Pages 1--63 from Triple-S, Inc.

with a point of service product
Serving: All of Puerto Rico
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
891 Self Only 892 Self and Family

RI 73-016

For changes in benefits
see pages 7 and 8. 1
1 Page 2 3
2001 Triple-S Table of Contents 2
Table of Contents
Introduction…………………………………………………………………. ............................................................ 4
Plain Language ....................................................................................................................................................... 4
Section 1. Facts about this HMO plan..................................................................................................................... 5
We also have point-of service (POS) benefits ......................................................................................... 5
How we pay providers ........................................................................................................................... 5
Who provides my health care? ............................................................................................................. 5
Patients' Bill of Rights ........................................................................................................................... 5
Service Area .......................................................................................................................................... 6
Section 2. How we change for 2001………………………………………............................................................... 7
Program-wide changes........................................................................................................................... 7
Changes to this Plan............................................................................................................................... 8
Section 3. How you get care .................................................................................................................................. 9
Identification cards ................................................................................................................................ 9
Where you get covered care ................................................................................................................... 9
· Plan providers.................................................................................................................................. 9
· Plan facilities ................................................................................................................................... 9
What you must do to get covered care .................................................................................................... 9
· Primary care .................................................................................................................................... 9
· Specialty care .................................................................................................................................. 9
· Hospital care.................................................................................................................................. 10
Circumstances beyond our control........................................................................................................ 10
Services requiring our prior approval.................................................................................................... 10
Section 4. Your costs for covered services ............................................................................................................ 12
· Copayments................................................................................................................................... 12
· Coinsurance................................................................................................................................... 12
Your out-of-pocket maximum .............................................................................................................. 12
Section 5. Benefits ............................................................................................................................................... 13
Overview............................................................................................................................................. 13
(a) Medical services and supplies provided by physicians and other health care professionals........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 24
(c) Services provided by a hospital or other facility, and ambulance services.................................... 28
(d) Emergency services/ accidents .................................................................................................... 31
(e) Mental health and substance abuse benefits ................................................................................ 34
(f) Prescription drug benefits .......................................................................................................... 37
(g) Special features ......................................................................................................................... 40
(h) Dental benefits........................................................................................................................... 41 2
2 Page 3 4
2001 Triple-S Table of Contents 3
Table of Contents (Continued)
(i) Point of service benefits ........................................................................................................... 43
Section 6. General exclusions --things we don't cover ........................................................................................ 44
Section 7. Filing a claim for covered services....................................................................................................... 45
Section 8. The disputed claims process ................................................................................................................ 47
Section 9. Coordinating benefits with other coverage ........................................................................................... 49
When you have…
· Other health coverage .................................................................................................................... 49
· What is Medicare? ......................................................................................................................... 49
· The Original Medicare Plan ........................................................................................................... 49
· Medicare managed care plan .......................................................................................................... 51
· Enrollment in Medicare Part B ....................................................................................................... 52
TRICARE/ Workers' Compensation/ Medicaid ..................................................................................... 52
Other Government agencies ................................................................................................................ 52
When others are responsible for injuries .............................................................................................. 52
Section 10. Definitions of terms we use in this brochure....................................................................................... 53
Section 11. FEHB facts ....................................................................................................................................... 55
Coverage information........................................................................................................................ 55
· No pre-existing condition limitation........................................................................................... 55
· Where you get information about enrolling in the FEHB Program .............................................. 55
· Types of coverage available for you and your family.................................................................. 55
· When benefits and premiums start ............................................................................................. 56
· Your medical and claims records are confidential....................................................................... 56
· When you retire........................................................................................................................ 56
When you lose benefits...................................................................................................................... 56
· When FEHB coverage ends ....................................................................................................... 56
· Spouse equity coverage............................................................................................................. 56
· Temporary Continuation of Coverage (TCC)............................................................................. 56
· Converting to individual coverage............................................................................................. 57
· Getting a Certificate of Group Health Plan Coverage................................................................. 57
Inspector General Advisory ............................................................................................................... 57
· Penalties for Fraud.................................................................................................................... 58
Department of Defense/ FEHB Demonstration Project........................................................................................... 59
Index ........................................................................................................................................................ 61
Summary of benefits ............................................................................................................................................ 62
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2001 Triple-S 4 Introduction/ Plain Language
Introduction
Triple-S, Inc. (Triple-S) 1441 Roosevelt Avenue
San Juan, Puerto Rico 00920
This brochure describes the benefits of Triple-S under our contract (CS-1090) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. Brochures are available in Spanish. You can get a copy by calling 787-749-4777.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2001, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are summarized on pages 7 and 8. Rates are shown at the end of this brochure.

Plain Language
The President and Vice President are making the Government's communication more responsive, accessible, and understandable to the public by requiring agencies to use plain language. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical terms, we use common words. "You" means the enrollee or family member; "we" means Triple-S.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan with other FEHB plans, you will find that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Triple-S 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We encourage you to see those physicians, hospitals, and other providers that contract with us. These Plan providers can help you coordinate your health care services. HMOs
emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practices when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

We also have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a non-Plan provider within our service area. These out-of-network benefits have higher out-of-pocket costs than our in-network

benefits. Out of the service area, we will pay benefits only when the services are due to a emergency or have been preauthorized by us. In general, we will only authorize care, equipment, or professional services out of the service
area when they are not available from a Plan provider in the service area.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or

coinsurance. When you get services out-of-network, we pay non-Plan providers in Puerto Rico based on the "medical benefits schedule" and we pay non-Plan providers outside of Puerto Rico based on ususal, customary, and reasonable
charges.
Who provides my health care?
Triple-S is an individual practice prepayment plan. You can receive care from any Plan doctor. A Plan doctor is a doctor of medicine (M. D.) licensed to practice in the Commonwealth of Puerto Rico who has agreed to accept the

Triple-S established fees as payment in full for surgery and certain other services. If you use a non-Plan doctor (except for speech or occupational therapy) you must pay the difference between the non-Plan doctor's charge and the
amount paid to you by Triple-S. A non-Plan doctor is any licensed doctor of medicine (M. D.) who is not a Plan doctor. Non-Plan doctors do not have to accept Triple-S established fees as payment in full. Most doctors practicing
in Puerto Rico are Plan doctors.
You can also receive services from a Plan hospital. This is a licensed general hospital in Puerto Rico that has signed a contract with Triple-S to render hospital services to persons insured by Triple-S. A non-Plan hospital is any licensed

institution that is not a Plan hospital and that is engaged primarily in providing bed patient with diagnosis and treatment under the supervision of physicians with 24-hour-a-day registered graduate nursing services. You must pay
any difference between the non-Plan hospital's charges and the amount paid to you by Triple-S.
Benefits are paid according to the "medical benefits schedule". This is the schedule of established fees on which this Plan's payment of covered medical expense is based, when the services are rendered within the service area. The

medical benefits schedule applies to Puerto Rico. When services are rendered outside the area this Plan pays usual, customary and reasonable charges.

Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must make available to you. 5
5 Page 6 7
2001 Triple-S 6 Section 1
Section 1. Facts about this HMO plan (Continued)
If you want more information about us, call 787/ 749-4777, or write to P. O. Box 363628, San Juan, Puerto Rico, 00936-3628. You may also contact us by fax at 787/ 749-4108 or visit our website at FEDINFO@ ssspr. com.

Service Area
To enroll with us, you must live or work in our Service Area. This is where our providers practice. Our service area is: Only Puerto Rico.

Ordinarily, you must get your care from providers who contract with us. We will pay only for emergency care and hospitalization of authorized special cases if you receive care outside our service area. Special cases means care,
equipment or professional services that are not available in our service area. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. This Plan offers reciprocity with the Blue Cross Blue Shield network through the Blue Card Program. If you or a family member
move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2001 Triple-S 7 Section 2
Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

· This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and day and visit limitations when you follow a treatment plan that we approve. Previously, we placed shorter day or
visit limitations on mental health and substance abuse services than we did on services to treat physical illness, injury, or disease.

· Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our
patient safety activities by calling 787-749-4777, or checking our website http:// www. ssspr. com . You can find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take these
five steps:
·· Speak up if you have questions or concerns.
·· Keep a list of all the medicines you take.
·· Make sure you get the results of any test or procedure.
·· Talk with your doctor and health care team about your options if you need hospital care.
·· Make sure you understand what will happen if you need surgery.
This Plan will evaluate the patient safety initiatives to ensure you better health care. Our safety programs include:

·· Drug interaction program
·· Dose check program
·· Medication alerts to physicians and dentists by means of a monthly publication (Pharma News)
·· Disease management program for asthma
·· 24 hours x 7 days call center for Triage
·· Managed care model for mental health and substance abuse. We provide:
·· concurrent review
·· discharge planning
·· case management
·· disease management for depression
·· 24 hours x 7 days call center
· We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the language referenced only women. 7
7 Page 8 9
2001 Triple-S 8 Section 2
Section 2. How we change for 2001 (Continued)
Changes to this Plan
· Your share of the non-Postal premium will increase by 7% for Self Only or 7% for Self and Family.
· We will cover prescription drugs based on a formulary. If you choose a brand name prescription drug, for which a generic bioequivalent prescription drug exists, you will pay the brand name copay and the difference between the cost
of the brand name prescription drug and the cost of the generic bioequivalent prescription drug.
You will pay the following in-formulary copayments:
·· $2 for generic bioequivalent prescription drug unit or refill;
·· $5 for preferred brand prescription drug unit or refill;
·· $10 for brand name unit or refill.
You will pay 20% or $10, whichever is higher, for out of formulary prescription drug unit or refill. 8
8 Page 9 10
2001 Triple-S 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 787-749-
4777.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims.
You can also get care from non-Plan providers, but it will cost you more.
· Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

· Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. The list is also on our website.

What you must do It depends on the type of care you need. First, you and each family member must choose a general practitioner physician. This decision is
important since your general practitioner physician provides for most of your health care.

· Primary care Your general practitioner physician can be, for example, a family practitioner. Your physician will provide most of your health care, or
refer you to a specialist.
If you want to change your general practitioner or if your general practitioner physician leaves the Plan, call us. We will help you select a
new one.
· Specialty care Your general practitioner physician will refer you to a specialist for needed care. However, you may see any specialist without a referral.

Here are other things you should know about specialty care:
· If you are seeing a specialist and your specialist leaves the Plan, call us. We will provide you a list of specialists within your area. You
may receive services from your current specialist until we can make arrangements for you to see someone else.

· If you have a chronic or disabling condition and lose access to your specialist because we: 9
9 Page 10 11
2001 Triple-S 10 Section 3
Section 3. How you get care (Continued)
··terminate our contract with your specialist for other than cause; or
··drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

··reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

· Hospital care Your Plan general practitioner physician or specialist will make necessary hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 787-749-4777. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

· You are discharged, not merely moved to an alternative care center; or
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Your general practitioner physician may refer you for most services. For
certain services, however, you or your Plan doctor must obtain approval from us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice. We call this review and approval precertification. You or your Plan
doctor must obtain our approval before sending you to a hospital. Call us at 787-749-4777. 10
10 Page 11 12
2001 Triple-S 11 Section 3
Section 3. How you get care (Continued)
We will provide benefits for covered services only when services are medically necessary to prevent, diagnose or treat your illness or
condition. But you or your Plan doctor must obtain authorization from this Plan before:

· Services outside the Service Area, except emergencies;
· Rental and purchase of durable medical equipment;
· Skilled Nursing Facility;
· Organ and tissue transplants;
· Genetic amniocentesis;
· CT Scans (including SPECT);
· Hepatobiliary ductal system imaging (HIDA);
· Magnetic resonance (MRI, MRA);
· Lithotripsy;
· Polysomnography;
· Speech and occupational therapy;
· All hospital admissions;
· Mandibular osteotomy;
· Mammoplasty;
· Mental health and substance abuse services rendered by Plan providers; and non Plan providers (point of service benefits); and

· Growth hormones. 11
11 Page 12 13
2001 Triple-S 12 Section 5
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
· Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your specialist you pay a copayment of $10 per office visit.
· Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 25% of our allowance for laboratory and diagnostic tests.

Your out-of-pocket maximum We do not have an out-of-pocket maximum. Your out-of-pocket expenses for benefits covered under this Plan are:
· The stated copayments which are required for covered benefits;
· Remaining charges after we reimburse you our established fees for point of service benefits when non-Plan providers are used; and

· The difference between the cost of the brand name prescription drug and the cost of the generic bioequivalent prescription drug, if you choose a
brand name prescription drug, for which a generic bioequivalent prescription drug exist.

· The 10% you pay of our established fees when you use non-Plan providers in our service area.
· The 10% you pay of the usual, customary and reasonable charge when you use non-Plan providers outside of our service area. 12
12 Page 13 14
2001 Triple-S 13 Section 5
Section 5. Benefits --OVERVIEW
(See pages 7and 8 for how our benefits changed this year and page 62 for a benefits summary.)

NOTE: This benefits section is broken into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 787-749-4777 or at our website at www. ssspr. com.

(a) Medical services and supplies provided by physicians and other health care professionals .................................... 14-23
· Diagnostic and treatment services · Lab, X-ray, and other diagnostic tests

· Preventive care, adult · Preventive care, children
· Maternity care · Family planning
· Infertility services · Allergy care
· Treatment therapies · Rehabilitative therapies

· Hearing services (testing and treatment) · Vision services (testing and treatment)
· Foot care · Orthopedic and prosthetic devices
· Durable medical equipment (DME) · Home health services
· Alternative treatments · Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals...................... 24-27
· Surgical procedures · Reconstructive surgery · Oral and maxillofacial surgery · Organ/ tissue transplants

· Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .................................................. 28-30
· Inpatient hospital · Outpatient hospital or ambulatory surgical

center
· Extended care benefits/ skilled nursing care facility benefits
· Hospice · Ambulance

(d) Emergency services/ accidents............................................................................................................ 31-33 · Medical emergency · Ambulance
(e) Mental health and substance abuse benefits ........................................................................................ 34-36
(f) Prescription drug benefits ......................................................................................................................... 37-39
(g) Special features ............................................................................................................................................. 40 · 24 hours, 7 days a week call center · Blue Card Program · Center of excellence for transplants/ heart

surgeries/ etc · High risk pregnancies · Blue Card Worldwide
(h) Dental benefits ......................................................................................................................................... 41-42
(i) Point of service benefits ................................................................................................................................ 43
Summary of benefits ............................................................................................................................................ 62 13
13 Page 14 15
2001 Triple-S Section 5( a) 14
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are
medically necessary.
· Plan physicians must provide or arrange your care.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

· YOU OR YOUR PLAN DOCTOR MUST GET PRECERTIFICATION OF SOME MEDICAL SERVICES AND SUPPLIES. Please refer to the precertification
information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

· If you use a non-Plan doctor or provider, you pay for services rendered and the Plan will reimburse you 90% of the Plan's established fee when services are rendered
within the service area, or 90% of the usual, customary and reasonable charge of the area in which the services are rendered when services are rendered outside the
service area. You pay all remaining charges.
Note: We will pay for services provided by a non-Plan provider outside the service area only if the services are for an emergency or if they have been preauthorized. In
general, we will only authorize care, equipment, or professional services that are not available from a Plan provider within the service area.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians

· In physician's office
$ 7.50 per office visit to your general practitioner physician

$10 per office visit to a specialist physician
Professional services of physicians
· In an urgent care center or emergency room
· During a hospital stay
· In a skilled nursing facility – precertification required (refer to Section 3)

· Initial examination of a newborn child covered under a family enrollment
· Office medical consultations

