All Federal employees and annuitants
who are eligible to enroll in the
Federal Employees Health Benefits
Program and who are, or become, members or
associate members of
the National Postal Mail Handlers Union, a division of
LIUNA,
AFL-CIO.
: If you are a non-postal employee/ annuitant, you will
automatically
become an associate member of the National Postal Mail Handlers Union upon
enrollment in the Mail Handlers Benefit Plan. There is no membership charge
for members of the
National Postal Mail Handlers Union, a division of LIUNA,
AFL-CIO.
$42 per year for an associate membership. New associate members will be
billed
by the Mail Handlers Union for annual dues when the Plan receives
notice of enrollment. Continuing
associate members will be billed by the
Mail Handlers Union for the annual membership. 1
1
Page 2 3
2002
Mail Handlers Benefit Plan 2 Table of Contents
Introduction
.................................................................................................................................................................................................
4
Plain Language
............................................................................................................................................................................................
4
Inspector General
Advisory.........................................................................................................................................................................
4
Section 1. Facts about this fee-for-service plan
.......................................................................................................................................
5
Section 2. How we change for
2002.........................................................................................................................................................
6
Section 3. How you get
benefits...............................................................................................................................................................
7
Identification cards
..................................................................................................................................................................
7
Where you get covered care
....................................................................................................................................................
7
Covered
providers..........................................................................................................................................................
7
Covered facilities
...........................................................................................................................................................
8
What you must do to get covered care
....................................................................................................................................
9
How to get approval
for...........................................................................................................................................................
9
Your hospital stay
(precertification)..............................................................................................................................
9
Other services
..............................................................................................................................................................
10
Section 4. Your costs for covered services
............................................................................................................................................
11
Copayments
.................................................................................................................................................................
11
Deductible....................................................................................................................................................................
11
Coinsurance
.................................................................................................................................................................
11
Differences between our allowance and the
bill..........................................................................................................
12
Your catastrophic protection
...........................................................................................................................................
12– 13
When government facilities bill
us........................................................................................................................................
13
If we overpay
you..................................................................................................................................................................
13
When you are age 65 or over and you do have Medicare
..............................................................................................
14
When you have
Medicare......................................................................................................................................................
15
Section 5.
Benefits..................................................................................................................................................................................
16
Overview
...............................................................................................................................................................................
16
(a) Medical services and supplies provided by physicians and other health
care professionals .................................... 17– 31
(b) Surgical
and anesthesia services provided by physicians and other health care
professionals................................. 32– 38
(c) Services provided
by a hospital or other facility, and ambulance
services............................................................... 39– 43
(d) Emergency services/
accidents...................................................................................................................................
44– 45
(e) Mental health and substance abuse
benefits..............................................................................................................
46– 48
(f) Prescription drug
benefits..........................................................................................................................................
49– 51
(g) Special
features................................................................................................................................................................
52
Flexible benefits option
...............................................................................................................................................
52
Worldwide Assistance
.................................................................................................................................................
52
(h) Dental
benefits...........................................................................................................................................................
53– 56
(i) Non-FEHB benefits available to Plan members
.............................................................................................................
57 2
2 Page 3 4
2002 Mail Handlers Benefit Plan 3 Table of
Contents
Section 6. General Exclusions —things we don't
cover.......................................................................................................................
58
Section 7. Filing a claim for covered services
.................................................................................................................................
59– 60
Section 8. The disputed claims
process............................................................................................................................................
61– 62
Section 9. Coordinating benefits with other coverage
...........................................................................................................................
63
When you have other health coverage
............................................................................................................................
63
Original
Medicare......................................................................................................................................................
63– 65
Medicare managed care
plan...........................................................................................................................................
66
TRICARE/ Workers Compensation/
Medicaid.................................................................................................................
66
When other Government agencies are responsible for your
care....................................................................................
67
When others are responsible for
injuries.........................................................................................................................
67
Section 10. Definitions of terms we use in this
brochure...................................................................................................................
68– 71
Section 11. FEHB facts
............................................................................................................................................................................
72
Coverage
information......................................................................................................................................................
72
No pre-existing condition limitation
........................................................................................................................
72
Where you get information about enrolling in the FEHB Program
......................................................................... 72
Types of coverage available for you and your
family..............................................................................................
72
When benefits and premiums start
...........................................................................................................................
72
Your medical and claims records are confidential
...................................................................................................
73
When you retire
........................................................................................................................................................
73
When you lose benefits
...................................................................................................................................................
73
When FEHB coverage ends
.....................................................................................................................................
73
Spouse equity
coverage............................................................................................................................................
73
Temporary Continuation of Coverage (TCC)
..........................................................................................................
73
Converting to individual coverage
...........................................................................................................................
74
Getting a Certificate of Group Health Plan Coverage
.............................................................................................
74
Long term care insurance is coming later in 2002
....................................................................................................................................
75
Department of Defense/ FEHB Program Demonstration Project
..............................................................................................................
76
Index..........................................................................................................................................................................................................
77
Summary of Standard Option benefits
......................................................................................................................................................
78
Summary of High Option benefits
............................................................................................................................................................
79
Rates
..........................................................................................................................................................................................................
80 3
3 Page 4 5
2002 Mail Handlers Benefit Plan 4 Introduction
Mail Handlers Benefit Plan P. O. Box 45118
Jacksonville, Florida
32232-5118
This brochure describes the benefits of the Mail Handlers Benefit
Plan. The National Postal Mail Handlers Union, a division of LIUNA, AFL-CIO has
entered into a contract (CS1146) with the Office of Personnel Management (OPM)
as authorized by the
Federal Employees Health Benefit law. This Plan is underwritten by Niagara
Fire Insurance Company, a CNA company. This brochure is the official statement
of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and
exclusions of this brochure.
If you are enrolled in
this Plan, you are entitled to the benefits described in this brochure. If you
are enrolled for Self and Family coverage, each eligible family member is also
entitled to these benefits. You do not have a right to benefits that were
available before
January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and are summarized on page 6. Rates are shown at
the end of this brochure.
Teams of Government and health plans' staff worked on all FEHB brochures to
make them responsive, accessible, and understandable to the public. For
instance,
Except for necessary technical terms, we use common words. "You"
means the enrollee or family member; "we" means the Mail
Handlers Benefit
Plan
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650.
Fraud increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or
misrepresented any
information, do the following:
Call the provider and ask for an
explanation. There may be an error.
If the provider does not resolve the
matter, call us at 1-800-410-7778 and explain the situation.
If we do not
resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE 202/
418-3300
The United States Office of Personnel Management Office of the Inspector
General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, D. C. 20415.
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 they try to obtain services for
a person who is not an
eligible family member, or are no longer enrolled in the Plan and try to obtain
benefits. Your agency may also take administrative action against you. 4
4 Page 5 6
2002 Mail Handlers Benefit Plan 5 Section 1
This Plan is a fee-for-service (FFS) plan. You can choose your own
physicians, hospitals, and other health care providers.
We reimburse you or
your provider for your covered services, usually based on a percentage of the
amount we allow. The type and extent of covered services, and the amount we
allow, may be different from other plans. Read brochures carefully.
Our fee-for-service plan offers services through a PPO. When you use our PPO
providers, you will receive covered services at reduced cost. Contact us for the
names of PPO providers. You can also go to our web page, which you can reach
through the FEHB
web site, www. opm. gov/ insure. Continued participation of
any specific provider cannot be guaranteed. When you phone for an appointment,
please remember to verify that the health care professional or facility is still
a PPO provider. Do not call OPM or your
agency for our provider directory.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. Provider networks may be more extensive
in some areas than others. We cannot guarantee the availability of every
specialty in all areas. If no
PPO provider is available, or you do not use a PPO provider, the standard
non-PPO benefits apply. If you receive non-covered services from a PPO provider,
the PPO discount will not apply and these services will be excluded from
coverage.
This Plan has a contract with United Behavioral Health to administer our
mental conditions/ substance abuse benefits. They have contracts with mental
health professionals to provide these services. See Section 5( e) page 46.
This Plan has a contract with MultiPlan. MultiPlan has entered into
contracts with non-PPO providers who have agreed to discount their charges. The
Plan will consider these providers as participating providers. Covered inpatient
medical hospital claims will be
considered at 100% of the negotiated amount,
subject to the applicable per-admission copayment. Covered services provided by
MultiPlan participating professionals are considered based on the MultiPlan
negotiated amount less any applicable deductibles and
coinsurance.
This Plan offers access to a network of dentists who have agreed to provide
services at a discounted rate. To find a preferred dentist in your area, call
1-888-788-5702 or visit the Plan's web site www. mhbp. com. For information
about the Plan's dental benefits, review
this brochure or call the Plan at
1-800-410-7778.
When you use a PPO provider or facility, our Plan allowance is the negotiated
rate for the service. You are not responsible for charges above the negotiated
amount.
Non-PPO facilities and providers do not have special agreements with
the Plan. Our payment is based on the Plan allowance for covered services. You
may be responsible for amounts over the allowance.
If PPO providers are
available in your area and you do not use them, your out-of-pocket expenses will
increase. The Plan will base its allowance on a fee schedule that represents an
average of the PPO fee schedules for a particular service in a particular
geographic area
(see definition of Plan allowance, page 70, for further
details).
When we obtain discounts from MultiPlan participating providers,
or through direct negotiations with non-PPO providers, we pass along your share
of the savings.
OPM requires that all FEHB Plans provide certain information to their
members. You may get information about us, our networks, providers, and
facilities. OPM's FEHB web site (www. opm. gov/ insure) lists the specific types
of information that we must make
available to you.
You can find out
about case management, which includes medical practices guidelines, and how we
determine if procedures are experimental or investigational.
If you want more information about us, call 1-800-410-7778, or write to: Mail
Handlers Benefit Plan, P. O. Box 45118, Jacksonville, FL, 32232-5118. You may
also visit our web site at www. mhbp. com. 5
5
Page 6 7
2002
Mail Handlers Benefit Plan 6 Section 2
Do not rely on these
change descriptions; this page is not an official statement of benefits. For
that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not change
benefits.
We changed the address for sending disputed claims to OPM. (Section 8)
Four states are added to the list of states designated as medically
underserved in 2002: Georgia, Montana, North Dakota and Texas.
Louisiana is
no longer designated as medically underserved. (Section 3)
Your share of the non-Postal High Option Self Only premium will increase by
17.2%. For High Option Self and Family your share
will increase by 15.4%.
Your share of the non-Postal Standard Option Self Only premium will increase
by 17%. For Standard Option Self and Family your
share will increase by 17%.
