The Benefit Plan

To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is: All of Broward, Dade and Palm Beach Counties, Florida.

Lab, X-ray and other diagnostic tests

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

Type of

Code

USPS Your

Location Information

Not covered: The same exclusions contained in this brochure that apply to other benefits apply to these mental health and substance abuse benefits, unless the services are included in a treatment plan that we approve.

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

Not covered:

naturopathic services

hypnotherapy

biofeedback

Not covered: The same exclusions contained in this brochure that apply to other benefits apply to these mental health and substance abuse benefits, unless the services are included in a treatment plan that we approve.

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

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued coverage with your provider for up to 90 days under the following conditions:

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

Non-Postal Premium

Postal Premium

Emergencies within our service area:

You will be transferred when medically feasible.

Mental health and substance abuse benefits

Diagnostic and treatment services

Emergencies within our service area:

You will be transferred when medically feasible.

Mental health and substance abuse benefits

Accidental injury benefit

High Option

Educational classes and programs

Other hospital services and supplies, such as:

Outpatient hospital or ambulatory surgical center

Prescribed drugs and medicines

Hospice care

Section 5 (d). Emergency services/accidents

Preventive care, adult

Preventive care, adult (Continued)

Preventive care, children

Section 5 (d). Emergency services/accidents

Section 5. Benefits -- OVERVIEW

Section 5. Benefits -- OVERVIEW

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

Table of Contents

Introduction................................................................................... 4

Plain Language.................................................................................. 4

Section 1. Facts about this HMO plan......................................................................................................................................... 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.................................................................................................................................................... 7

Section 3. How you get care ......................................................................................................................................... 8

Identification cards....................................................................................................................................................... 8

Where you get covered care....................................................................................................................................... 8

Plan providers........................................................................................................................................................ 8

Plan facilities........................................................................................................................................................... 8

What you must do to get covered care..................................................................................................................... 8

Primary care............................................................................................................................................................ 8

Specialty care......................................................................................................................................................... 9

Hospital care........................................................................................................................................................... 9

Circumstances beyond our control.......................................................................................................................... 10

Services requiring our prior approval...................................................................................................................... 10

Section 4. Your costs for covered services............................................................................................................................... 11

Copayments.......................................................................................................................................................... 11

Deductible............................................................................................................................................................. 11

Coinsurance.......................................................................................................................................................... 11

Your out-of-pocket maximum.................................................................................................................................... 11

Section 5. Benefits................................................................................. 12

Overview...................................................................................................................................................................... 12

(a) Medical services and supplies provided by physicians and other health care professionals........... 13

(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........................................... 29

(d) Emergency services/accidents..................................................................................................................... 32

(e) Mental health and substance abuse benefits............................................................................................ 34

(f) Prescription drug benefits............................................................................................................................. 37

(g) Special features............................................................................................................................................... 40

(h) Dental benefits................................................................................................................................................ 41

Section 6. General exclusions -- things we don't cover........................................................................................................... 42

Section 7. Filing a claim for covered services............................................................................................................................ 43

Section 8. The disputed claims process..................................................................................................................................... 45

Section 9. Coordinating benefits with other coverage............................................................................................................. 47

When you have

Other health coverage........................................................................................................................................ 47

Original Medicare............................................................................................................................................... 47

Medicare managed care..................................................................................................................................... 47

TRICARE/Workers' Compensation/Medicaid...................................................................................................... 49

Other Government agencies..................................................................................................................................... 51

When others are responsible for injuries............................................................................................................... 51

Section 10. Definitions of terms we use in this brochure........................................................................................................ 52

Section 11. FEHB facts.................................................................................................................................................................. 54

Coverage information................................................................................................................................................