$10 per office visit

Diagnostic and treatment services – Continued on next page 14
14 Page 15 16
2001 Triple-S Section 5( a) 15
Diagnostic and treatment services (Continued) You pay
· Second surgical opinion
· Vaccines for pediatric and adult immunizations
Nothing
$10 per office visit. Nothing for vaccines for pediatric and adult
immunizations.
At home $15 per physician visit.
Nothing for nurse and health aids visit

Not covered:
· Private nursing care, except for treatment of mental illness
All charges

Lab, X-ray and other diagnostic tests
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap tests
· Pathology
· X-rays
· Non-routine Mammograms
· Cat Scans/ Magnetic resonance (MRI, MRA) – precertification
required (refer to Section 3)

· Hepatobiliary ductal system imaging (HIDA) – precertification
required (refer to Section 3)

· Polysomnography – precertification required (refer to Section 3)
· Genetic amniocentesis-precertification required (refer to Section 3)
· Ultrasound
· Non-invasive vascular and cardiovascular tests

25%. Nothing for X-rays. 15
15 Page 16 17
2001 Triple-S Section 5( a) 16
Preventive care, adult You pay
Routine screenings, such as:
· Blood lead level
· Total Blood Cholesterol
· Colorectal Cancer Screening, including
·· Fecal occult blood test
·· Sigmoidoscopy, screening

$7.50 per office visit to your general practitioner physician , $10
per office visit to a specialist physician; and 25% for laboratory
tests in lab facilities and diagnostic tests.

· Prostate Specific Antigen (PSA test)
Routine pap test Nothing if you receive these services during your office visit;
otherwise, $10 per office visit.

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

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

$10 per office visit. Nothing for X-ray.

Routine Immunizations, limited to:
· Tetanus-diphtheria (Td)
· Influenza
· Pneumococcal vaccine, annually, age 65 and over
· Tetanus toxoid
· Hepatitis B

$10 per office visit. Nothing per vaccine or immunization.

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

· Diphtheria-tetanus-pertussis (Dtp)
· Diphtheria-tetanus toxoids (Dt)
· Measles, mumps and rubella (Mmr)
· Varicella and varivax
· Hemophilus influenza B

$10 per office visit. Nothing per vaccine or immunization. 16
16 Page 17 18
2001 Triple-S Section 5( a) 17
Preventive care, children (Continued) You pay
· Influenza
· Tetanus toxoid
· Hepatitis B

$10 per office visit. Nothing per vaccine or immunization.

· Examinations, such as:
·· Eye exams to determine the need for vision correction.
·· Ear exams to determine the need for hearing correction
·· Examinations done on the day of immunizations
· Well-child care charges for routine examinations, immunizations and care

$10 per office visit. Nothing per vaccine or immunization

Maternity care
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:
·· You do not need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your baby.

·· You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your
inpatient stay if medically necessary. Be sure to tell the hospital personnel that you are a Plan member so they can notify us. You or a
family member should notify us within 48 hours unless it was not reasonably possible to notify us within that time. It is your
responsibility to ensure that we had been timely notified.

·· We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

·· We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).

Nothing

Not covered: Routine sonograms to determine fetal age, size or sex All charges 17
17 Page 18 19
2001 Triple-S Section 5( a) 18
Family planning You pay
· Voluntary sterilization
· Surgically implanted contraceptives
· Intrauterine devices (IUDs)

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges
Infertility services
Diagnosis and treatment of infertility, such as:
· Artificial insemination:
·· intravaginal insemination (IVI)
·· intracervical insemination (ICI)
·· intrauterine insemination (IUI)

$10 per office visit

Not covered:
· Assisted reproductive technology (ART) procedures, such as:
·· in vitro fertilization
·· embryo transfer and GIFT
· Services and supplies related to excluded ART procedures
· Cost of donor sperm
· Fertility drugs

All charges

Allergy care
Testing and treatment $10 per office visit
Allergy vaccine Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges 18
18 Page 19 20
2001 Triple-S Section 5( a) 19
Treatment therapies You pay
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on pages 26 and 27.
· Respiratory and inhalation therapy up to a maximum of 20 sessions per year

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

· Growth hormone therapy (GHT)
Note: – We will only cover GHT when we precertify the treatment. You or your Plan doctor should call 787-749-4777 for precertification.
We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin
treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT
is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in
Section 3.

$10 per office visit and/ or respiratory therapy session

Not covered: Services not shown as covered All charges
Rehabilitative therapies
Physical, occupational and speech therapy --
Up to two consecutive months per condition, if significant improvement can be expected, for the services ordered by a physician of each of the
following:
· Physical therapy
·· rendered by qualified physical therapists supervised by a physician specialized in physical therapy;

· Occupational and speech therapy (precertification required. Refer to Section 3).
·· rendered by certified speech therapists; and
·· rendered by certified occupational therapists.

Note: We only cover therapy to restore bodily function or speech when there has been a total or partial loss of bodily function or functional
speech due to illness or injury. 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.

$10 per office visit and/ or physical therapy
For speech and occupational therapy you should pay the
provider's claim and seek reimbursement from us.

Rehabilitative therapies --Continued on next page 19
19 Page 20 21
2001 Triple-S Section 5( a) 20
Rehabilitative therapies (Continued) You pay
Not covered:
· long-term rehabilitative therapy
· exercise programs
· cardiac rehabilitation

All charges

Hearing services (testing and treatment)
· Hearing testing performed by a Plan physician for adult and children (see Preventive care, children) $10 per office visit

Not covered:
· hearing aids, testing and examinations for them
· Timpanometry

All charges

Vision services (testing and treatment)
· In addition to medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, annual eye refractions (that
include the written lens prescription) may be obtained from Plan providers.
$10 per office visit

· Lenses following cataract removal $10 per office visit
· Eye exam to determine the need for vision correction for children (see preventive care) $10 per office visit

Not covered:
· Eyeglasses or contact lenses, corrective lenses, frames, fitting of contact lenses

· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery
· Optometrist services

All charges

Foot care
Routine foot care performed by a Plan doctor when you are under active treatment for a metabolic or peripheral vascular disease, such as
diabetes.
$10 per office visit

Foot care --Continued on next page 20
20 Page 21 22
2001 Triple-S Section 5( a) 21
Foot care (Continued) You pay
Not covered:
· Treatment of weak, strained or flat feet
· podiatric services

All charges

Orthopedic and prosthetic devices
· Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

· Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see Section 5 (c) for payment information. See 5
(b) for coverage of the surgery to insert the device.

Nothing if provided by a Plan doctor or provider
If provided by a non-Plan doctor, provider or medical equipment
supplier, you should pay the provider's claim and seek
reimbursement from this Plan. Plan reimburses you 90% of
established fees.
Not covered:
· orthopedic and corrective shoes
· arch supports
· foot orthotics
· heel pads and heel cups
· lumbosacral supports
· corsets, trusses, elastic stockings, support hose, and other supportive devices

· artificial limbs and eyes; stump hose

All charges 21
21 Page 22 23
2001 Triple-S Section 5( a) 22
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and other respiratory equipment. Under this benefit, we also cover:

· hospital type beds;
· Non motorized wheel chairs
· iron lungs;
· oxygen equipment; and
· other respiratory equipment
Note: You must obtain a precertification from us. Refer to Section 3. Call us at 787-749-4777 as soon as your Plan physician prescribes this
equipment to obtain a precertification. We will arrange with a health care provider to rent or sell you durable medical equipment at
discounted rates and will tell you more about this service when you call.

$10 per office visit

Not covered:
· Motorized wheel chairs
· Crutches
· Walkers
· Blood glucose monitors
· Insulin pumps
· Other durable medical equipment not shown above.

All charges

Home health services
· Home health care ordered by a Plan physician (who will periodically review the program for continuing appropriateness and need) and
provided by nurses or home health aide.
· Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
· nursing care requested by, or for the convenience of, the patient or the patient's family;

· nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.
· homemaker services

All charges 22
22 Page 23 24
2001 Triple-S Section 5( a) 23
Alternative treatments You pay
Not covered:
· chiropractic services
· naturopathic services
· hypnotherapy
· biofeedback
· osteopathic services
· acupuncture
· podiatric services

All charges

Educational classes and programs
Our disease management programs are addressed to deal with pregnancy and asthma conditions. They provide individual education
by using recognized protocols of professional entities. Counseling from professional specialists is also available.

