . . 19 Substance Abuse Up to 20 outpatient visits per year. You pay a $20 copay per visit . . . . . . . . . . . . . . . . . . . 19

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 . . . . . . . . . . . . . . . . . . . 18

Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You

pay a $7 copay per prescription unit or refill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Dental Care Accidental injury benefit; you pay nothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Vision Care No current benefit

Out- of- pocket Copayments are required for a few benefits; however, after your out- of- pocket expenses reach a maximum of $1,500 per Self Only enrollment or $3,000 per Self and Family enrollment, per calendar year, covered benefits will be provided at 100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Notes

1999 Rate Information for Bluegrass Family Health

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

Postal rates apply to 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.