No pre-existing condition limitation............................................................................................................ 54

Where you get information about enrolling in the FEHB Program......................................................... 54

Types of coverage available for you and your family.............................................................................. 54

When benefits and premiums start.............................................................................................................. 54

Your medical and claims records are confidential..................................................................................... 55

When you retire............................................................................................................................................. 55

When you lose benefits........................................................................................................................................ 55

When FEHB coverage ends......................................................................................................................... 55

Spouse equity coverage............................................................................................................................... 55

Temporary Continuation of Coverage (TCC)............................................................................................ 55

Converting to individual coverage............................................................................................................. 56

Getting a Certificate of Group Health Plan Coverage ............................................................................. 56

Inspector General Advisory...................................................................................................................................... 56

Index ................................................................................................................................................................................... 57

Summary of benefits....................................................................................................................................................................... 59

Rates..Back cover

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 filla 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 (800) 213-1133.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments, deductibles, and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

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

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

What you must do to get care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. You and you family member(s) may choose a primary care physician to attend to your medical needs.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see see your specialist for a certain number of visits without additional referrals.

Self Referrals

You may self-refer for direct access to certain specialist without a referral from your primary care doctor for the following services from participating providers listed in our provider directory:

Chiropractic care for up to 20 visits within a 12-month period.

Dermatology care for up to 5 visits within a 12-month period for minor procedures and testing.

Well woman care to a gynecology specialist for an annual well woman exam.

Podiatric care for a podiatric evaluation. On-going podiatric treatment, surgery, or diagnostic tests must be preauthorized by this Plan.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician willwork with plan, to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or

drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 826-2862. 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 primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process preauthorization. Your physician must obtain preauthorization for the following services.

All transplants (organ, bone marrow)

Custom durable medical equipment

Custom prosthetics and orthotics

Infertility treatment

Nursing home placement

Any treatment that is considered experimental

Mental health/substance abuse

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 primary care physician you pay a copayment of $10 per office visit

Deductible We do not have a deductible

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for care.

Example: In our Plan, you pay 50% of our allowance for drugs to treat sexual dysfunction.

Your out-of-pocket maximum

for coinsurance and copayments After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments for the following services do not count toward your out-of-pocket maximum, and you must continue to pay copayments for these services:

prescription drugs.

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

(See page 7 for how our benefits changed this year and page 59 for a benefits summary.)

NOTE: This benefits section is dividedinto 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 (800) 213-1133.

(a) Medical services and supplies provided by physicians and other health care professionals .13-23

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, treatment, and supplies)

Vision services (testing, treatment, and supplies)

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.......................... 24-28

Surgical procedures

Reconstructive surgery

Oral and maxillofacial surgery

Organ/tissue transplants

Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services............................................................. 29-31

Inpatient hospital

Outpatient hospital or ambulatory surgical center

Extended care benefits/skilled nursing care facility benefits

Hospice care

Ambulance

(d) Emergency services/accidents........................................................................................................................................ 32-33

Medical emergency Ambulance

(e) Mental health and substance abuse benefits............................................................................................................... 34-36

(f) Prescription drug benefits37-39

(g) Special features 40

24 hour EMT Line

Service for deaf and hearing impairment

(h) Dental benefits. 41

Summary of benefits59

Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
	I M P O R T A N T	Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. Plan physicians must provide or arrange your care. We have no calendar year deductible. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.		I M P O R T A N T
Benefit Description			You pay
Diagnostic and treatment services
Professional services of physicians In physicians office Office medical consultations			$10 per office visit
At home In an urgent care center During a hospital stay In a skilled nursing facility Initial examination of a newborn child covered under a family enrollment Office medical consultations Second surgical opinion			Nothing
Lab, X-ray and other diagnostic tests
Tests, such as: Blood tests Urinalysis Non-routine pap tests Pathology X-rays Non-routine Mammograms Cat Scans/MRI Ultrasound Electrocardiogram and EEG			Nothing if you receive these services during your office visit; otherwise, $10 per visit
Preventive care, adult
Routine screenings, such as: Blood lead level One annually Total Blood Cholesterol once every three years, ages 19 through 64 Colorectal Cancer Screening, including Fecal occult blood test			$10 per office visit