· Asthma program – Addressed to enhance the quality of life of the asthmatic insured by teaching them self health care and illness
management.
· Pregnancy educational program – Provides education about pregnancy during prenatal, delivery and postnatal stages.
Emphasizes risk factors that every women should know to have a healthy delivery and to avoid complications.

· Both programs coordinate services with the case management program when the insured needs service alternatives to handle
his/ her health care. They also provide counseling from health educators within the workplace. Individual education also includes
the distribution of written literature.

Nothing 23
23 Page 24 25
2001 Triple-S Section 5( b) 24
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan physicians must provide or arrange your care.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
· The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5 (c) for charges associated with the
facility (i. e. hospital, surgical center, etc.).
· YOU OR YOUR PLAN DOCTOR MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require precertification and identify which surgeries require precertification.

Note: We will pay for services provided by a non-Plan provider outside the service area only if the services are for an emergency or if they have been preauthorized. In general, we will
only authorize care, equipment, or professional services that are not available from a Plan provider within the service area.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
· Treatment of fractures, including casting
· Normal pre-and post-operative care by the surgeon
· Correction of amblyopia and strabismus
· Endoscopy procedure
· Biopsy procedure
· Removal of tumors and cysts
· Correction of congenital anomalies (see reconstructive surgery)
· Surgical treatment of morbid obesity
· Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces and prosthetic devices for device coverage information.

· Lithotripsy procedure.

Nothing
For insertion of internal prosthetic devices member pays nothing if
provided by a Plan doctor or provider. If provided by a non-Plan
doctor, provider or medical equipment supplier, you should
pay the provider's claim and seek reimbursement from us. We will
reimburse you 90% of our established fees.

Surgical procedures --Continued on next page 24
24 Page 25 26
2001 Triple-S Section 5( b) 25
Surgical procedures (Continued) You pay
· Voluntary sterilization
· Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are covered under 5 (a).

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

Nothing

Not covered:
· Reversal of voluntary sterilization
· Surgical assistance

All charges

Reconstructive surgery
· Surgery to correct a functional defect
· Surgery to correct a condition caused by injury or illness if:
·· the condition produced a major effect on the member's appearance and

·· the condition can reasonably be expected to be corrected by such surgery
· Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

· All stages of breast reconstruction surgery following a mastectomy, such as:
·· surgery to produce a symmetrical appearance on the other breast;
·· treatment of any physical complications, such as lymphedemas;
·· breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

Nothing

Reconstructive surgery --Continued on next page 25
25 Page 26 27
2001 Triple-S Section 5( b) 26
Reconstructive surgery (Continued) You pay
Not covered:
· Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
· Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, performed only when medically necessary limited to:

· Reduction of fractures of the jaws or facial bones;
· Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

· Removal of stones from salivary ducts;
· Excision of leukoplakia or malignancies;
· Excision of cysts and incision of abscesses when done as independent procedures; and

· Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges

Organ/ tissue transplants
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas

Nothing

Organ and tissue transplants --Continued on next page 26
26 Page 27 28
2001 Triple-S Section 5( b) 27
Organ/ tissue transplants (Continued) You pay
· Liver
· Lung: Single –Double
· Allogeneic (donor) bone marrow transplants
· Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
· You or your Plan doctor must obtain a precertification from us before an organ and tissue transplant. Refer to Section 3.

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

Nothing

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

· Implants of artificial organs
· Transplants not listed as covered

All charges

Anesthesia
Professional services provided in –
· Hospital (inpatient)
Nothing

Professional services provided in –
· Hospital outpatient department
· Ambulatory surgical center

Nothing 27
27 Page 28 29
2001 Triple-S Section 5( c) 28
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they
are medically necessary.

· Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care.
Any costs associated with the professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).

· YOU OR YOUR PLAN DOCTOR MUST GET A PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section
3 to be sure which services require precertification.

· If you use a non-participating hospital, this Plan will reimburse $60 per day, except for hospitalization due to accidental injury or a medical emergency as
shown on page 31.
Note: We will pay for services provided by a non-participating hospital outside the service area only if it is preauthorized. In general, we will authorize out of
area hospitalizations only for special cases that require equipment, mode of treatment or specialist care not available in Puerto Rico.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
· ward, semiprivate, or intensive care accommodations;
· general nursing care; and
· meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing per inpatient admission to a Plan hospital. Plan reimburses
you up to $60 daily for an inpatient admission to a non-Plan hospital
in the service area. You pay all charges over the $60 per day.

Inpatient hospital --Continued on next page 28
28 Page 29 30
2001 Triple-S Section 5( c) 29
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
· Operating, recovery, maternity, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests and X-rays
· Administration of blood and blood products

Nothing

· Blood or blood plasma, if not donated or replaced
· Dressings, splints, casts, and sterile tray services
· Medical supplies and equipment, including oxygen
· Anesthetics, including nurse anesthetist services
· Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Not covered:
· Custodial care, rest cures, domiciliary or convalescent care
· Non-covered facilities, such as nursing homes, schools
· Personal comfort items, such as telephone, television, barber services, guest meals and beds

· Private nursing care

All charges

Outpatient hospital or ambulatory surgical center
· Operating, recovery, and other treatment rooms
· Drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services
· Administration of blood and blood plasma, and other biologicals
· Blood or blood plasma, if not donated or replaced
· Pre-surgical testing
· Dressings, casts, and sterile tray services
· Medical supplies, including oxygen
· Anesthetics and anesthesia service
· NOTE: – We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment.

We do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member. All charges 29
29 Page 30 31
2001 Triple-S Section 5( c) 30
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): Unlimited medically appropriate care, 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. You or your Plan
doctor must obtain authorization from your Plan before Skilled Nursing
Facility confinement, as discussed on pages 10 and 11.

Nothing

Not covered: custodial care, rest cures, domicile or convalescent care. All charges
Hospice care
Not covered: Independent nursing, homemaker services, hospice care All charges

Ambulance
· Local professional ambulance service authorized by a Plan doctor when medically appropriate

· Air ambulance services within the Service Area will be rendered by a Plan provider.

You should submit the provider's claim and seek reimbursement from
us. We pay all charges. You pay nothing.

Nothing

Not covered: Air ambulance outside of the Service Area. All charges 30
30 Page 31 32
2001 Triple-S Section 5( d) 31
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

I M
P O
R T
A N
T
What is a medical emergency?

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

What to do in case of emergency?
Emergencies within our service area:
We have available a 24 hour toll free number. Call 1-800-255-4375 for professional medical advise regarding your condition. Also, you can contact your general practitioner physician. In extreme emergencies, if you are unable to
contact your general practitioner physician or the 24 hour toll free number, contact the local emergency system (e. g., the 911 telephone system or 343-2550) or go to the nearest hospital emergency room. When you call the 24 hour toll
free number and receive a precertification from there, the $5 copay is waived. Also, if the emergency results in admission to a hospital, you pay nothing for the inpatient admission.

· Be sure to tell the emergency room personnel that you are a Plan member so they can notify this Plan. You or a family member should notify this Plan within 48 hours unless it was not reasonably possible to notify this Plan
within that time. It is your responsibility to ensure that this Plan has been timely notified.
If you need to be hospitalized, this Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify this 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.
· When non-Plan providers are used this Plan pays 90% of Plan's established fees for doctor's services and full coverage for other services to the extent the services would have been covered if received from Plan providers.