We increased the calendar year deductible for High Option from $150 to $200
per person and from $450 to $600 per family.
We increased the calendar year
deductible for Standard Option from $200 to $250 per person and from $600 to
$750 per family.
We cover routine screening for chlamydial infection.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We now cover ostomy supplies under Durable Medical Equipment. Previously,
these supplies were covered as prescription drugs.
We added coverage for one
routine cholesterol screening and one routine urinalysis per year.
We added
coverage for outpatient services billed by the outpatient department of a
hospital.
We changed the benefit for services performed and billed in
conjunction with an outpatient office visit. Any same-day services
(except
immunizations or allergy shots) will be subject to the annual deductible and
coinsurance.
We now cover Department of Defense facilities as preferred providers.
Previously, overseas facilities were not considered as
preferred providers.
We changed the service provider for the Performance Lab program from LabCorp
to Quest Diagnostics. 6
6 Page
7 8
2002 Mail Handlers Benefit Plan
7 Section 3
We will send you an identification (ID) card when you
enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a
prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation
(for annuitants), or
your Employee Express confirmation letter.
If you
do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 1-800-410-7778.
You can get care from any "covered provider" or "covered facility." How much
we pay – and you pay – depends on the type of covered provider or facility you
use. If you use our preferred
providers, you will pay less.
We consider the following to be covered providers when they perform covered
services within the scope of their license or certification:
a licensed
doctor of medicine (M. D.)
a licensed doctor of osteopathy (D. O.)
a
licensed doctor of podiatry (D. P. M.)
a licensed dentist
a chiropractor
a licensed clinical physical therapist
a licensed occupational therapist
a licensed speech therapist
a clinical psychologist
a clinical
social worker
an optometrist
an audiologist
an acupuncturist
a
physician's assistant
a nurse midwife
a nurse practitioner/ clinical
specialist
a nursing school-administered clinic
. Note: We cover any licensed medical practitioner for any covered service
performed within the scope of that license in states OPM determines are
"medically
underserved." For 2002, the states are: Alabama, Georgia, Idaho,
Kentucky, Mississippi, Missouri, Montana, New Mexico, North Dakota, South
Carolina, South Dakota, Texas, Utah, and Wyoming. 7
7
Page 8 9
2002
Mail Handlers Benefit Plan 8 Section 3
Covered facilities
include:
. A facility which meets the following criteria: has
permanent
facilities and equipment for the primary purpose of performing surgical and/ or
renal dialysis procedures on an outpatient basis; provides treatment by or under
the supervision of
doctors and nursing services whenever the patient is in the facility; does
not provide inpatient accommodations; and is not, other than incidentally, a
facility used as an office or clinic for the
private practice of a doctor or
other professional. The Plan will apply its outpatient surgical facility
benefits only to facilities that have been accredited by the Joint Commission on
the
Accreditation of Healthcare Organizations (JCAHO) or the Accreditation
Association for Ambulatory HealthCare (AAAHC), or that have Medicare
certification as an ASC facility.
. The Plan may approve coverage of providers who are not
currently shown
as Covered providers, to provide mental conditions/ substance abuse treatment
under the managed In-Network benefit. Coverage of these providers is limited to
circumstances
where the Plan has approved the treatment plan.
. An institution that is
accredited as a hospital under the Hospital Accreditation
Program of the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or any
other institution that is operated pursuant to law, under the supervision of a
staff of doctors
(M. D. or D. O.) and with 24-hour-a-day nursing services, and that is
primarily engaged in providing:
(a) general inpatient acute care and treatment of sick and injured persons
through medical, diagnostic, and major surgical facilities, all of which
facilities must be provided on its
premises or under its control; or
(b)
specialized inpatient acute medical care and treatment of sick or injured
persons through medical and diagnostic facilities (including X-ray and
laboratory) on its premises under its
control, or through a written agreement with a hospital or with a specialized
provider of those facilities; or
(c) a licensed birthing center.
In no event shall the term "hospital"
include any part of a hospital that provides long-term care, rather than acute
care, or a convalescent nursing home, or any institution or part thereof that:
(a) is used principally as a convalescent facility, rest facility, nursing
facility, or facility for the aged; or
(b) furnishes primarily domiciliary
or custodial care, including training in the routines of daily living; or
(c) is operated as a school; or
(d) is operated as a residential
treatment facility regardless of its State licensure or accreditation status.
. A facility that:
(a) provides primarily inpatient care to terminally
ill patients;
(b) is licensed/ certified by the jurisdiction in which it
operates;
(c) is supervised by a staff of doctors (M. D. or D. O.) with at
least one such doctor on call 24 hours a day;
(d) provides 24-hour-a-day nursing services under the direction of a
registered nurse (R. N.) and has a full-time administrator; and
(e) provides
an ongoing quality assurance program. 8
8 Page 9 10
2002 Mail
Handlers Benefit Plan 9 Section 3
It depends on the kind of care
you want to receive. You can go to any provider you want, but we must approve
some care in advance.
If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal Employees
Health Benefits
(FEHB) Program and you enroll in another FEHB Plan, or
lose access to your PPO specialist because we terminate our contract with
your specialist for
other than cause,
you may be able to continue seeing your specialist and receiving any PPO
benefits 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 and any PPO benefits continue
until the end of your postpartum care, even if it is beyond the 90 days.
We pay for covered services from the effective date of your enrollment.
However, if you are in the hospital when your enrollment in our Plan begins,
call our customer relations department
immediately at 1-800-410-7778.
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 92nd day after you become a member of this Plan, whichever happens
first.
These provisions apply only to the hospitalized person.
is the process by which —prior to your inpatient hospital admission —we
evaluate the medical necessity of your proposed stay and the number of days
required to treat your
condition. Unless we are misled by the information
given to us, we won't change our decision on medical necessity.
In most cases, your physician or hospital will take care of precertification.
Because you are still responsible for ensuring that we are asked to precertify
your care, you should always ask your
physician or hospital whether they
have contacted us.
We will reduce our benefits for the inpatient hospital stay by $500 if no one
contacts us for precertification. In addition, if the stay is not medically
necessary, we will not pay any benefits for
the room and board charges. If
the reason for the admission is for services or supplies we don't cover,
non-covered cosmetic surgery, for example, we will not pay any benefits.
Any stay greater than 23 hours must be precertified.
You, your representative, your doctor, or your hospital must call the Plan at
least two working
days before admission. The toll-free number is
1-800-410-7778.
Provide the following information:
Enrollee's name and Plan
identification number; Patient's name, birth date and phone number;
Reason for hospitalization, proposed treatment or surgery; Name of hospital
or facility;
Name and phone number of admitting doctor; and Number of
planned days of confinement.
We will then tell the doctor and hospital the
number of approved days of confinement for the care of the patient's condition.
Written confirmation of the Plan's certification decision will be sent to
you, your doctor, and the hospital. If the length of stay needs to be
extended, follow the procedures on the following page. 9
9 Page 10 11
2002 Mail Handlers Benefit Plan 10 Section 3
When there is an emergency admission due to a condition that puts the
patient's life in danger or could cause serious damage to bodily function, you,
your representative, the doctor, or the hospital
must telephone
1-800-410-7778 within two business days following the day of admission, even if
the patient has been discharged from the hospital. Otherwise, inpatient benefits
otherwise payable
for the admission will be reduced by $500.
You do not need to precertify a maternity admission for a routine delivery.
However, if your medical condition requires you to stay more than 48 hours after
a vaginal delivery or 96 hours after
a cesarean section, then you, your
representative, your physician or the hospital must contact us for
precertification of additional days. Further, if your baby stays after you are
discharged, then you,
your representative, your physician or the hospital
must contact us for precertification of additional days for your baby.
If your hospital stay —including for maternity care —needs to be extended,
you, your representative, your doctor or the hospital must ask us to approve the
additional days.
When we precertified the admission but you remained in the
hospital beyond the number of days
we approved and you did not get the
additional days precertified, then:
for the part of the admission that we determined was medically necessary, we
will pay inpatient benefits, but
for the part of the admission that was not medically necessary, we will pay
only 70% of the covered medical services and supplies otherwise payable on an
outpatient basis and will not
pay room and board benefits.
If no one
contacted us, we will decide whether the hospital stay was medically necessary.
If we determine that the stay was medically necessary, we will pay the
inpatient charges, less the $500 penalty.
If we determine that it was not medically necessary for you to be an
inpatient, we will not pay room and board hospital benefits. We will only pay
70% for covered medical supplies
and services that are otherwise payable on
an outpatient basis.
If we denied the precertification request, we will not
pay room and board inpatient hospital
benefits. We will only pay 70% for
covered medical supplies and services that are otherwise payable on an
outpatient basis.
You do not need precertification in these cases:
You are admitted to a
hospital outside the United States.
You have another group health insurance
policy that is the primary payer for the hospital stay.
Your Medicare Part A
is the primary payer for the hospital stay. Note: If you exhaust your
Medicare hospital benefits and do not want to use your Medicare lifetime
reserve days, then we will become the primary payer and you need
precertification.
Your stay is less than 23 hours.
Some services require a referral, precertification, or prior authorization.
This Plan requires a prior authorization for medically necessary outpatient
hospital services
provided in connection with dental procedures. Call
1-800-410-7778 to request preauthorization.
This Plan requires preauthorization of mental conditions/ substance abuse
services under the
managed In-Network benefit. See Section 5( e) page 46.
This Plan requires preauthorization of certain drugs. See Section 5( f) page
49. 10
10 Page 11
12
2002 Mail Handlers Benefit Plan 11
Section 4
This is what you will pay out-of-pocket for your covered
care:
A copayment is a fixed amount of money you pay to the provider,
facility, pharmacy, etc., when you receive services.
Example: When you see your PPO physician you pay a copayment of $15 per
visit.
A deductible is a fixed amount of covered expenses you must incur for certain
covered services and supplies before we start paying benefits for those
services. Copayments and coinsurance do not
count toward any deductible.
The calendar year deductible for covered medical services and supplies is
$200 per person under
High Option and $250 per person under Standard Option.
Under a family enrollment, the medical services and supplies deductible is
satisfied for all family members when the combined
covered expenses applied to the calendar year deductible for family members
reach $600 under High Option and $750 under Standard Option.
The calendar year deductible for covered mental and nervous/ substance abuse
services is $200
per person under High Option and $250 per person under
Standard Option. This deductible is in addition to the medical services
deductible. Under a family enrollment, the mental and
nervous/ substance abuse services deductible is satisfied for all family
members when the combined covered expenses applied to the calendar year
deductible reach $600 under High
Option and $750 under Standard Option.