Sigmoidoscopy, screening every five years starting at age 50			$10 per office visit
Prostate Specific Antigen (PSA test) one annually for men age 40 and older			$10 per office visit
Routine pap test Note: The office visit is covered if pap test is received on the same day; see Diagnostic and Treatment services, above.			$10 per office visit

Preventive care, adult (Continued)	You pay
Routine mammogram covered for women age 35 and older, as follows: From age 35 through 39, one during this five year period From age 40 through 64, one every calendar year At age 65 and older, one every two consecutive calendar years	$10 per office visit
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.	All charges.
Routine Immunizations, limited to: Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations) Influenza/Pneumococcal vaccines, annually, age 65 and over	$10 per office visit
Preventive care, children	You pay
Childhood immunizations recommended by the American Academy of Pediatrics	$10 per office visit
Examinations, such as: Eye exams through age 17 to determine the need for vision correction. Ear exams through age 17 to determine the need for hearing correction Examinations done on the day of immunizations ( through age 22) Well-child care charges for routine examinations, immunizations and care (through age 22)	$10 per office visit

Maternity care	You pay
Complete maternity (obstetrical) care, such as: Prenatal care Delivery Postnatal care Note: Here are some things to keep in mind: You do not need to precertify your normal delivery; see page 29 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. We cover routine nursery care of the newborn child during the covered portion of the mothers maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).	$10 per office visit
Not covered: Routine sonograms to determine fetal age, size or sex	All charges
Family planning
Voluntary sterilization Surgically implanted contraceptives Injectable contraceptive drugs Intrauterine devices (IUDs)	$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic counseling,	All charges.
Infertility services	You pay
Diagnosis and treatment of infertility, such as: Artificial insemination: intravaginal insemination (IVI) intracervical insemination (ICI)	$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 Allergy injection	$10 per office visit
Allergy serum	Nothing
Not covered: provocative food testing and sublingual allergy desensitization	All charges.
Treatment therapies	You pay
Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 27. Respiratory and inhalation therapy Dialysis Hemodialysis and peritoneal dialysis Intravenous (IV)/Infusion Therapy Home IV and antibiotic therapy Growth hormone therapy (GHT) Note: We will only cover GHT when we preauthorize the treatment. Call (305) 408-5853 for preauthorization. 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.	$10 per office visit

Rehabilitative therapies	You pay
Physical therapy, occupational therapy and speech therapy -- 60 days per condition for the services of each of the following: qualified physical therapists; speech therapists; and occupational therapists. Note: We only cover therapy to restore bodily function or speech when there has been a total or partial loss of bodily function or functional speech due to illness or injury.	$10 per office visit
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided up to 21 days per condition.	Nothing
Not covered: long-term rehabilitative therapy exercise programs	All charges.
Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury Hearing testing for children through age 17 (see Preventive care, children)	$10 per office visit
Not covered: all other hearing testing hearing aids, testing and examinations for them	All charges.

Vision services (testing, treatment, and supplies)	You pay
Eye exam to determine the need for vision correction for children through age 17 (see preventive care)	$10 per office visit
Not covered: Eyeglasses or contact lenses and, after age 17, examinations for them Eye exercises and orthoptics Radial keratotomy and other refractive surgery	All charges
Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. See orthopedic and prosthetic devices for information on podiatric shoe inserts.	$10 per office visit
Not covered: Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)	All charges.

Orthopedic and prosthetic devices	You pay
Artificial limbs and eyes; stump hose Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device. Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.	$10 per office visit
Not covered: orthopedic and corrective shoes arch supports foot orthotics heel pads and heel cups lumbosacral supports corsets, trusses, elastic stockings, support hose, and other supportive devices prosthetic replacements provided less than 3 years after the last one we covered]	All charges.
Durable medical equipment (DME)	You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover: hospital beds; wheelchairs; crutches; walkers; blood glucose monitors Note: Call us at (800) 213-1133 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.	$10 per office visit
Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide. Services include oxygen therapy, intravenous therapy and medications.	Nothing
Not covered: nursing care requested by, or for the convenience of, the patient or the patients family; care by nurses primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.	All charges.
Alternative treatments
Chiropractic services when approved by your primary care physician	$10 per office visit
Not covered: naturopathic services hypnotherapy biofeedback	All charges.
Educational classes and programs
Coverage is limited to: Smoking Cessation. Diabetes self-management Pre-Natal Classes CPR Heart saver course CPR for infants and children Asthma education Hypertension education Prognosis news letter Catastrophic management plan	Nothing