Emergencies outside our service area:
You can contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Benefits are available for any medically necessary health service that is immediately required because of
injury or unforeseen illness through Blue Cross and Blue Shield plan providers. When non-Plan providers are used this Plan pays 90% of usual, customary and reasonable charges for the area in which the emergency services are
rendered. 31
31 Page 32 33
2001 Triple-S 32 Section 5( d)
Section 5 (d). Emergency services/ accidents (Continued)
· With your authorization, this Plan will pay benefits directly to non-Plan providers of your emergency care upon receipt of their claims. Non-Plan 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 this 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 this Plan's decision, you may request reconsideration in accordance with the disputed claims procedure described on page 47.

Benefit Description You pay
Emergency within our service area
· Emergency care at a doctor's office
· Emergency care at emergency room and an urgent care center
· Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

$10 per office visit
$5; if we precertify, the copayment is waived

Nothing
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
· Emergency care at a doctor's office
· Emergency care at an urgent care center

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

You should submit the provider's claim and seek reimbursement
from this Plan. Plan reimburses you 90% of usual, customary and
reasonable charges for the area in which emergency services are
rendered. With your authorization, this Plan will pay
benefits directly to non-Plan providers of your emergency care
upon receipt of their claims.

Not covered:
· Elective care or non-emergency care
· Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

· Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Emergency outside our service area --Continued on next page 32
32 Page 33 34
2001 Triple-S 33 Section 5( d)
Ambulance You pay
· Local professional ambulance service when medically appropriate. See 5( c) for non-emergency service.

· Air ambulance services within the Service Area will be rendered by a Plan provider
You should submit the provider's claim and seek reimbursement
from us.

Nothing

Not covered: Air ambulance service outside of the Service Area All charges 33
33 Page 34 35
2001 Triple-S 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve "parity" with other benefits. This means that we will provide mental health and substance abuse benefits differently than in the past.

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
· All benefits are subject to the definitions, limitations, and exclusions in this brochure.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

· YOU OR YOUR PLAN DOCTOR MUST GET PRECERTIFICATION OF THESE SERVICES. See the instructions after the benefits description below.
· This Plan pays its established fees for necessary professional services. If you use a non-Plan doctor or provider, you pay for services rendered and the Plan will reimburse you 90% of the Plan's established fee when services are
rendered within the service area; or 90% of the usual, customary and reasonable charge of the area in which the services are rendered when services are rendered outside the service area. Note: We will pay for services provided
by a non-Plan provider outside the service area only if the services are for an emergency or if they have been preauthorized. In general, we will only authorize care, equipment, or professional services that are not available
from a Plan provider within the service area.
· You must obtain our approval before services are rendered.
· You can access information about Mental Parity Act by visiting our website at http:// www. ssspr. com.

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

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

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

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

· Medication management

$10 per office visit and/ or therapy

· Diagnostic tests 25% laboratory and diagnostic tests. Nothing for X-rays. See Lab,
X-ray and other diagnostic tests (Section 5a).

Mental health and substance abuse benefits --Continued on next page. 34
34 Page 35 36
2001 Triple-S 35 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
· Services provided by a hospital or other facility
· Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about a treatment plan on the treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Precertification To be eligible to receive these benefits you must follow your treatment plan and the following authorization process:
· you or your Plan doctor or provider should call 1-800-660-4896 for
assistance. This is a 24 hour toll free number to help you obtain the precertification and the most appropriate care for your mental or

substance abuse condition.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued coverage with
your provider for up to 90 days under the following conditions:
· If your mental health or substance abuse professional provider with whom
you are currently in treatment leaves the plan at our request for other than cause, or

· If changes to this plan's benefit structure for 2001 cause your out-of-pocket
costs for your out-of-network provider to be greater than they were in contract year 2000.

If these conditions apply to you, we will allow you reasonable time to transfer your care to a network mental health or substance abuse professional provider.
During the transitional period, you may continue to see your treating provider and will not pay any more out-of-pocket than you did in the year 2000 for
services. This transitional period will begin with our notice to you of the change in coverage and will end 90 days after you receive our notice. If we write to you
before October 1, 2000, the 90-day period ends before January 1, 2001, and this transitional benefit does not apply.

Limitation We may limit your benefits if you do not follow your treatment plan.
Mental health and substance abuse benefits --Continued on next page 35
35 Page 36 37
2001 Triple-S 36 Section 5( e)
Description You pay
POS mental health and substance abuse benefits
This Plan pays its established fees for necessary professional services. If you use a non-Plan doctor or provider, you pay for services rendered and the Plan will reimburse you 90% of the Plan's established fee when services are
rendered within the service area; or 90% of the usual, customary and reasonable charge of the area in which the services are rendered when services are rendered outside the service area. Note: We will pay for services provided by
a non-Plan provider outside the service area only if the services are for an emergency or if they have been preauthorized. In general, we will only authorize care, equipment, or professional services that are not available from
a Plan provider within the service area.
You must obtain our approval before services are rendered.
Special nursing care for each 8-hour period not to exceed 72 consecutive hours, when ordered by the attending psychiatrist.

Psychological tests if performed by a qualified psychologist.
Plan reimburses you $18 per period for a registered nurse; $12 per
period for a licensed practical nurse; $12 per period for a
psychiatric aide. You pay the remaining charges.

Plan reimburses you up to $35 for a full battery of tests. You pay the
remaining charges.
Not covered: POS services we have not approved, half-way home, residential treatment and services related to a drug detection and
rehabilitation program.
All charges 36
36 Page 37 38
2001 Triple-S 37 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the chart beginning on the next page.

· All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
· If you use a non-Plan pharmacy, this Plan will reimburse you 75% of this Plan's established fees for prescription drugs and you pay all remaining

charges.

I M
P O
R T
A N
T

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

· We use a formulary. A formulary is a list of medicines that represents a previous evaluation of the Plan's Pharmacy and Therapeutics Committee regarding their efficiency, safety and cost
effectiveness; that guarantee the therapy quality, minimizing inadequate utilization that could affect the patient's health.

Benefits are provided to the member and member's direct dependents who have this coverage, for medications included in the formulary when prescribed by a doctor or a dentist; after applicable
copays are paid.
· These are the dispensing limitations. Federal Drug Administration (FDA) guidelines are used by this Plan to manage the pharmacy coverage. These include dosing, generic bioequivalent

medications and new drug classification, among others.
We cover prescription drugs dispensed within six months of a doctor or dentist's original prescription not to exceed the normal 34 days supply. The pharmacy network will not dispense any order too

soon after the last one was filled. If this is your case, the pharmacy will contact the Plan to obtain an authorization. Also, the pharmacy will contact the Plan to obtain an authorization for dose changes
and for charges over $500 per dispensed prescription.
When you are planning a trip and need a prescription drug refill in advance, you must show the pharmacy the prescription, along with the airline tickets, to allow the pharmacy to contact the Plan to

obtain an authorization.
The member will pay the brand name copay and the difference between the cost of the brand name prescription drug and the cost of the generic bioequivalent prescription drug; if he/ she chooses a brand

name prescription drug, for which a generic bioequivalent prescription drug exist. If a generic bioequivalent does not exist, you still have to pay the brand copay.

· When you have to file a claim.
You must file a claim whenever you use a non-network pharmacy. Plan reimburses 75% of its established fees for prescription drugs and you pay the remaining charges. Submit your itemized bill

and/ or receipts to us. Also read Section 7 Filing a claim for covered services for required information.

Prescription drug benefits begin on the next page. 37
37 Page 38 39
2001 Triple-S 38 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician or dentist and obtained from a Plan pharmacy:

We will cover prescription drugs based on a formulary. You will pay the brand name copay and the difference between the cost of the brand
name prescription drug and the cost of the generic bioequivalent prescription drug; if you choose a brand name prescription drug, for
which a generic bioequivalent prescription drug exists. Covered prescription drugs and accessories include:

· Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as
excluded below.
· Insulin
· Disposable needles and syringes for the administration of covered medications

· Contraceptive drugs and devices
· Vitamins only if they include the legend: "Federal law prohibits dispensing without a prescription"

· Smoking cessation drugs, including nicotine patches
· Intravenous fluids and drugs for home use, implantable drugs, and some injectable drugs are covered under the Medical and Surgical
Benefits (also covered under the Medical and Surgical Benefits provided as part of a home health service program).