The calendar year deductible for prescription drugs is $250 per person under
High Option and
$600 per person under Standard Option. Under a family
enrollment, this deductible is met when the family has incurred $500 under High
Option and $1,200 under Standard Option.
Note: If you change plans during Open Season, you do not have to start a new
deductible under your old plan between January 1 and the effective date of your
new plan. If you change plans at
another time during the year, you must
begin a new deductible under your new plan.
And, if you change options in
this Plan during the year, we will credit the amount of covered expenses already
applied toward the deductible of your old option to the deductible of your new
option.
Coinsurance is the percentage of our allowance that you must pay for your
care. Coinsurance doesn't begin until you meet your deductible.
Example: You
pay 30% of our allowance for non-PPO office visits.
Note: If your provider
routinely waives (does not require you to pay) your copayments, deductibles, or
coinsurance, the provider is misstating the fee and may be violating the law. In
this
case, when we calculate our share, we will reduce the provider's fee by the
amount waived.
For example, if your physician ordinarily charges $100 for a
covered service but routinely waives your 30% coinsurance, the actual charge is
$70. We will pay $49 (70% of the actual charge of
$70). 11
11 Page
12 13
2002 Mail Handlers Benefit Plan
12 Section 4
Our "Plan allowance" is the amount we use to
calculate our payment for covered services. Fee-for-service plans arrive at
their allowances in different ways, so their allowances vary. For more
information about how we determine our Plan allowance, see the definition of
Plan allowance in Section 10.
Often, the provider's bill is more than a fee-for-service Plan's allowance.
Whether or not you have to pay the difference between our allowance and the bill
will depend on the provider you use.
agree to limit what they will bill you.
Because of that, when you use a preferred
provider, your share of covered
charges consists only of your deductible, coinsurance or copayment. Here is an
example: You see a PPO physician for an office visit who charges $150,
but our allowance is $100. You are only responsible for your copayment. That
is, you pay just $15 of our $100 allowance. Because of the agreement, your PPO
physician will not bill you for
the $50 difference between our allowance and
his bill.
, on the other hand, have no agreement to limit what they will
bill you.
When you use a non-PPO provider, you will pay your deductible and
coinsurance -any difference between our allowance and the charges on the bill.
Here is an example: You see a
non-PPO physician who charges $150 and our allowance is again $100. Because
you've met your deductible, you are responsible for your coinsurance, so you pay
30% of our $100
allowance ($ 30). Plus, because there is no agreement
between the non-PPO physician and us, he can bill you for the $50 difference
between our allowance and his bill. For details on how we
determine the Plan
allowance, please see Section 10.
providers agree to limit what they can
collect from you. You will still have to pay
your deductible and
coinsurance. These providers agree to write off the difference between billed
charges and the discount amount.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician. The
table uses our example of a service
for which the physician charges $150 and
our allowance is $100. The table shows the amount you pay if you have met your
calendar year deductible.
Physician's charge $150 $150
Our allowance We set it at: $100 We set it
at: $100
We pay $85 70% of our allowance: $70
You owe:
Copayment $15
30% of our allowance: $30
+ Difference up to charge No: 0 Yes: 50
$15 $80
For those services with coinsurance (excluding mental health and
substance abuse care), we pay 100% of the Plan allowance for the remainder of
the calendar year after your coinsurance expenses
total these amounts:
$2,500 for services of PPO providers/ facilities under the High Option
$4,000 for services of PPO providers/ facilities under the Standard Option
$4,000 for services of PPO and Non-PPO providers/ facilities, combined,
under the High or
Standard Option.
For mental health and substance abuse benefits, we pay 100% of the Plan
allowance for the remainder of the calendar year after your coinsurance expenses
total these amounts:
$2,500 for services of In-network providers/ facilities under the High Option
$4,000 for services of In-network providers/ facilities under the Standard
Option 12
12 Page
13 14
2002 Mail Handlers Benefit Plan
13 Section 4
(continued)
Note: Your
out-of-pocket maximum does not apply to these benefits:
Skilled nursing care
Prescription drugs
Any out-of-network mental health and substance abuse
care
Hospice
Dental services
Rehabilitative and alternative
therapies
Worldwide Assistance benefit
Note: The following cannot be counted toward out-of-pocket expenses:
Deductibles
Copayments
Expenses incurred under Prescription Drug
Benefits
Expenses in excess of the Plan allowance or maximum benefit
limitations
Any out-of-network expenses for mental health and substance
abuse care
Amounts you pay for non-compliance with this Plan's cost
containment requirements
Coinsurance for skilled nursing care
Non-covered services and supplies
Coinsurance for alternative and
rehabilitative therapy
Facilities of the Department of Veterans Affairs, the Department of Defense,
and the Indian Health Service are entitled to seek reimbursement from us for
certain services and supplies they provide to
you or a family member. They
may not seek more than their governing laws allow.
We pay benefits for
Department of Defense facilities as preferred providers.
We will make diligent efforts to recover benefit payments we made in error
but in good faith. We may reduce subsequent benefit payments to offset
overpayments. 13
13 Page
14 15
2002 Mail Handlers Benefit Plan
14 Section 4
Under the FEHB law, we must limit our payments for
those benefits you would be entitled to if you had Medicare. And, your physician
and hospital must follow Medicare rules and cannot bill you for more than they
could bill you if you had Medicare. The
following chart has more information
about the limits.
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or a family member of
an annuitant or former spouse; and
are not employed in a position that gives
FEHB coverage. (Your employing office can tell you if this applies.)
the law requires us to base our payment on an amount —the "equivalent
Medicare amount" —set by Medicare's rules for what
Medicare would pay, not
on the actual charge;
you are responsible for your coinsurance and any applicable deductibles or
copayments you owe under this Plan;
you are not responsible for any charges
greater than the equivalent Medicare amount; we will show that amount on the
explanation of benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare
equivalent amount.
, the law requires us to base our payment and your coinsurance on…
an
amount set by Medicare and called the "Medicare approved amount," or
the
actual charge if it is lower than the Medicare approved amount.
Participates with Medicare or accepts Medicare assignment for the claim and
is a member of our PPO network,
your deductibles, coinsurance, and
copayments;
Participates with Medicare and is in our PPO network, your deductibles,
coinsurance, copayments, and any balance up to the Medicare approved amount;
Does not participate with Medicare, your deductibles, coinsurance,
copayments, and any balance up to 115% of the Medicare approved amount
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect only up to
the Medicare approved amount.
Our explanation of benefits (EOB) form will
tell you how much the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the
physician or hospital to reduce the charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us. 14
14 Page 15 16
2002 Mail Handlers Benefit Plan 15 Section 4
We limit our payment to an amount that supplements the benefits that
Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part
B (Medical insurance), regardless of
whether Medicare pays. Note: We pay our
regular benefits for emergency services to an institutional provider, such as a
hospital, that does not participate with Medicare and is not
reimbursed by
Medicare.
If you are covered by Medicare Part B and it is primary, your
out-of-pocket costs for services that both Medicare Part B and we cover depend
on whether your physician accepts Medicare
assignment for the claim.
When Medicare is primary, all or part of your
Plan deductibles and coinsurance will be waived as indicated below:
When Medicare Part A is primary, the Plan will waive applicable per-admission
copayments and
coinsurance for Inpatient Hospital Benefits and Inpatient
Mental Conditions/ Substance Abuse Benefits
When Medicare Part B is primary, the Plan will waive applicable deductibles,
copayments and
coinsurance for surgical and medical services billed by
physicians, durable medical equipment, orthopedic and prosthetic appliances, and
ambulance services.
When Medicare Part B is primary, the Plan will waive the calendar year
deductible (but not the
coinsurance) for nursing benefits and outpatient
mental conditions and substance abuse benefits.
When Medicare Parts A and B are primary, the Plan will waive the deductible
for prescription
drugs purchased through the mail order prescription drug
program.
Note: The Plan will not waive the deductible and coinsurance for retail
prescription drugs.
If your physician does not accept Medicare assignment, the physician may not
bill you for more than 115% of the amount Medicare bases its payment on, called
the "limiting charge." The
Medicare Summary Notice (MSN) that Medicare will
send you will have more information about the limiting charge. If your physician
tries to collect more than allowed by law, ask the physician
to reduce the
charges. If the physician does not, report the physician to your Medicare
carrier who sent you the MSN form. Call us if you need further assistance.
A physician may ask you to sign a private contract agreeing that you can be
billed directly for services Medicare ordinarily covers. Should you sign an
agreement, Medicare will not pay any
portion of the charges, and we will not
increase our payment. We will still limit our payment to the amount we would
have paid after Medicare's payment.
Please see Section 9, Coordinating benefits with other coverage, for
more information about how we coordinate benefits with Medicare. 15
15 Page 16 17
2002
Mail
Handlers
Benefit
Plan
16
Section
5
See
page
6
for
how
our
benefits
changed
this
year
and
pages
78-
79
for
a
benefits
summary.)
This
benefits
section
is
divided
into
subsections.
Please
read
the
important
things
you
should
keep
in
mind
at
the
beginning
of
each
subsection.
Also
read
the
General
Exclusions
in
Section
6;
they
apply
to
the
benefits
in
the
following
subsections.
To
obtain
claims
forms,
claims
filing
advice,
or
more
information
about
our
benefits,
contact
us
at
1-
800-
410-
7778
or
at
our
web
site
at
www.
mhbp.
com
.
(a)
Medical
services
and
supplies
provided
by
physicians
and
other
health
care
professionals
........................................................................................................................
17– 31
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
Vision
services
Foot
care
Orthopedic
and
prosthetic
devices
Durable
medical
equipment
Home
health
services
Chiropractic Alternative treatment Educational
classes
and
programs
(b)
Surgical
and
anesthesia
services
provided
by
physicians
and
other
health
care
professionals
....................................................................................................................
32– 38
Surgical
procedures
Reconstructive
surgery
Oral
and
maxillofacial
surgery
Organ/
tissue
transplants
Anesthesia
(c)
Services
provided
by
a
hospital
or
other
facility,
and
ambulance
services...................................................................................................................................................
39– 43
Inpatient
hospital
Hospice Outpatient
hospital
or
ambulatory
surgical
center
Ambulance Extended care
benefit/
Skilled
nursing
care
facility
benefit
(d)
Emergency
services/
Accidents......................................................................................................................................................................................................................
44– 45
Accidental
injury
Medical
emergency
Ambulance
(e)
Mental
health
and
substance
abuse
benefits..................................................................................................................................................................................................