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
	I M P O R T A N T	Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. Plan physicians must provide or arrange your care. We have no calendar year deductible. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5 ( c ) for charges associated with the facility (i.e. hospital, surgical center, etc.).		I M P O R T A N T
Benefit Description			You pay
Surgical procedures
Such as: Treatment of fractures, including casting Normal pre- and post-operative care by the surgeon Correction of amblyopia and strabismus Endoscopy procedure Biopsy procedure Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery) Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over. Insertion of internal prostethic devices. See 5(a) Orthopedic braces and prosthetic devices for device coverage information.			$10 per office visit; nothing for hospital visits

Surgical procedures continued on next page.

Surgical procedures (Continued)	You pay
Voluntary sterilization Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are covered under 5(a). Treatment of burns Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.	$10 per office visit
Not covered: Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.	All charges.
Reconstructive surgery
Surgery to correct a functional defect Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the members appearance and the condition can reasonably be expected to be corrected by such surgery Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.	$10 per office visit

Reconstructive surgery (Continued)	You pay
All stages of breast reconstruction surgery following a mastectomy, such as: surgery to produce a symmetrical appearance on the other breast; treatment of any physical complications, such as lymphedemas; breast prostheses and surgical bras and replacements (see Prosthetic devices) Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.	See above.
Not covered: Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury Surgeries related to sex transformation	All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional malocclusion; Removal of stones from salivary ducts; Excision of leukoplakia or malignancies; Excision of cysts and incision of abscesses when done as independent procedures; and Other surgical procedures that do not involve the teeth or their supporting structures.	$10 per office visit
Not covered: Oral implants and transplants Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)	All charges.

Organ/tissue transplants

You pay

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single Double

Pancreas

Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

National Transplant Program (NTP)

Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-approved clinical trial at a Plan-designated center of excellence and if approved by the Plans medical director in accordance with the Plans protocols.

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

Nothing

Not covered:

Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs

Transplants not listed as covered

All charges

Anesthesia

You pay

Professional services provided in

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Nothing

Professional services provided in

Office

$10 per office visit

Inpatient hospital	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 Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services Take-home items Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home	Nothing
Not covered: Custodial care Non-covered facilities, such as nursing homes, extended care facilities, schools Personal comfort items, such as telephone, television, barber services, guest meals and beds Private nursing care Blood and blood derivatives not replaced by the member	All charges.
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals Pre-surgical testing Dressings, casts, and sterile tray services Medical supplies, including oxygen Anesthetics and anesthesia service NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.	Nothing
Not covered: blood and blood derivatives not replaced by the member	All charges
Extended care benefits/skilled nursing care facility benefits	You pay
This Plan provides a comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary.	$100 per admission
Not covered: custodial care	All charges
Hospice care
Hospice care is covered in the home or hospice facility when life expectancy is 6 months or less and when all necessary medical procedures have been exhausted. Services include inpatient and outpatient care and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness.	Nothing
Not covered: Independent nursing, homemaker services	All charges
Ambulance
Local professional ambulance service when medically appropriate	Nothing

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

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

We have no calendar year deductible.

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

What is a medical emergency?

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

What to do in case of emergency:

Call your primary care doctor. If you are unable to contact your doctor, call 911 or go to the nearest emergency room. Be sure to tell the emergency room personnel that you are a Plan member so that can notify the Plan.