You will pay the following in-formulary copayments:
· $2 for bioequivalent prescription drug unit or refill
· $5 for preferred brand prescription drug unit or refill
· $10 for brand name unit or refill.
Note: If you choose a brand name prescription drug, for which a
generic bioequivalent prescription drug exists, you will pay the brand
name copay and the difference between the cost of the brand name
prescription drug and the cost of the generic bioequivalent prescription
drug.
You will pay the following out of the formulary copayment:

· 20% or $10, whichever is higher, for out of formulary
prescription drug unit or refill.
Note: If a generic bioequivalent does not exist, you will still have
to pay the brand name copay.
Here are some things to keep in mind about our prescription drug program:

· A generic bioequivalent will be dispensed if it exists, unless your physician specifically requires a name brand. If you receive a name
brand drug when a Federally-approved generic drug exists, and your physician has not specified Dispense as Written for the name brand
drug, you have to pay the brand name copay and the difference in cost between the name brand drug and the generic.

· We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a list of drugs that we selected to
meet patient needs at a lower cost. To order a prescription drug brochure, call 787-749-4777.

Prescription drugs benefits --Continued on next page 38
38 Page 39 40
2001 Triple-S 39 Section 5( f)
Covered medications and supplies (Continued) You pay
Not covered:
· Drugs and supplies for cosmetic purposes
· Nutrients and food supplements even if a physician prescribes or administers them

· Drugs available without a prescription or for which there is a nonprescription equivalent available
· Medical supplies such as dressings and antiseptics
· Drugs supplied by pharmacies located outside of Puerto Rico, the United States and its territories

· Medication for treatment of infertility or impotence
· Drugs to enhance athletic performance
· Drugs that are experimental or investigational unless approved by the Federal Drug Administration (FDA)

· New drugs not approved by the plan's Pharmacy and Therapeutic Committee

All Charges 39
39 Page 40 41
2001 Triple-S Section 5( g) 40
Section 5 (g). Special Features
Feature Description
24 hours, 7 days a week call center We offer these services so the members can have immediate access to clinical advice to help them decide when to go to the emergency room
immediately, and how to avoid a visit to emergency room for routine care. Scientifically based protocols are entered into a computer and are

followed consistently. Members are oriented on how to reduce risk and manage their disease. Call us at 1-800-255-4375.

Blue Card Program Blue Card Program is available to all members insured with a Blue Cross and Blue Shield Association Plan. When you need hospital and
medical services in any state out of the service area, you can receive them through the Plan providers of this Program. Call 1-800-810-2583

or 787-749-4777 for additional information.

Centers of excellence for transplants/ heart
surgery/ etc

We offer you the benefit of the Blue Quality Centers for Transplant which is a cooperative effort among the Blue Cross and/ or Blue Shield
Plans, Blue Cross and Blue Shield Association and Participating Institutions to facilitate the provision of quality of care in a cost-effective
manner from leading institutions for six transplant types: heart, single or bilateral lung, combination heart-bilateral lung, liver,
simultaneous pancreas-kidney, and bone marrow/ stem cell (autologous/ allogeneic).

High risk pregnancies Our pregnancy educational program provides education about pregnancy during prenatal, delivery and postnatal stages. Emphasizes
risk factors that every women should know to have a healthy delivery and to avoid complications.

Blue Card Worldwide Blue Card Worldwide is available to all members insured with a Blue Cross and Blue Shield Association Plan. When you need emergency
hospital and medical services out of the service area or the United States of America, you can receive them through the Plan providers of this

Program in other countries. Call 1-800-810-2583 for additional information. 40
40 Page 41 42
2001 Triple-S Section 5( h) 41
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan dentists must provide or arrange your care.
· We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient; we do not cover the dental procedure unless it is described below.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must
result from an accidental injury. An injury caused by chewing is not considered an accidental injury.
Nothing

Dental benefits You pay
If a non-Plan dentist is used, you pay a 30% coinsurance and any remaining difference between this Plan's payment of 90% of its established fee and the actual charge for services rendered in Puerto Rico. For care outside of Puerto
Rico, the member will pay the 30% coinsurance and any remaining difference between 100% of this Plan's payment established fee and the actual charge. The following list shows the dental services covered by this Plan.

Plan dentist means a duly authorized dentist with a regular license issued by the designated entity of the government of Puerto Rico, and who is a bona fide member of the "Colegio de Cirujanos Dentistas de Puerto Rico", who has
signed a contract with Triple-S to render dental services. Non-Plan dentist means a duly authorized dentist with a regular license, who has not signed a contract with Triple-S to render dental services.

Dental coverage is limited to:
Diagnostic
· Periodic oral evaluation
· Limited oral evaluation
· Comprehensive oral evaluation
· Periapical and bitewing X-rays (limited to six periapical X-rays and no more than two bitewing X-rays per calendar year)

· Preventive Prophylaxis (adult and child)
· Fluoride treatment, one every six month. Fluoride treatment is limited to members under 19 years of age.

Nothing

Dental benefits --Continued on next page 41
41 Page 42 43
2001 Triple-S 42 Section 5( h)
Dental benefits You pay
Restorative
· Amalgam restorations
· Plastic, porcelain or composite (anterior and posterior tooth)
· Other restorative services (pin retention per tooth, in addition to restorations)

· Sedative filling
Adjunctive General Services
· Application of desensitizing medicament
· Gingival curettage, surgical (emergency treatment), for one or two teeth in the same quadrant

· Treatment of complications (post-surgical-unusual circumstances, by report)
Endodontics
· Pulp capping-direct (excluding final restoration)
· Pulp capping-indirect (excluding final restoration)
Oral Surgery
· Extractions
· Surgical removal of erupted tooth
· Surgical removal of residual tooth roots
· Incision and drainage of abscess -intra-oral soft tissue
· Surgical removal of impacted tooth

30%
30%
30%
30%

Not covered: Other dental services not shown as covered. All charges 42
42 Page 43 44
2001 Triple-S 43 Section 5( i)
Section 5 (i). Point of service benefits
Facts about this Plan's POS option
At your option, within our service area (Puerto Rico) you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need care, except for the benefits listed below under "What
is not covered." Outside of our service area, only emergency care or care that has been preauthorized will be covered under the POS option. In general, we will only authorize coverage outside of our service area for care,
equipment, or professional services that are not available from a Plan provider.

Point of Service (POS) Benefits
You can receive care from any non-Plan doctor within our service area without a referral. A non-Plan doctor is any licensed doctor of medicine (M. D.) who is not a Plan doctor. Non-Plan doctors do not have to accept Triple-S
established fees as payment in full. If you use a non-Plan doctor (except for speech or occupational therapy) you must pay the difference between the non-Plan doctor's charge and the amount paid to you by us.

You can also receive services from a non-Plan hospital within our service area. A non-Plan hospital is any licensed institution that is not a Plan hospital and that is engaged primarily in providing bed patient with diagnosis and
treatment under the supervision of physicians with 24-hour-a-day registered graduate nursing services. A non-Plan hospital does not have to accept Triple-S established fees as payment in full. You must pay any difference between
the non-Plan hospital's charges and the amount paid to you by us. We reimburse you up to $60 daily for non-Plan hospital inpatient admissions.

Benefits are paid according to the "medical benefits schedule". This is the schedule of established fees on which this Plan's payment of covered medical expense is based, when the services are rendered within the
service area. The medical benefits schedule applies to Puerto Rico. When services are rendered outside the service area, the Plan's payment is based on usual, customary and reasonable charges.

If you use a non-Plan doctor or provider, you pay for services rendered and we will reimburse you 90% of the Plan's established fee when services are rendered within the service area, or 90% of the usual, customary and
reasonable charge of the area in which the services are rendered when services are rendered outside the service area.