46– 48
(f)
Prescription
drug
benefits
.............................................................................................................................................................................................................................
49– 51
(g)
Special
features
...................................................................................................................................................................................................................................................
52
Flexible
benefits
option
Worldwide
Assistance
(h)
Dental
benefits
..............................................................................................................................................................................................................................................
53–
56
(i)
Non-FEHB
Benefits
available
to
Plan
members.................................................................................................................................................................................................
57
SUMMARY
OF
BENEFITS................................................................................................................................................................................................................................
78– 79 16
16 Page
17 18
2002
Mail
Handlers
Benefit
Plan
17
Section
5(
a)
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.
The
calendar
year
deductible
is:
$250
per
person
($
750
per
family)
for
Standard
Option
and
$200
per
person
($
600
per
family)
for
High
Option.
The
calendar
year
deductible
applies
to
almost
all
benefits
in
this
Section.
We
added
"(
No
deductible)"
to
show
when
the
calendar
year
deductible
does
not
apply.
See
Section
4
for
more
information
about
deductibles
and
other
cost-
sharing
features
such
as
coinsurance
and
copayments.
The
non-
PPO
benefits
are
the
regular
benefits
of
this
Plan.
PPO
benefits
apply
only
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-
PPO
benefits
apply.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
Also
read
Section
9
about
coordinating
benefits
with
other
coverage,
including
with
Medicare.
Professional
services
of
physicians
In
physician's
office
(this
includes
evaluation
and
management
services
related
to
chemotherapy,
hemodialysis
and
radiation
therapy)
At
home In an urgent
care
center
Office
medical
consultations
Second
surgical
opinions
provided
in
a
physician's
office
PPO:
$15
copayment
per
office
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
$15
copayment
per
office
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Same-
day
services
performed
and
billed
in
conjunction
with
the
office
visit
(except
allergy
shots,
rabies
shots
or
immunizations)
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
Diagnostic
and
treatment
services
–
continued
on
next
page 17
17 Page
18 19
2002
Mail
Handlers
Benefit
Plan
18
Section
5(
a)
(continued)
Professional
services
of
physicians
during
a
hospital
stay
Note:
Outpatient
cancer
treatment
(chemotherapy,
X-
rays,
or
radiation
therapy)
and
dialysis
services
are
paid
under
Treatment
therapy,
page
24.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
Covered: Routine physical
checkups
and
related
tests
except
those
covered
under
preventive
care
Thermography
and
related
visits
Chelation
therapy
provided
in
an
outpatient
setting
Orthoptic
visits
and
related
services
All
Charges
All
Charges
Tests,
such
as:
Blood
tests
Urinalysis Non-routine
pap
tests
Pathology X-rays Non-routine
Mammograms
CAT
Scans/ MRI
Ultrasound Electrocardiogram
and
EEG
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount Note: If
your
PPO
provider
uses
a
non-
PPO
lab
or
radiologist,
we
will
pay
non-
PPO
benefits
for
any
lab
and
X-
ray
charges.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount Note: If
your
PPO
provider
uses
a
non-
PPO
lab
or
radiologist,
we
will
pay
non-
PPO
benefits
for
any
lab
and
X-
ray
charges.
Performance
Lab
You
can
use
this
voluntary
program
if
this
Plan
is
your
primary
insurance
carrier.
You
show
your
Mail
Handlers
Benefit
Plan
identification
card
and
ask
your
doctor
to
send
your
lab
order
to
Quest
Diagnostics.
As
long
as
Quest
Diagnostics
does
the
testing,
you
will
not
have
to
file
any
claims.
To
learn
of
a
location
near
you,
call
1-
800-
377-
7220,
or
visit
the
Plan's
web
site
at
www. mhbp.
com
.
Nothing
(No
deductible)
Nothing
(No
deductible)
Not
Covered: Handling and
administrative
charges
Routine
lab
services
except
as
covered
under
Preventive
care
All
charges
All
charges 18
18 Page 19 20
2002
Mail
Handlers
Benefit
Plan
19
Section
5(
a)
Routine
screenings,
limited
to:
Mammogram
for
women
age
35
and
older:
>From
age
35
to
39
—one
during
this
five
year
period
>From
age
40
to
64
—one
every
calendar
year
At
age
65
and
older
—one
every
two
consecutive
calendar
years
Pap
smear
—one
per
calendar
year
for
women
age
18
and
older Note: The
office
visit
is
covered
if
pap
test
is
received
on
the
same
day.
Prostate
Specific
Antigen
(PSA)
—one
per
calendar
year
for
men
age
40
and
older
Colorectal
cancer
screening,
including:
Fecal
occult
blood
(stool)
test
—one
per
calendar
year
for
members
age
40
and
older
Screening
sigmoidoscopy
—one
every
two
consecutive
calendar
years
for
members
age
50
and
older
Blood
cholesterol
–
one
per
calendar
year
for
all
members
Urinalysis
–
one
per
calendar
year
for
all
members
Chlamydial
infection
screening
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Routine
immunizations
provided
during
an
office
visit
PPO:
$15
copayment
per
office
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
$15
copayment
per
office
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Not
Covered: Routine physical
checkups
and
related
tests
except
those
listed
above
All
Charges
All
Charges 19
19 Page 20 21
2002
Mail
Handlers
Benefit
Plan
20
Section
5(
a)
Childhood
immunizations
recommended
by
the
American
Academy
of
Pediatrics
for
members
under
age
22
PPO:
Nothing
(No
deductible)
Non-
PPO:
The
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
Nothing
(No
deductible)
Non-
PPO:
The
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Well-
child
visits
to
a
doctor
for
covered
dependents
up
to
age
18
PPO:
$15
copayment
per
office
visit
(No
deductible).
All
charges
after
the
Plan
has
paid
$100
per
child
per
calendar
year.
Non-
PPO:
All
charges
after
the
Plan
has
paid
$75
per
child
per
calendar
year
(No
deductible)
PPO:
$15
copayment
per
office
visit
(No
deductible).
All
charges
after
the
Plan
has
paid
$100
per
child
per
calendar
year.
Non-
PPO:
All
charges
after
the
Plan
has
paid
$75
per
child
per
calendar
year
(No
deductible)
Routine
screenings,
limited
to:
Blood
cholesterol
–
one
per
calendar
year
for
all
members
Urinalysis
–
one
per
calendar
year
for
all
members
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount 20
20 Page
21 22
2002
Mail
Handlers
Benefit
Plan
21
Section
5(
a)
Complete
maternity
(obstetrical)
care,
including:
Pre-
natal
care
Delivery Anesthesia Post-natal
care
Note:
Here
are
some
things
to
keep
in
mind:
You
do
not
need
to
precertify
your
admission
for
a
normal
delivery;
see
page
10
for
other
circumstances
such
as
extended
stays
for
you
or
your
baby.
You
may
remain
in
the
hospital/
birthing
center
up
to
48
hours
after
a
regular
delivery
and
96
hours
after
a
cesarean
delivery.
We
will
cover
an
extended
stay,
if
medically
necessary,
but
you,
your
representative,
your
doctor
or
your
hospital
must
precertify.
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
if
we
cover
the
infant
under
a
Self
and
Family
enrollment. We pay hospitalization
and
surgeon's
services
(delivery)
the
same
as
for
illness
and
injury.
See
Hospital
benefits
(Section
5(
c))
and
Surgery
benefits
(Section
5(
b)).
Newborn
exams
are
payable
under
Section
5(
a).
Newborn
charges
incurred
as
a
result
of
illness,
are
considered
expenses
of
the
child,
not
the
mother,
and
are
subject
to
a
separate
precertification
and
separate
inpatient
copayment. Maternity benefits
will
be
paid
at
the
termination
of
pregnancy.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
Covered: Standby doctors Home uterine
monitoring
devices
Services
provided
to
the
newborn
if
the
infant
is
not
covered
under
a
self
and
family
enrollment
All
Charges
All
Charges 21
21 Page 22 23
2002
Mail
Handlers
Benefit
Plan
22
Section
5(
a)
Voluntary
family
planning
services,
limited
to:
Voluntary
sterilization
Surgically
implanted
contraceptives
(such
as
Norplant)
Intrauterine
devices
(IUDs)
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Injectable
contraceptive
drugs
(such
as
Depo
provera)
Note:
We
cover
oral
contraceptive
drugs
in
Section
5(
f).
PPO:
$15
copayment
per
office
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
$15
copayment
per
office
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Not
covered: Reversal of
voluntary
surgical
sterilization
All
Charges
All
Charges
Diagnosis
and
treatment
of
infertility,
except
as
shown
in
Not
covered Note: Certain
prescription
drugs
for
the
treatment
of
infertility
are
covered
under
Prescription
drug
benefits.
Call
the
Plan
for
a
list
of
drugs
that
are
covered
for
this
service,
or
go
to
www.
mhbp.
com
for
a
link
to
the
list.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Infertility services
after
voluntary
sterilization
Assisted
reproductive
technology
(ART)
procedures
such
as:
artificial
insemination in vitro fertilization embryo transfer and
Gamete
Intrafallopian
Transfer
(GIFT) intravaginal
insemination
(IVI)
intracervical
insemination
(ICI)
intrauterine
insemination
(IUI)
Services
and
supplies
related
to
ART
procedures
Cost
of
donor
sperm
Cost
of
donor
egg
All
Charges
All
Charges 22
22 Page 23 24
2002
Mail
Handlers
Benefit
Plan
23
Section
5(
a)
Testing,
including
materials
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Allergy
serum
PPO:
$5
copayment
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
$5
copayment
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Allergy
injections
(not
including
allergy
serum)
PPO:
$5
copayment
per
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
$5
copayment
per
visit
(No
deductible)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Not
covered: Any services
or
supplies
considered
by
the
National
Institute
of
Health
and
the
National
Institute
of
Allergy
and
Infectious
Disease
to
be
not
effective
to
diagnose
allergies
and/
or
not
effective
in
preventing
an
allergy
reaction
All
Charges
All
Charges 23
23 Page 24 25
2002
Mail
Handlers
Benefit
Plan
24
Section
5(
a)
Chemotherapy
and
radiation
therapy
Note:
High
dose
chemotherapy
in
association
with
autologous
bone
marrow
transplants
is
limited
to
those
transplants
listed
on
page
37.
Dialysis
—Hemodialysis
and
peritoneal
dialysis
Intravenous
(IV)/
Antibiotic
Infusion
Therapy
Hyperbaric
oxygen
therapy
Treatment
room
Observation
room
Note:
These
therapies
(excluding
the
related
office
visits)
are
covered
under
this
benefit
when
billed
by
the
outpatient
section
of
a
hospital,
clinic
or
a
physician's
office.