If you need to be hospitalized, the Plan must be notified within 48 hours, unless it is not possible. If you are

Hospitalized in a non Plan facility and Plan doctors believe care can be better provided in a Plan hospital,

Emergencies outside our service area:

Benefits are available for any medically necessary health service outside our service area that is immediately required because of unforeseen illness. You pay $75 per hospital emergency room visit. If the emergency results in admission to a hospital, the co-pay is waived

Benefit Description	You pay
Emergency within our service area

Emergency care at a doctor's office	$10 per visit
Emergency care at an urgent care center	Nothing
Emergency care as an outpatient or inpatient at a hospital including doctors services	$25 per visit at a participating hospital; $75 per visit at a non-participating hospital
Not covered: Elective care or non-emergency care	All charges.
Emergency outside our service area
Emergency care at a doctor's office	$10 per visit
Emergency care at an urgent care center	Nothing
Emergency care as an outpatient or inpatient at a hospital, including doctors' services	$75 per visit
Not covered: Elective care or non-emergency care Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.	All charges.
Ambulance
Professional ambulance service when medically appropriate. See 5(c) for non-emergency service.	Nothing
Not covered: air ambulance	All charges.

Section 5 (e). Mental health and substance abuse benefits

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:

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 clinically appropriate to treat your condition.

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

BenefitDescription

You pay

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.

For example, this can include:

services by providers such as psychiatrists, psychologists, or clinical social workers,

any diagnostic test that they order,

any facilities that they admit you to, or

any drugs that are prescribed for your condition.

In some cases, our network providers may refer you to community based programs if they are appropriate to treat your condition such as self-help groups or 12 step programs.

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. Cost sharing and limitations for benefits that we cover (for example, visit/day limits, deductibles, coinsurance, copayments, and out-of-pocket maximums) for mental health and substance abuse are based on the cost sharing and limits for similar benefits under our network medical, hospital, prescription drug, diagnostic testing, and surgical benefits.

For example, the same copayment ($10 per office visit) that applies when you visit a specialist for a physical illness or disease applies to a visit to a mental health or substance abuse provider for a therapy session.

You will pay the same copayment or coinsurance for a prescription drug to treat a mental health or substance abuse condition as you would for a prescription to treat a physical illness or disease.

Diagnostic tests

.Services provided by a hospital of other facility

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

Nothing

All charges.

Mental health and substance abuse benefits -- Continued on next page.

Section 5 (f). Prescription drug benefits
	I M P O R T A N T	Here are some important things to keep in mind about these benefits: We cover prescribed drugs and medications, as described in the chart beginning on the next page. All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary. We have no calendar year deductible Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.	I M P O R T A N T
	There are important features you should be aware of. These include: Who can write your prescription. A licensed physician must write the prescription or A plan physician or licensed dentist must write the prescription . Where you can obtain them. You must fill the prescription at a Plan pharmacy, We use a formulary. The formulary is developed by the Plans Pharmacy and Therapeutic Committee and is based on the Michigan Medicaid formulary. The drugs shown on the Plans formulary are evaluated for their therapeutic value and cost. New drugs are added or deleted from the formulary based on determinations made by the Michigan Medicaid program, and the Pharmacy and Therapeutics Committee. These are the dispensing limitations.Prescription drugs will be dispensed for up to a 31-day supply. When you have to file a claim. Contact us (800) 213-1133. We will assist you in your claim.

Prescription drug benefits begin on the next page.

Benefit Description

You pay

Covered medications and supplies

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy.

Drugs for which a prescription is required by law

Insulin

Disposable needles and syringes for the administration of covered medications

Contraceptive drugs and devices

Injectable contraceptive drugs

Implanted time-release medications, such as Norplant

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

Compounded dermatological preparations

Nitroglycerine, Phenobarbital or Thyroid U.S.P.