Non-Plan providers are under no obligation to accept our established fees as payment in full. You pay all charges remaining for outpatient care above our established fees when non-Plan providers are used, in addition
to the copayments. For all other care under this benefit you pay all remaining charges after we have paid benefits.

What is covered
Point of service benefits are described in Section 5 of this brochure.

Precertification
Read Section 3 for services requiring our prior approval.

What is not covered
Point of service benefits exclusions are described in Section 5 of this brochure. 43
43 Page 44 45
2001 Triple-S 44 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness or condition and we agree, as discussed under What Services Require Our Prior Approval on page 10.

We do not cover the following:
· Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits) outside our service area or eligible self-referred services (POS benefits) within our service area;

· Services, drugs, or supplies you receive while you are not enrolled in this Plan;
· Services, drugs, or supplies that are not medically necessary;
· Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

· Experimental or investigational procedures, treatments, drugs or devices;
· Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or
incest;
· Services, drugs, or supplies related to sex transformations;
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or

· Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. 44
44 Page 45 46
2001 Triple-S 45 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital and drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 787-749-4777.

When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:
· Covered member's name and ID number;
· Name and address of the physician or facility that provided the service or supply;

· Dates you received the services or supplies;
· Diagnosis;
· Type of each service or supply;
· The charge for each service or supply;
· A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and
· Receipts, if you paid for your services.
· For prescription drugs also include:
· Prescription drug name;
· Daily dosage;
· Prescription number;
· Dispensed supply; and
· National drug Code (NDC)
Submit your claims to:
Triple-S
P. O. Box 363628
San Juan, Puerto Rico 00936-3628 45
45 Page 46 47
2001 Triple-S 46 Section 7
Section 7. Filing a claim for covered services (Continued)
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 46
46 Page 47 48
2001 Triple-S 47 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for precertification:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Triple-S, P. O. Box 363628, San Juan, Puerto Rico 00936-3628; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or (b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request— go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.
We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
· 90 days after the date of our letter upholding our initial decision; or
· 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division II, P. O. Box 436, Washington, D. C. 20044-0436.

Send OPM the following information:
· A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

· Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
· Copies of all letters you sent to us about the claim;
· Copies of all letters we sent to you about the claim; and
· Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim. 47
47 Page 48 49
2001 Triple-S 48 Section 8
Section 8. The disputed claims process (Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or precertification/ prior approval, then call us at 787-749-4777 and we will expedite our review; or
(b) We denied your initial request for care or precertification/ prior approval, then:
·· If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

·· You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 48
48 Page 49 50
2001 Triple-S 49 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays
medical expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.

· What is Medicare? Medicare is a Health Insurance Program for:
·· People 65 years of age and older.
·· Some people with disabilities, under 65 years of age.
·· People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
·· Part A (Hospital Insurance). Most people do not have to pay for Part A.
·· Part B (Medical Insurance). Most people pay monthly for Part B.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare managed care plan you have.

· The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B benefits.
You may go to any doctor, specialist, or hospital that accepts Medicare. Medicare pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.

When you are enrolled in this Plan and Original Medicare, you still need to follow the rules in this brochure for us to cover your care.

(Primary payer chart begins on next page.) 49
49 Page 50 51
2001 Triple-S 50 Section 9
Section 9. Coordinating benefits with other coverage (Continued)
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

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

2) Are an annuitant, ü
3) Are a reemployed annuitant with the Federal government when…
a) Thepositionis excludedfromFEHB,or………………………………… ……….. ü

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

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), ü
5) Are enrolled in Part B only, regardless of your employment status, ü (for Part B
services)

ü (for other
services)
6) Are a former Federal employee receiving Workers'Compensation and the Office of Workers'Compensation Programs has determined

that you are unable to return to duty,

ü (except for claims
related to Workers' Compensation.)

B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and…

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD, ü
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD, ü
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, ü
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant………………………………………………… ………. ü
b) Are an active employee………………………………………… ……………………….. ……. ü 50
50 Page 51 52
2001 Triple-S 51 Section 9
Section 9. Coordinating benefits with other coverage (Continued)
Claims process --You probably will never have to file a claim form when you have both our Plan and Medicare.

· When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically
and we will pay the balance of covered charges. You will not need to do anything. To find out if you need to do something about filing your
claims, call us at 787-749-4777.
We waive some costs when you have Medicare --When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows: If
you are enrolled in Medicare Part A and Part B we will waive copays and coinsurance.

· Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans cover all Medicare Part A and B benefits. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan, the following options are available to you:

This Plan and another Plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary even out of the managed
care Plan's network and/ or service area (if you use our Plan providers), and we will waive our copayments and coinsurance.

Suspended FEHB coverage and a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed
care plan premium). For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the
Medicare+ Choice service area. 51
51 Page 52 53
2001 Triple-S 52 Section 9
Section 9. Coordinating benefits with other coverage (Continued)
· Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

Workers' Compensation We do not cover services that:
· you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
· OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your benefits. You must use our providers. If
medical benefits provided under such law are exhausted, we will be financially responsible for services or supplies that are otherwise covered
by us. We are entitled to be reimbursed by OWCP for services we provided that were later found to be payable by OWCP.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or for injuries hospital care for injuries or illness caused by another person, you must
reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our
subrogation procedures. 52
52 Page 53 54
2001 Triple-S 53 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a
person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include but are not
limited to:
· personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;

· homemaking, such as preparing meals or special diets;
· moving the patient;
· acting as a companion or sitter;
· supervising medication that can usually be self-administered; or
· treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording
temperature, pulse, and respirations, or administration and monitoring of feeding systems.

Experimental or investigational services This Plan considers factors which it determines to be most relevant under
the circumstances, such as: published reports and articles in the authoritative medical, scientific, and peer review literature; or written
protocols used by the treating facility or being used by another facility studying substantially the same drug, device, or medical treatment. This
Plan also considers Federal and other governmental agency approval as essential to the treatment of an injury or illness by, but not limited to, the
following: American Medical Association, U. S. Surgeon General, U. S. Department of Public Health, the Food and Drug Administration, or the
National Institutes of Health. 53
53 Page 54 55
2001 Triple-S 54 Section 10
Section 10. Definitions of terms we use in this brochure (Continued)
Medically necessary Services, drugs, supplies, or equipment provided by a hospital or covered provider of health care services that the Plan determines:
· are appropriate to diagnose or treat the patient's condition, illness or injury;
· are consistent with standards of good medical practice in the United States;
· are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
· are not a part of or associated with the scholastic education or vocational training of the patient; and
· in the case of inpatient care, cannot be provided safely on an outpatient basis.
The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug, or equipment does not, in itself, make it
medically necessary.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. The plan allowance in our service area,
Puerto Rico, is the medical benefits schedule, the fees Plan doctors have agreed to accept as payment in full. The Plan allowance outside of the
service area is the usual, customary and reasonable charge.

Us/ We Us and we refer to Triple-S.
You You refers to the enrollee and each covered family member. 54
54 Page 55 56
2001 Triple-S 55 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

· When you may change your enrollment;
· How you can cover your family members;
· What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

· When your enrollment ends; and
· When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your

employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan. 55
55 Page 56 57
2001 Triple-S 56 Section 11
Section 11. FEHB facts (Continued)
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

· OPM, this Plan, and subcontractors when they administer this contract;
· This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when

coordinating benefit payments and subrogating claims;
· Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

· OPM and the General Accounting Office when conducting audits;
· Individuals involved in bona fide medical research or education that does not disclose your identity; or

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

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

·· Your enrollment ends, unless you cancel your enrollment, or
·· You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

· Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact
your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices.

· TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire.

You may not elect TCC if you are fired from your Federal job due to gross misconduct. 56
56 Page 57 58
2001 Triple-S 57 Section 11
Section 11. FEHB facts (Continued)
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure.