Retail
pharmacy
charges
for
chemotherapy
and
prescription
drugs
to
treat
the
side
effects
of
chemotherapy
are
covered
under
Prescription
Drugs,
see
Section
5(
f).
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Rabies
shots
and
related
services
Nothing
Nothing
Not
covered: Chelation therapy,
except
if
the
covered
services
and
supplies
are
provided
during
a
precertified
inpatient
admission Chemotherapy
supported
by
a
bone
marrow
transplant
or
with
stem
cell
support
for
any
diagnosis
not
listed
as
covered
under
Section
5(
b)
All
Charges
All
Charges 24
24 Page 25 26
2002
Mail
Handlers
Benefit
Plan
25
Section
5(
a)
Outpatient
physical
therapy,
speech
therapy,
and
occupational
therapy Note: The
annual
$2,000
combined
rehabilitative,
chiropractic
and
alternative
therapies
maximum
includes
all
covered
services
and
supplies
billed
for
these
therapies.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum.
Not
covered: Charges billed
after
the
Plan
has
paid
the
combined
$2,000
rehabilitative,
chiropractic
and
alternative
treatment
therapies
maximum
Exercise
programs
All
Charges
All
Charges 25
25 Page 26 27
2002
Mail
Handlers
Benefit
Plan
26
Section
5(
a)
One
hearing
aid
per
ear
and
related
services
are
covered
only
when
the
hearing
loss
was
caused
by
an
accidental
injury.
The
hearing
aid
must
be
purchased
within
120
days
of
the
accident
and
the
patient
must
be
covered
by
the
Plan
at
the
time
of
purchase. Note: The
calendar
year
deductible
applies.
All
charges
over
$200
for
one
hearing
aid
per
ear
All
charges
over
$200
for
one
hearing
aid
per
ear
Testing
(non-
routine)
Note:
The
calendar
year
deductible
applies.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Routine hearing
tests,
hearing
aids,
and
related
services
when
the
hearing
loss
is
not
directly
related
to
an
accidental
injury
All
Charges
All
Charges
One
pair
of
eyeglasses
or
contact
lenses
to
correct
an
impairment
directly
caused
by
an
accidental
ocular
injury
or
intraocular
surgery
(such
as
for
cataracts).
The
eyeglasses
or
contact
lenses
must
be
purchased
within
one
year
of
the
injury
or
surgery
and
the
patient
must
be
covered
by
the
Plan
at
the
time
of
purchase. Note: The calendar
year
deductible
applies.
All
charges
over
$50
for
one
set
of
eyeglasses
or
$100
for
contact
lenses
(including
examination)
All
charges
over
$50
for
one
set
of
eyeglasses
or
$100
for
contact
lenses
(including
examination)
Not
covered: Routine eye
exams
Eye
glasses,
contact
lenses
and
examinations
not
directly
related
to
an
ocular
injury
or
intraocular
surgery
Eye
exercises,
refractions
and
related
office
visits
Radial
keratotomy
including
laser
keratotomy
and
other
refractive
surgery
All
Charges
All
Charges 26
26 Page 27 28
2002
Mail
Handlers
Benefit
Plan
27
Section
5(
a)
We
pay
the
professional
services
for
routine
foot
care
for
established
diabetics.
We
also
pay
for
medically
necessary
surgeries
under
the
surgery
benefit.
See
Section
5(
b).
PPO:
$15
copayment
per
office
visit
(No
deductible),
and
10%
of
the
Plan's
allowance
for
other
services
performed
during
the
visit
(deductible
applies)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
the
office
visit
(No
deductible);
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
other
services
performed
during
the
visit
(deductible
applies)
PPO:
$15
copayment
per
office
visit
(No
deductible),
and
10%
of
the
Plan's
allowance
for
other
services
performed
during
the
visit
(deductible
applies)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
the
office
visit
(No
deductible);
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
other
services
performed
during
the
visit
(deductible
applies)
Not
Covered: Cutting, trimming
and
removal
of
corns,
calluses
or
the
free
edge
of
toenails,
and
similar
routine
treatment
of
conditions
of
the
foot
except
for
the
established
diagnosis
of
diabetes
All
Charges
All
Charges
Orthopedic
and
prosthetic
devices
(see
Definitions
—Section
10)
when
recommended
by
an
MD
or
DO,
including:
Artificial
limbs
and
eyes,
stump
hose;
Externally
worn
breast
prostheses
and
surgical
bras,
including
necessary
replacements
following
a
mastectomy;
Note:
Call
the
Plan
to
locate
a
vendor.
10%
of
the
Plan's
allowance
10%
of
the
Plan's
allowance
Not
Covered: Orthopedic
and
corrective
shoes
unless
attached
to
a
brace
Arch
supports Foot orthotics
and
related
office
visits
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
unless
a
replacement
is
needed
for
medical
reasons
Penile
prosthetics
All
Charges
All
Charges 27
27 Page 28 29
2002
Mail
Handlers
Benefit
Plan
28
Section
5(
a)
Durable
Medical
Equipment
(DME)
is
equipment
and
supplies
that: 1. Are
prescribed
by
your
attending
physician
(i.
e.,
the
physician
who
is
treating
your
illness
or
injury);
2.
Are
medically
necessary;
3.
Are
primarily
and
customarily
used
only
for
a
medical
purpose; 4. Are generally
useful
only
to
a
person
with
an
illness
or
injury; 5. Are designed
for
prolonged
use;
and
6.
Serve
a
specific
therapeutic
purpose
in
the
treatment
of
an
illness
or
injury.
We
cover
rental
or
purchase,
at
our
option,
including
repair
and
adjustment,
of
durable
medical
equipment
such
as
oxygen
and
dialysis
equipment.
The
Plan
will
limit
its
benefit
for
the
rental
of
durable
medical
equipment
to
an
amount
no
greater
than
what
it
would
have
paid
if
the
equipment
had
been
purchased.
Under
this
benefit
we
also
cover:
Wheelchairs Hospital beds Oxygen equipment Ostomy supplies
(including
supplies
purchased
at
a
pharmacy) Note: Call us
at
1-
800-
410-
7778
to
get
information
about
durable
medical
equipment
PPO
providers.
Any
equipment
billed
by
rehabilitative
therapists
or
alternative
medicine
providers
is
covered
under
that
benefit
and
subject
to
the
combined
annual
maximum.
Note:
For
those
members
who
have
Medicare
Part
B
as
their
primary
payer,
diabetic
supplies
will
be
covered
under
this
benefit.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount Durable
medical
equipment
–
continued
on
next
page 28
28 Page
29 30
2002
Mail
Handlers
Benefit
Plan
29
Section
5(
a)
(continued
)
Not
Covered: Equipment
replacements
provided
less
than
3
years
after
the
last
one
we
covered
Charges
for
service
contracts
for
purchased
equipment
Safety,
hygiene,
convenience
and
exercise
equipment
Household
or
vehicle
modifications
including
seat,
chair
or
van
lifts;
computer
switchboard
Communication
equipment
including
computer
"story
boards,"
"light
talkers,"
and
enhanced
vision
systems
Air
conditioners,
air
purifiers,
humidifiers,
ultraviolet
lighting
(except
for
the
treatment
of
psoriasis)
Wigs
or
hair
pieces
Motorized
scooters,
lifts,
ramps,
prone
standers
and
other
items
that
do
not
meet
the
DME
definition
Dental
appliances
used
to
treat
sleep
apnea
and/
or
temporomandibular
joint
dysfunction
Charges
for
educational/
instructional
advice
on
how
to
use
the
durable
medical
equipment
All
rental
charges
above
the
purchase
price
All
Charges
All
Charges 29
29 Page 30 31
2002
Mail
Handlers
Benefit
Plan
30
Section
5(
a)
A
registered
nurse
(R.
N.)
or
licensed
practical
nurse
(L.
P.
N.)
is
covered
for
outpatient
services
when:
Prescribed
by
your
attending
physician
(i.
e.,
the
physician
who
is
treating
your
illness
or
injury)
for
outpatient
services; The physician
indicates
the
length
of
time
or
number
of
visits
the
services
are
needed;
The
physician
identifies
the
specific
professional
skills
required
by
the
patient
and
the
medical
necessity
for
skilled
services.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$700
annual
maximum
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
$700
for
these
services.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$700
annual
maximum
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
$700
for
these
services.
Not
covered: Inpatient private
duty
nursing
Nursing
care
requested
by,
or
for
the
convenience
of,
the
patient's
family
Services
primarily
for
hygiene,
feeding,
exercising,
moving
the
patient,
homemaking,
companionship
or
giving
oral
medication All charges
after
the
Plan
has
paid
$700
for
covered
nursing
services
All
Charges
All
Charges
Chiropractic
care
Manipulation
of
the
spine
and
extremities
Adjunctive
procedures
such
as
ultrasound,
electrical
muscle
stimulation,
vibratory
therapy,
and
cold
pack
application
Note:
The
annual
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapies
maximum
includes
all
covered
services
and
supplies
billed
for
these
therapies.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum. 30
30 Page 31 32
2002
Mail
Handlers
Benefit
Plan
31
Section
5(
a)
Acupuncture Note: The annual
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapies
maximum
includes
all
covered
services
and
supplies
billed
for
these
therapies.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
the
Plan
has
paid
the
$2,000
combined
rehabilitative,
chiropractic
and
alternative
treatment
therapy
maximum.
Not
covered: Naturopathic
and
homeopathic
services
Chelation
therapy,
except
if
the
covered
services
and
supplies
are
provided
during
a
precertified
inpatient
hospitalization Thermography,
biofeedback
and
related
visits
Charges
after
the
$2,000
combined
rehabilitative,
chiropractic
therapies
and
alternative
treatments
annual
maximum
has
been
paid
by
the
Plan
Note:
Services
of
certain
alternative
treatment
providers
may
be
covered
in
medically
underserved
areas
—
see
page
7.
All
Charges
All
Charges
Smoking
Cessation
—Up
to
$100
for
one
smoking
cessation
program
per
member
per
lifetime
Note:
All
benefits
are
paid
directly
to
you.
Smoking
deterrents
are
covered
under
prescription
drugs.
See
Section
5(
f).
All
charges
over
$100
All
charges
over
$100
Not
Covered: Self help or
self
management
programs
such
as
diabetic
self
management Charges for educational/
instructional
advice
on
how
to
use
durable
medical
equipment
All
Charges
All
Charges 31
31 Page 32 33
2002
Mail
Handlers
Benefit
Plan
32
Section
5(
b)
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.