Intravenous Fluids and medication for home use

$5 per generic/$15 per brand name prescription

Drugs for sexual dysfunction

50% of charges

Covered medications and supplies (continued)

You pay

Here are some things to keep in mind about our prescription drug program:

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

We administer an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 800/826-2862

Not covered:

Drugs and supplies for cosmetic purposes

Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines

Smoking cessation drugs and medication, including nicotine patches

Drugs to enhance athletic performance

Medical supplies such as dressings and antiseptics

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Fertility drugs

All Charges

Section 5 (h). Dental benefits
	I M P O R T A N T	Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. Plan dentists must provide or arrange your care. We have no calendar year deductible. We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is described below. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.		I M P O R T A N T
Accidental injury benefit			You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury and treatment must be received within six months of the accident.			Nothing
Dental benefits
We have no other dental benefits.

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

The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

Services, drugs, or supplies you receive while you are not enrolled in this Plan;

Services, drugs, or supplies that are not medically necessary;

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

Experimental or investigational procedures, treatments, drugs or devices;

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

Services, drugs, or supplies related to sex transformations; or

Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

Section 8. The disputed claims process

Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step	Description
1	Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and (b) Send your request to us at: Total Health Choice, Inc. 8701 SW 137^th Avenue, Suite 200, Miami, Florida 33183. and (c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and (d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
2	We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or (b) Write to you and maintain our denial -- go to step 4; or (c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our requestgo to step 3.
3	You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
4	If you do not agree with our decision, you may ask OPM to review it.
	You must write to OPM within: 90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or 120 days after we asked for additional information.
	Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III, 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. The Disputed Claims process (Continued)
	Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim. Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim. Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must provide a copy of your specific written consent with the review request. Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.
5	OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
6	If you do not agree with OPMs decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, 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 preauthorization/prior approval, then call us at (800) 213-1133 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division III at 202/606-0737 between 8 a.m. and 5 p.m. eastern time.

Section 9. Coordinating benefits with other coverage

When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called double coverage.

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

When we are the primary payer, we will pay the benefits described in this brochure.

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

What is Medicare? Medicare is a health Insurance Program for:

People 65 years of age and older.

Some people with disabilities, under 65 years of age.

People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:

Part A (Hospital Insurance). Most people do not have to pay for Part A.

Part B (Medical Insurance). Most people pay monthly for Part B.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + 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.)
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly.

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

Claims process You probably will never have to file a claim form when you have both our Plan and Medicare.

When we are 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 is you nneed to do something about filing your claims, call us at (800) 213-1133.

We waive some costs when you have Medicare When Medicare is the primary payer, we do not waive copays or deductibles except as associated with an authorized inpatient hospitalization.

Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare part B, we do not waive copays for medical services of supplies.

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 Medicaremanaged care plan, the following options are available to you:

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this case, we do not waive any of our copayments or coinsurance for your FEHB coverage.

This Plan and another Plans Medicare managed care plan: You may enroll in another plans Medicare managed care plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plans network and/or service area, but we will not waive any of our copayments or 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.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be

Medicare Part B covered under the FEHB Program. We cannot require you to enroll in Medicare.

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

Workers Compensation We do not cover services that:

you need because of a workplace-related disease or injury that the Office of Workers Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State,

are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for

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

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

Section 11. FEHB facts

No pre-existing condition We will not refuse to cover the treatment of a condition that you had

limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www.opm.gov/insure. Also, your employing or retirement office

about enrolling in the can answer your questions, and give you a Guide to Federal Employees

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

When you may change your enrollment;

How you can cover your family members;

What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and

When the next open season for enrollment begins.

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

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

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

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

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

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

records are confidential the following will have access to it:

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

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

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

OPM and the General Accounting Office when conducting audits;

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

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

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

When you lose benefits

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

Your enrollment ends, unless you cancel your enrollment, or

You are a family member no longer eligible for coverage.

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

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

coverage continue to get benefits under your former spouses enrollment. But, you may be eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouses employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices.

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

You may not elect TCC if you are fired from your Federal job due to gross misconduct.

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 313/871-2000 and explain the situation.

If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/418-3300 or write to: The United States Office of Personnel Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the person tries to obtain services for a someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take administrative action against you.