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

·· You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days

after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and
we will not impose a waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled with us. You
can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions
for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

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

· Call the provider and ask for an explanation. There may be an error. · If the provider does not resolve the matter, call us at 787-749-4777
and explain the situation. · If we do not resolve the issue, call THE HEALTH CARE FRAUD
HOTLINE--202/ 418-3300 or write to: The United States Office of Personnel Management, Office of the Inspector General Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415. 57
57 Page 58 59
2001 Triple-S 58 Section 11
Section 11. FEHB facts (Continued)
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate
anyone who uses an ID card if the person tries to obtain services for a person who is not an eligible family member, or are no longer enrolled in
the Plan and tries to obtain benefits. Your agency may also take administrative action against you. 58
58 Page 59 60
2001 Triple-S 59 DoD/ FEHB Demonstration Project
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to enroll in the FEHB
Program. The demonstration will last for three years and began with the 1999 open season for the year 2000. Open season enrollments will be effective January
1, 2001. DoD and OPM have set up some special procedures to implement the Demonstration Project, noted below. Otherwise, the provisions described in this
brochure apply.

Who is eligible DoD determines who is eligible to enroll in the FEHB Program. Generally, you may enroll if:

· You are an active or retired uniformed service member and are eligible for Medicare;
· You are a dependent of an active or retired uniformed service member and are eligible for Medicare;
· You are a qualified former spouse of an active or retired uniformed service member and you have not remarried; or
· You are a survivor dependent of a deceased active or retired uniformed service member; and
· You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.

The demonstration areas · Dover AFB, DE · Commonwealth of Puerto Rico · Fort Knox, KY · Greensboro/ Winston Salem/ High Point, NC
· Dallas, TX · Humboldt County, CA area · New Orleans, LA · Naval Hospital, Camp Pendleton, CA
· Adair County, IA · Coffee County, GA
When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2000 open season, November 13, 2000, through December 11, 2000. Your coverage
will begin January 1, 2001. DoD has set-up an Information Processing Center (IPC) in Iowa to provide you with information about how to enroll. IPC staff will
verify your eligibility and provide you with FEHB Program information, plan brochures, enrollment instructions and forms. The toll-free phone number for the
IPC is 1-877/ DOD-FEHB (1-877/ 363-3342).
You may select coverage for yourself (Self Only) or for you and your family (Self and Family) during the 2000 and 2001 open seasons. Your coverage will begin
January 1 of the year following the open season during which you enrolled.
If you become eligible for the DoD/ FEHB Demonstration Project outside of open season, contact the IPC to find out how to enroll and when your coverage will
begin. 59
59 Page 60 61
2001 Triple-S 60 DoD/ FEHB Demonstration Project
Department of Defense/ FEHB Demonstration Project (Continued)
DoD has a web site devoted to the Demonstration Project. You can view information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations and zip code lists at www. tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2001 Guide to Federal Employees Health Benefits Plans Participating in the DoD/ FEHB Demonstration Project," on the
OPM web site at www. opm. gov.

TCC eligibility See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the only individual eligible
for TCC is one who ceases to be eligible as a "member of family" under your self and family enrollment. This occurs when a child turns 22, for example, or if you
divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10, United States Code. For these individuals, TCC begins the
day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC enrollment terminates after 36 months or the end of the Demonstration Project,
whichever occurs first. You, your child, or another person must notify the IPC when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project area, you cancel your coverage, or your coverage is terminated for any reason. TCC is
not available when the demonstration project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project. 60
60 Page 61 62
2001 Triple-S 61 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 41 Allergy tests 18
Alternative treatment 23 Ambulance 30, 31, 33
Anesthesia 27 Autologous bone marrow
transplant 27 Biopsies 24
Blood and blood plasma 29 Breast cancer screening 16
Casts 29 Changes for 2001 7, 8
Chemotherapy 19 Childbirth 17
Cholesterol tests 16 Claims 45-46
Coinsurance 53 Colorectal cancer screening 16
Congenital anomalies 24 Contraceptive devices and drugs 38
Coordination of benefits 49-52 Crutches 22
Custodial care 53 Definitions 53-54
Dental care 41 Diagnostic services 14, 15, 28, 29,
34, 41 Disputed claims review 47-48
Donor expenses (transplants) 27 Dressings 29, 39
Durable medical equipment (DME) 22
Educational classes and programs 23 Effective date of enrollment 55
Emergency 31-33 Experimental or investigational 44,
53 Eyeglasses 20
Family planning 18 Fecal occult blood test 16

General Exclusions 44 Hearing services 20
Home health services 22 Hospice care 30
Home nursing care 22 Hospital 28
Immunizations 15-17 Infertility 18, 39
In-hospital physician care 24 Inpatient Hospital Benefits 28,
31, 35 Insulin 22, 38
Laboratory and pathological services 15, 16, 29, 34
Magnetic Resonance Imaging (MRI) 11, 15
Mammograms 15 Maternity Benefits 17
Medicaid 52 Medically necessary 54
Medicare 49-52 Mental Conditions/ Substance
Abuse Benefits 34-36 Newborn care 15, 17
Nurse 15, 22 Licensed Practical Nurse 36
Nurse Anesthetist 29 Nurse Practitioner 36
Psychiatric Nurse 36 Registered Nurse 36
Nursery charges 17 Obstetrical care 17
Occupational therapy 19 Ocular injury 20
Office visits 14-20 Oral and maxillofacial surgery 26
Orthopedic devices 21 Out-of-pocket expenses 12
Outpatient facility care 29 Oxygen 22, 29

Pap test 16 Physical therapy 19
Physician 5 Point of service (POS) 36, 43
Precertification 10, 35, 43 Preventive care, adult 16
Preventive care, children 16 Prescription drugs 37
Preventive services 16, 41 Prior approval 10, 43
Prostate cancer screening 16 Prosthetic devices 21, 24, 25
Psychologist 34, 36 Radiation therapy 19
Rehabilitation therapies 19 Renal dialysis 19
Room and board 28 Second surgical opinion 15
Skilled nursing facility care 14 Smoking cessation 38
Speech therapy 19 Splints 29
Sterilization procedures 18, 25 Subrogation 52
Substance abuse 34-36 Surgery 24-27
· Anesthesia 27, 29 · Oral 42
· Outpatient 29 · Reconstructive 25, 26
Syringes 38 Temporary continuation of
coverage 56 Transplants 26, 27, 40
Treatment therapies 19 Vision services 17, 20
Well child care 17 Wheelchairs 22
Workers' compensation 52 X-rays 15, 29, 34, 41 61
61 Page 62 63
2001 Triple-S 62 Summary
Summary of benefits for the Triple-S Plan – 2001
· Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

Benefits You Pay Page
Medical services provided by physicians: · Diagnostic and treatment services provided in the office................ Office visit copay:$ 7.50 general practitioner; $10 specialist, 25%

for laboratory and diagnostic
tests; nothing for X-rays. 14

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

Nothing
28
29

Emergency benefits:
· In-area.........................................................................................

· Out-of-area ..................................................................................

Emergency room $5; waived if precertified. Nothing for hospital.
10%
31-33

Mental health and substance abuse treatment..................................... Regular benefits 34
Prescription drugs ............................................................................. In-formulary: $2 for bioequivalent prescription
drug unit or refill; $5 for preferred brand
prescription drug unit or refill; and $10 for brand
name unit or refill.
Out of the formulary: 20% or $10, whichever is
higher, for out of formulary prescription
drug unit or refill.

37

Dental Care.................................................................................... Nothing for diagnostic services; 30% all other services. 41
Vision Care.................................................................................... $10 per office visit 20
Special features: · 24 hours, 7 days a week call center · Blue Card Program · Center of excellence for transplants/ heart surgeries/ etc · High risk pregnancies · Blue Card Worldwide 40

Point of Service benefits --Yes 36, 43 62
62 Page 63
2001 Triple-S 63
2001 Rate Information for Triple-S, 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 career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

All of Puerto Rico
Self Only 891 $68.36 $22.79 $148.12 $49.37 $80.90 $10.25

Self and Family 892 $146.82 $48.94 $318.11 $106.04 $173.74 $22.02 63

Page Navigation Panel