The
calendar
year
deductible
is:
$250
per
person
($
750
per
family)
for
Standard
Option
and
$200
per
person
($
600
per
family)
for
High
Option.
The
calendar
year
deductible
applies
to
almost
all
benefits
in
this
Section.
We
added
"(
No
deductible)"
to
show
when
the
calendar
year
deductible
does
not
apply.
See
Section
4
for
more
information
about
deductibles
and
other
cost-
sharing
features
such
as
coinsurance
and
copayments.
The
non-
PPO
benefits
are
the
regular
benefits
of
this
Plan.
PPO
benefits
apply
only
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-
PPO
benefits
apply.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
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
surgery.
Look
in
Section
5(
c)
for
charges
associated
with
the
facility
charge
(i.
e.
hospital,
surgical
center,
etc.).
.
Please
refer
to
the
precertification
information
shown
in
Section
3.
A
comprehensive
range
of
services,
such
as:
Operative
procedures
(performed
by
the
primary
surgeon)
Treatment
of
fractures,
including
casting;
Normal
pre-
and
post-
operative
care
by
the
surgeon;
Endoscopy
procedures
(diagnostic
and
surgical);
Biopsy
procedures; Electroconvulsive therapy; Removal of tumors
and
cysts;
Correction
of
congenital
anomalies
(see
Reconstructive
surgery);
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Surgical
procedures
–
continued
on
next
page 32
32 Page
33 34
2002
Mail
Handlers
Benefit
Plan
33
Section
5(
b)
(continued)
Surgical
treatment
of
morbid
obesity
—a
condition
in
which
an
individual
weighs
100
pounds
or
100%
over
his
or
her
normal
weight
according
to
current
underwriting
standards;
eligible
members
must
be
age
18
or
over;
Insertion
of
internal
prosthetic
devices
(See
Section
5(
a)
—
Orthopedic
and
prosthetic
devices
—for
device
coverage
information); Voluntary sterilization,
Norplant
(a
surgically
implanted
contraceptives),
and
intrauterine
devices
(IUDs);
Treatment
of
burns;
Correction
of
amblyopia
&
strabismus.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
When
multiple
or
bilateral
surgical
procedures
are
performed
during
the
same
operative
session
by
the
same
surgeon,
the
Plan's
benefit
is
determined
as
follows:
For
the
primary
procedure:
PPO:
the
Plan's
full
allowance
or
Non-
PPO:
the
Plan's
full
allowance
For
the
secondary
procedure:
PPO:
one-
half
of
the
Plan's
allowance
or
Non-
PPO:
one-
half
of
the
Plan's
allowance
For
the
tertiary
procedure
and
any
other
subsequent
procedures: PPO: one-
quarter
of
the
Plan's
allowance
or
Non-
PPO:
one-
quarter
of
the
Plan's
allowance
PPO:
10%
of
the
Plan's
allowance
for
the
individual
procedure Non-PPO:
30%
of
the
Plan's
allowance
for
the
individual
procedure
and
any
difference
between
the
Plan's
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
for
the
individual
procedure Non-PPO:
30%
of
the
Plan's
allowance
for
the
individual
procedure;
and
any
difference
between
the
Plan's
allowance
and
the
billed
amount
Surgical
Procedures
–
continued
on
next
page 33
33 Page
34 35
2002
Mail
Handlers
Benefit
Plan
34
Section
5(
b)
(continued)
Co-
surgeons When the surgery
requires
two
surgeons
with
different
skills
to
perform
the
surgery,
the
Plan's
allowance
for
each
surgeon
is
50%
of
what
it
would
pay
a
single
surgeon
for
the
same
procedure(
s).
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Assistant
surgeon
When
a
surgery
requires
an
assistant
surgeon,
the
Plan
will
reduce
its
benefits
for
the
assistant
surgeon
to
20%
of
the
allowance
for
the
surgery.
PPO:
Nothing Non-PPO: The
difference
between
our
allowance
and
the
billed
amount
PPO:
Nothing Non-PPO: The
difference
between
our
allowance
and
the
billed
amount
Not
covered: Multiple or
bilateral
surgical
procedures
performed
through
the
same
incision
that
are
"incidental"
to
the
primary
surgery.
That
is,
the
procedure
would
not
add
time
or
complexity
to
patient
care.
We
do
not
pay
extra
for
incidental
procedures.
Reversal
of
voluntary
sterilization
Services
of
a
standby
surgeon
Routine
treatment
of
conditions
of
the
foot
except
for
services
rendered
to
established
diabetics
Cosmetic
surgery
(See
definition,
page
35)
Radial
keratotomy,
laser
and
other
refractive
surgery
All
Charges
All
Charges 34
34 Page 35 36
2002
Mail
Handlers
Benefit
Plan
35
Section
5(
b)
Surgery
to
correct
a
functional
defect;
Surgery
to
correct
a
condition
caused
by
injury
or
illness
if:
The
condition
produces
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;
and
webbed
fingers
and
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. (See Prosthetic
devices
for
coverage
of
breast
prostheses
and
surgical
bras
and
replacements.)
Note:
If
you
need
a
mastectomy,
you
may
choose
to
have
this
procedure
performed
on
an
inpatient
basis
and
remain
in
the
hospital
up
to
48
hours
after
the
procedure.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
Covered: Cosmetic surgery
-
any
surgical
procedure
(or
any
portion
of
a
procedure)
performed
primarily
to
improve
physical
appearance
through
a
change
in
bodily
form,
except
repair
of
accidental
injury
or
caused
by
illness
Surgery
related
to
sex
transformation
or
sexual
dysfunction
All
Charges
All
Charges 35
35 Page 36 37
2002
Mail
Handlers
Benefit
Plan
36
Section
5(
b)
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 impacted teeth
that
are
not
completely
erupted
(bony,
partial
bony,
and
soft
tissue
impactions);
Removal
of
stones
from
salivary
ducts;
Excision
of
leukoplakia,
tori
or
malignancies;
Excision
of
cysts
and
incision
of
abscesses
when
done
as
independent
procedures;
Temporomandibular
joint
dysfunction
surgery;
Other
surgical
procedures
that
do
not
involve
the
teeth
or
their
supporting
structures.
Note:
The
related
hospitalization
(inpatient
and
outpatient)
are
covered
if
medically
necessary.
See
Section
5(
c).
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Oral/ dental
implants
and
transplants;
Procedures
that
involve
the
teeth
or
their
supporting
structures,
such
as
the
periodontal
membrane,
gingiva,
and
alveolar
bone(
these
procedures
may
be
considered
as
covered
dental
procedures
under
the
High
Option
dental
benefits); Conservative
treatment
of
temporomandibular
joint
dysfunction
(TMJ)
All
Charges
All
Charges 36
36 Page 37 38
2002
Mail
Handlers
Benefit
Plan
37
Section
5(
b)
Limited
to:
Cornea Heart Heart/ lung Kidney Liver Pancreas Single
lung Double
lung
Intestinal
transplants
(small
intestine)
and
the
small
intestine
with
the
liver
or
small
intestine
with
multiple
organs
such
as
the
liver,
stomach,
and
pancreas
Allogenic
(donor)
bone
marrow
transplants
for
chronic
myelogenous
leukemia,
acute
leukemia,
aplastic
anemia,
severe
combined
immuno-
deficiency
disease,
Wiscott-
Aldrich
syndrome,
advanced
Hodgkin's
lymphoma,
advanced
non-
Hodgkin's
lymphomas,
and
myelodysplastic
syndrome
(in
advanced
form).
Autologous
(self)
bone
marrow
transplants
(autologous
stem
cell
and
peripheral
stem
cell
support)
for
chronic
or
acute
lymphocytic
or
non-
lymphocytic
leukemia;
advanced
Hodgkin's
lymphoma;
advanced
non-
Hodgkin's
lymphomas;
resistant
or
recurrent
neuroblastoma;
testicular,
mediastinal,
retroperitoneal,
and
ovarian
germ
cell
tumors;
breast
cancer;
multiple
myeloma;
and
epithelial
ovarian
cancer. Note: We
cover
related
medical
and
hospital
expenses
of
the
donor
when
we
cover
the
recipient.
Surgical
transplant
of
body
organ/
tissue
means
transfer
of
a
body
organ(
s)
tissue(
s)
from
the
donor
to
the
recipient
(allogenic)
or
a
bone
marrow
graft
in
which
the
donor
and
recipient
are
the
same
person
(autologous).
PPO:
10%
of
the
Plan's
allowance
and
all
charges
over
$300,000 Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
over
$300,000.
Note:
The
maximum
benefit
for
any
organ/
tissue
transplant(
s)
is
$300,000
per
occurrence.
Included
in
the
$300,000
maximum
are
hospital,
surgical,
and
medical
expenses
of
the
recipient
but
not
the
covered
expenses
of
the
donor.
Benefits
issued
for
charges
related
to
complications
arising
during
the
transplant
confinement
(same
admission)
are
subject
to
the
$300,000
maximum.
The
cost
of
outpatient
prescription
drugs
related
to
the
transplant
is
not
subject
to
the
$300,000
limit.
Chemotherapy,
when
supported
by
a
bone
marrow
transplant
or
autologous
stem
cell
support,
is
covered
only
for
the
specific
diagnoses
listed.
PPO:
10%
of
the
Plan's
allowance
and
all
charges
over
$300,000 Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
over
$300,000.
Note:
The
maximum
benefit
for
any
organ/
tissue
transplant(
s)
is
$300,000
per
occurrence.
Included
in
the
$300,000
maximum
are
hospital,
surgical,
and
medical
expenses
of
the
recipient
but
not
the
covered
expenses
of
the
donor.
Benefits
issued
for
charges
related
to
complications
arising
during
the
transplant
confinement
(same
admission)
are
subject
to
the
$300,000
maximum.
The
cost
of
outpatient
prescription
drugs
related
to
the
transplant
is
not
subject
to
the
$300,000
limit.
Chemotherapy,
when
supported
by
a
bone
marrow
transplant
or
autologous
stem
cell
support,
is
covered
only
for
the
specific
diagnoses
listed. Organ/ tissue
transplants
–
continued
on
next
page 37
37 Page
38 39
2002
Mail
Handlers
Benefit
Plan
38
Section
5(
b)
(continued)
Not
covered: Donor screening
tests
and
donor
search
expenses,
except
those
performed
on
the
actual
donor;
Services
and
supplies
for
or
related
to
transplants
not
listed
as
covered. Related services
or
supplies
include
administration
of
chemotherapy
when
supported
by
transplant
procedures.