Accidental injury 41

Allergy tests 17

Alternative treatment 23

Ambulance 31

Anesthesia 27

Autologous bone marrow transplant 27

Biopsies 24

Birthing centers 16

Blood and blood plasma 29

Casts 24

Catastrophic protection 23

Changes for 2001 7

Chemotherapy 18

Childbirth 16

Cholesterol tests 14

Circumcision 16

Claims 43

Coinsurance 11

Colorectal cancer screening 14

Contraceptive devices and drugs 38

Coordination of benefits 47

Covered charges 11

Crutches 21

Deductible 11

Definitions 52

Dental care 41

Diagnostic services 13

Disputed claims review 45

Donor expenses (transplants) 27

Dressings 29

Durable medical equipment (DME) 21

Educational classes and programs 23

Effective date of enrollment 55

Emergency 32

Experimental or investigational 42

Eyeglasses 20

Family planning 16

Fecal occult blood test 14

General Exclusions 42

Hearing services 19

Home health services 22

Hospice care 30

Home nursing care 22

Hospital 29

Immunizations 15

Infertility 16

Inhospital physician care 29

Inpatient Hospital Benefits 29

Insulin 38

Laboratory and pathological services 13

Magnetic Resonance Imagings (MRIs) 14

Mammograms 15

Maternity Benefits 16

Medicaid 50

Medically necessary 53

Medicare 47

Mental Conditions/Substance Abuse Benefits 34

Neurological testing 14

Newborn care 16

Non-FEHB Benefits 42

Nursery charges 16

Obstetrical care 16

Occupational therapy 19

Ocular injury 13

Office visits 13

Oral and maxillofacial surgery 26

Orthopedic devices 21

Ostomy and catheter supplies 22

Out-of-pocket expenses 11

Outpatient facility care 29

Oxygen 22

Pap test 14

Physical examination 13

Physical therapy 14

Physician 13

Preventive care, adult 14

Preventive care, children 14

Prescription drugs 37

Preventive services 23

Prior approval 10

Prostate cancer screening 14

Prosthetic devices 21

Psychologist 34

Psychotherapy 34

Radiation therapy 18

Rehabilitation therapies 19

Renal dialysis 18

Room and board 29

Second surgical opinion 13

Skilled nursing facility care 13

Smoking cessation 23

Speech therapy 19

Splints 29

Sterilization procedures 25

Subrogation 51

Substance abuse 34

Surgery 24

Anesthesia 27

Oral 26

Outpatient 36

Reconstructive 25

Syringes 29

Temporary continuation of coverage 55

Transplants 27

Treatment therapies 18

Vision services 20

Well child care 15

Wheelchairs 21

Workers compensation 55

X-rays 14

Feature	Description

24 hour Emergency Medical Technician (EMT) line	For any of your health concerns, 24 hours a day, 7 days a week, you may call (305) 405-5700 and talk with an emergency technician who will discuss treatment options and answer your health questions.
Services for deaf and hearing impaired	If you have a hearing impairment, you may call Total Health Choice by using the TTY/TTD line at (800) 649-3777 for assistance

Benefits	You Pay	Page
Medical services provided by physicians: Diagnostic and treatment services provided in the office...................	Office visit copay: $10 primary care; $10 specialist	13
Services provided by a hospital: Inpatient...................................................................................................... Outpatient...................................................................................................	$100 per admission Nothing	24 24
Emergency benefits: In-area......................................................................................................... Out-of-area.................................................................................................	$25 per visit at a participating hospital; $75 per visit at a non-participating hospital $75 per visit	32 32
Mental health and substance abuse treatment........................................	Regular cost sharing	34
Prescription drugs..........................................................................................	$5 generic/$15 brand name per prescription	37
Dental Care..................................................................................................	Nothing for preventive services.	41
Vision Care...................................................................................................	No benefit.	20
Special features: 24 hour EMT Line Services for deaf and hearing impaired		40
Protection against catastrophic costs (your out-of-pocket maximum)..................................................................	Nothing after $1,500/Self Only or $3,000/Family enrollment per year	11

Section 5 (c). Services provided by a hospital or other facility, and ambulance services

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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).

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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.

$100 per admission