All
Charges
All
Charges
Professional
services
for
the
administration
of
anesthesia
in
hospital
and
out
of
hospital.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount Note: If
your
PPO
provider
uses
a
non-
PPO
anesthesiologist,
we
will
pay
non-
PPO
benefits
for
any
anesthesia
charges.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount Note: If
your
PPO
provider
uses
a
non-
PPO
anesthesiologist,
we
will
pay
non-
PPO
benefits
for
any
anesthesia
charges. 38
38 Page 39 40
2002
Mail
Handlers
Benefit
Plan
39
Section
5(
c)
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.
Unlike
Sections
5(
a)
and
5(
b),
in
this
section
the
calendar
year
deductible
applies
to
only
a
few
benefits.
In
that
case,
we
added
"(
calendar
year
deductible
applies)".
If
applicable,
the
calendar
year
deductible
is
$250
per
person
($
750
per
family)
for
Standard
Option
and
$200
per
person
($
600
per
family)
for
High
Option.
The
non-
PPO
benefits
are
the
regular
benefits
of
this
Plan.
PPO
benefits
apply
only
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-
PPO
benefits
apply.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
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
in
Sections
5(
a)
or
(b).
Note:
When
you
use
a
PPO
hospital,
keep
in
mind
that
the
professionals
who
provide
services
to
you
in
the
hospital,
such
as
radiologists,
emergency
room
physicians,
anesthesiologists,
and
pathologists
may
not
all
be
preferred
providers.
.
Please
refer
to
the
precertification
information
listed
in
Section
3
to
be
sure
which
services
require
precertification.
Room
and
board,
such
as
Ward,
semiprivate,
or
intensive
care
accommodations,
including
birthing
centers;
general
nursing
care;
and
meals
and
special
diets.
Note:
We
only
cover
a
private
room
when
you
must
be
isolated
to
prevent
contagion.
Otherwise,
we
will
pay
the
hospital's
average
charge
for
semiprivate
accommodations.
PPO:
$150
per
admission
Non-
PPO:
$300
per
admission
PPO:
Nothing Non-PPO: $250
per
admission Inpatient hospital –
continued
on
next
page 39
39 Page
40 41
2002
Mail
Handlers
Benefit
Plan
40
Section
5(
c)
(continued)
Other
hospital
services
and
supplies,
such
as:
Operating,
recovery,
maternity,
and
other
treatment
rooms
Prescribed
drugs
and
medicines
Pathology
tests
Diagnostic
laboratory
and
X-
rays
Blood
or
blood
plasma
Dressings,
splints,
casts,
and
sterile
tray
services
Medical
supplies
and
equipment,
including
oxygen
Anesthetics,
including
nurse
anesthetist
services
Autologous
blood
donations
Internal
prosthesis
Note:
We
base
payment
on
whether
the
facility
or
a
health
care
professional
bills
for
the
services
or
supplies.
For
example,
when
the
hospital
bills
for
its
anesthetists'
services,
we
pay
Hospital
benefits
and
when
the
anesthetist
bills
directly
we
pay
under
Section
5(
b)
Surgical
and
Anesthesia
Services
benefits.
Note:
The
maximum
benefit
for
any
organ/
tissue
transplant,
as
described
on
page
37
is
$300,000
per
occurrence.
Benefits
issued
for
charges
related
to
complications
arising
during
the
transplant
confinement
(same
admission)
is
subject
to
the
$300,000
maximum.
Included
in
the
$300,000
maximum
are
hospital,
surgical,
and
other
medical
expenses.
The
cost
of
related
outpatient
prescription
drugs
is
not
subject
to
this
limit.
Chemotherapy,
when
supported
by
a
bone
marrow
transplant
or
autologous
stem
cell
support
is
covered
only
for
the
specific
diagnoses
listed
on
page
37.
Note:
The
Plan
pays
Inpatient
Hospital
Benefits
as
shown
above
in
connection
with
dental
procedures
only
when
a
non-
dental
physical
impairment
exists
that
makes
hospitalization
necessary
to
safeguard
the
health
of
the
patient.
See
page
39
See
page
39
Inpatient
hospital
–
continued
on
next
page 40
40 Page
41 42
2002
Mail
Handlers
Benefit
Plan
41
Section
5(
c)
(continued)
Not
covered: A hospital
admission,
or
portion
thereof,
that
is
not
medically
necessary
(see
definition),
including
an
admission
for
medical
services
that
did
not
require
the
acute
hospital
inpatient
(overnight)
setting,
but
could
have
been
provided
in
a
doctor's
office,
outpatient
department
of
a
hospital,
or
some
other
setting
without
adversely
affecting
the
patient's
condition
or
the
quality
of
medical
care
rendered.
Hospital
admissions
for
medical
rehabilitation
unless
the
admission
is
to
an
approved
acute
inpatient
rehabilitation
facility
and
the
patient
can
actively
participate
in
a
minimum
of
3
hours
of
acute
inpatient
rehabilitation
to
include
any
combination
of
the
following
therapies:
physical,
occupational,
speech,
respiratory
therapy
per
day.
Custodial
care;
see
Section
10:
Definitions.
Non-
covered
facilities,
such
as
nursing
homes,
subacute
care
facilities,
extended
care
facilities,
schools,
domiciliaries
and
rest
homes.
Personal
comfort
items,
such
as
telephone,
television,
barber
services,
guest
meals
and
beds.
Private
inpatient
nursing
care.
Institutions
that
do
not
meet
the
definition
of
covered
hospitals.
All
Charges
All
Charges 41
41 Page 42 43
2002
Mail
Handlers
Benefit
Plan
42
Section
5(
c)
Operating,
recovery,
and
other
treatment
rooms
Prescribed
drugs
and
medicines
Diagnostic
laboratory
tests,
X-
rays
and
pathology
services
Administration
of
blood,
blood
plasma,
and
other
biologicals Blood and blood
plasma,
if
not
donated
or
replaced
Pre-
surgical
testing
Dressings,
casts,
and
sterile
tray
services
Medical
supplies,
including
anesthesia
and
oxygen
Anesthetics
and
anesthesia
services
Note:
We
cover
hospital
services
and
supplies
related
to
dental
procedures
when
necessitated
by
a
non-
dental
physical
impairment. Note: If the stay
is
greater
than
23
hours,
you
need
to
precertify
the
admission.
Note:
For
services
billed
by
the
surgeon
and
the
anesthetist,
see
Section
5(
b),
Surgical
and
anesthetic
services
provided
by
physicians
and
other
health
care
professionals.
PPO:
Nothing
after
the
calendar
year
deductible
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
PPO:
Nothing
after
the
calendar
year
deductible
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
Not
covered: Surgical facility
charges
billed
by
entities
that
are
not
accredited
by
the
Joint
Commission
on
the
Accreditation
of
Healthcare
Organizations
(JCAHO)
or
the
Accreditation
Association
for
Ambulatory
HealthCare
(AAAHC),
or
which
do
not
have
Medicare
certification
as
an
ASC
facility.
All
charges
All
charges
No
benefit
All
Charges
All
Charges 42
42 Page 43 44
2002
Mail
Handlers
Benefit
Plan
43
Section
5(
c)
Hospice
is
a
coordinated
program
of
maintenance
and
supportive
care
for
the
terminally
ill
provided
by
a
medically
supervised
team
under
the
direction
of
a
Plan-
approved
independent
hospice
administration.
We
pay
$5,000
per
lifetime
for
any
combination
of
inpatient
and
outpatient
services.
If
you
use
a
PPO
provider,
your
out-
of-
pocket
expenses
will
be
reduced.
PPO:
All
charges
after
the
Plan
has
paid
$5,000
Non-
PPO:
All
charges
after
the
Plan
has
paid
$5,000
PPO:
All
charges
after
the
Plan
has
paid
$5,000
Non-
PPO:
All
charges
after
the
Plan
has
paid
$5,000
Not
covered: Independent
nursing,
and
homemaker
services
Charges
above
$5,000.
All
Charges
All
Charges
Local
professional
ambulance
service
when
medically
appropriate
to
the
first
hospital
where
treated
and
from
that
hospital
to
the
next
nearest
hospital
or
medical
facility
if
necessary
treatment
is
not
available
at
the
first
hospital
Air
ambulance
to
the
nearest
hospital
where
treatment
is
available
and
only
if
there
is
no
emergency
ground
transportation
available
or
suitable
and
the
patient's
condition
requires
immediate
evacuation
PPO:
10%
of
the
Plan's
allowance
(calendar
year
deductible
applies)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
PPO:
10%
of
the
Plan's
allowance
(calendar
year
deductible
applies)
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
Not
covered:
Non-
medically
necessary
transport
All
Charges
All
Charges 43
43 Page 44 45
2002
Mail
Handlers
Benefit
Plan
44
Section
5(
d)
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.
The
calendar
year
deductible
is:
$250
per
person
($ 750
per
family)
for
Standard
Option
and
$200
per
person
($ 600
per
family)
for
High
Option.
The
calendar
year
deductible
applies
to
almost
all
benefits
in
this
Section.
We
added
"( No
deductible)"
to
show
when
the
calendar
year
deductible
does
not
apply.
See
Section
4
for
more
information
about
deductibles
and
other
cost-sharing
features
such
as
coinsurance
and
copayments.
The
non-PPO
benefits
are
the
regular
benefits
of
this
Plan.
PPO
benefits
apply
only
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-PPO
benefits
apply.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
Also
read
Section
9
about
coordinating
benefits
with
other
coverage,
including
with
Medicare.
If
you
receive
outpatient
care
for
your
accidental
injury
in
a
hospital
emergency
room
or
urgent
care
center,
we
cover:
Non-surgical
physician
services
and
supplies;
Related
outpatient
hospital
services;
Observation
room;
Surgery. Note: We pay
inpatient
hospital
benefits
if
you
are
admitted.
Note:
Repair
of
sound
natural
teeth
due
to
an
accidental
injury
is
covered
under
this
benefit.
The
services
and
supplies
must
be
provided
within
one
year
of
the
accident
and
the
patient
must
be
a
member
of
the
Plan
at
the
time
the
services
were
rendered. Masticating
(chewing)
incidents
are
not
considered
to
be
accidental
injuries.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Accidental
injury
–
continued
on
next
page 44
44 Page
45 46
2002
Mail
Handlers
Benefit
Plan
45
Section
5(
d)
(continued)
Non-
surgical
physician
services
provided
in
a
doctor's
office
for
your
accidental
injury.
PPO:
$15
copayment
per
office
visit
(No
deductible);
and
10%
of
the
Plan's
allowance
for
other
services
performed
during
the
visit
(calendar
year
deductible
applies) Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
per
office
visit
(No
deductible);
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
other
services
(calendar
year
deductible
applies)
PPO:
$15
copayment
per
office
visit
(No
deductible);
and
10%
of
the
Plan's
allowance
for
other
services
performed
during
the
visit
(calendar
year
deductible
applies) Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
per
office
visit
(No
deductible);
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
other
services
(calendar
year
deductible
applies)
Outpatient
medical
or
surgical
services
and
supplies
for
services
rendered
in
a
hospital
emergency
room
or
urgent
care
center
(including
observation
room)
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Non-
surgical
physician
services
and
supplies
provided
in
a
doctor's
office
PPO:
$15
copayment
per
office
visit
(No
deductible);
and
10%
of
the
Plan's
allowance
for
other
services
performed
during
the
visit
(calendar
year
deductible
applies) Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
per
office
visit
(No
deductible);
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
other
services
(calendar
year
deductible
applies)
PPO:
$15
copayment
per
office
visit
(No
deductible);
and
10%
of
the
Plan's
allowance
for
other
services
performed
during
the
visit
(calendar
year
deductible
applies) Non-PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
per
office
visit
(No
deductible);
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
for
other
services
(calendar
year
deductible
applies)
Local
professional
ambulance
service
when
medically
appropriate
to
the
first
hospital
where
treated
and
from
that
hospital
to
the
next
nearest
hospital
or
medical
facility
if
necessary
treatment
is
not
available
at
the
first
hospital.
Air
ambulance
to
the
nearest
hospital
where
treatment
is
available
and
only
if
there
is
no
emergency
ground
transportation
available
or
suitable
and
the
patient's
condition
warrants
immediate
evacuation.
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan's
allowance
Non-
PPO:
30%
of
the
Plan's
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered:
When
used
for
non-
emergency
purposes
All
Charges
All
Charges 45
45 Page 46 47
2002
Mail
Handlers
Benefit
Plan
46
Section
5(
e)
You
may
choose
to
get
care
Out-
of-
Network
or
In-
Network.
When
you
receive
In-
Network
care,
you
must
get
our
approval
for
services
and
follow
a
treatment
plan
we
approve.
If
you
do,
cost-
sharing
and
limitations
for
In-
Network
mental
health
and
substance
abuse
benefits
will
be
no
greater
than
for
similar
benefits
of
other
illnesses
and
conditions.
If
In-
Network
care
is
not
authorized,
Out-
of-
Network
benefits
will
be
paid.
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
and/
or
clinically
appropriate.
The
Mental
health
and
substance
abuse
benefits
calendar
year
deductible
is
$250
per
person
($
750
per
family)
for
Standard
Option
and
$200
per
person
($
600
per
family)
for
High
Option.
The
calendar
year
deductible
applies
to
almost
all
benefits
in
this
Section.
We
added
"(
No
deductible)"
to
show
when
the
calendar
year
deductible
does
not
apply.
This
calendar
year
deductible
is
in
addition
to
the
calendar
year
deductible
for
medical
services
and
the
calendar
year
deductible
for
prescription
drugs.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
Also
read
Section
9
about
coordinating
benefits
with
other
coverage,
including
with
Medicare.
If
you
do
not
obtain
and
follow
an
approved
treatment
plan
we
will
provide
Out-
of-
Network
benefits.
.
See
the
instructions
after
the
benefits
descriptions
below.
.
In-
Network
mental
health
and
substance
abuse
benefits
are
below,
then
Out-
of-
Network
benefits
begin
on
page
48.
All
diagnostic
and
treatment
services
contained
in
a
treatment
plan
that
we
approve.
The
treatment
plan
may
include
services,
drugs,
and
supplies
described
elsewhere
in
this
brochure. Note: Managed
In-
Network
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
illnesses
or
conditions
Your
cost
sharing
responsibilities
are
no
greater
than
for
other
illnesses
or
conditions
Outpatient
professional
services,
including
individual
or
group
therapy
by
providers
approved
by
the
Managed
In-
Network
vendor.
This
may
include
services
provided
by
a
Licensed
Professional
Counselor
or
Licensed
Marital
Family
Therapist. Medication management
$15
copayment
per
office
visit
(No
deductible)
$15
copayment
per
office
visit
(No
deductible)
Managed
In-
Network
Benefits
–
continued
on
next
page 46
46 Page
47 48
2002
Mail
Handlers
Benefit
Plan
47
Section
5(
e)
(continued)
Inpatient
professional
services
10%
of
the
Plan's
allowance
10%
of
the
Plan's
allowance
Electroshock
therapy
and
laboratory
procedures
Diagnostic
tests
including
psychological
testing
10%
of
the
Plan's
allowance
10%
of
the
Plan's
allowance
Services
provided
by
a
hospital
or
other
inpatient
facility
Services
in
approved
alternative
care
settings
such
as
partial
hospitalization,
half-
way
house,
residential
treatment,
full-
day
hospitalization,
facility
based
intensive
outpatient
treatment
$150
per
admission
Nothing
Not
covered:
Services
we
have
not
approved
All
Charges
All
Charges
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.
To
be
eligible
to
receive
these
enhanced
mental
health
and
substance
abuse
benefits
you
must
follow
your
treatment
plan
and
the
following
network
authorization
process:
Call
the
Plan
at
1-
800-
410-
7778
to
be
referred
to
the
Managed
Network
vendor.
If
you
do
not
call,
the
charges
will
be
processed
as
Out-
of-
Network
benefits.
If
you
do
not
obtain
an
approved
treatment
plan
we
will
provide
only
Out-
of-
Network
benefits 47
47 Page
48 49
2002
Mail
Handlers
Benefit
Plan
48
Section
5(
e)
Outpatient
professional
services
to
treat
mental
conditions
and
substance
abuse
Note:
One
day
in
partial
hospitalization/
day
treatment
program
is
considered
as
one
outpatient
visit
30%
of
the
Plan's
allowance
for
up
to
20
visits
after
the
mental
conditions/
substance
abuse
calendar
year
deductible
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
20
visits.
30%
of
the
Plan's
allowance
for
up
to
20
visits
after
the
mental
conditions/
substance
abuse
calendar
year
deductible
and
any
difference
between
our
allowance
and
the
billed
amount.
All
charges
after
20
visits.
Inpatient
professional
services
to
treat
mental
conditions
and
substance
abuse
30%
of
the
Plan's
allowance
after
the
mental
conditions/
substance
abuse
calendar
year
deductible.
And
any
difference
between
our
allowance
and
the
billed
amount.
30%
of
the
Plan's
allowance
after
the
mental
conditions/
substance
abuse
calendar
year
deductible.
And
any
difference
between
our
allowance
and
the
billed
amount.
Electroshock
therapy,
diagnostic
tests
and
laboratory
procedures
30%
of
the
Plan's
allowance
after
the
mental
conditions/
substance
abuse
calendar
year
deductible.
And
any
difference
between
our
allowance
and
the
billed
amount.
30%
of
the
Plan's
allowance
after
the
mental
conditions/
substance
abuse
calendar
year
deductible.
And
any
difference
between
our
allowance
and
the
billed
amount.
Inpatient
care
to
treat
mental
conditions
includes
ward
or
semiprivate
accommodations
and
other
hospital
charges
$300
per
admission
and
30%
of
covered
charges
for
up
to
45
days
per
calendar
year.
And
any
charges
for
services
rendered
after
the
covered
45
days.
$250
per
admission
and
30%
of
covered
charges
for
up
to
45
days
per
calendar
year.
And
any
charges
for
services
rendered
after
the
covered
45
days.
Inpatient
care
to
treat
substance
abuse
includes
room
and
board
and
ancillary
charges
for
confinements
in
a
treatment
facility
for
rehabilitative
treatment
of
alcoholism
or
substance
abuse
$300
per
admission
and
30%
of
covered
charges
for
up
to
45
days
per
calendar
year.
And
any
charges
for
services
rendered
after
the
covered
45
days.
$250
per
admission
and
30%
of
covered
charges
for
up
to
45
days
per
calendar
year.
And
any
charges
for
services
rendered
after
the
covered
45
days.
Not
covered
Out-
of-
Network:
Services,
that
in
the
Plan's
judgement,
are
not
medically
necessary Services by
pastoral,
marital,
drug/
alcohol
and
other
counselors Treatment
for
learning
disabilities
and
mental
retardation
Services
rendered
or
billed
by
schools,
licensed
residential
treatment
centers
or
halfway
houses
or
members
of
their
staffs
All
Charges
All
Charges
The
medical
necessity
of
your
to
a
hospital
or
other
covered
facility
must
be
precertified
for
you
to
receive
these
Out-
of-
Network
benefits.
Emergency
admissions
must
be
reported
within
two
business
days
following
the
day
of
admission
even
if
you
have
been
discharged.
Otherwise,
the
benefits
payable
will
be
reduced
by
$500.
See
Section
3
for
details.
See
these
sections
of
the
brochure
for
more
valuable
information
about
these
benefits:
Section
4,
Your
costs
for
covered
services ,
for
information
about
out-
of-
pocket
maximum
for
In-
Network
benefits.
Section
7,
Filing
a
claim
for
covered
services ,
for
information
about
submitting
Out-
of-
Network
claims. 48
48 Page
49 50
2002
Mail
Handlers
Benefit
Plan
49
Section
5(
f)
Please
remember
all
benefits
are
subject
to
the
definitions,
limitations
and
exclusions
in
this
brochure
and
are
payable
only
when
we
determine
they
are
medically
necessary.
The
deductible
for
prescription
drugs
is
separate
from
the
annual
deductible
for
medical
benefits
and
separate
from
the
annual
deductible
for
mental
health
and
substance
abuse.
We
added
"(
No
deductible)"
to
show
when
the
calendar
year
prescription
drug
deductible
does
not
apply.
The
Calendar
Year
prescription
drug
deductible
is
$600
per
person
($
1,200
per
family)
for
Standard
Option.
The
Plan
will
waive
the
prescription
deductible
for
mail
order
purchases
for
members
who
have
Medicare
Parts
A
and
B
as
their
primary
coverage.
The
Calendar
Year
prescription
drug
deductible
is
$250
per
person
($
500
per
family)
for
High
Option.
The
Plan
will
waive
the
prescription
deductible
for
mail
order
purchases
for
members
who
have
Medicare
Parts
A
and
B
as
their
primary
coverage.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
Also
read
Section
9
about
coordinating
benefits
with
other
coverage,
including
with
Medicare.
.
These
include:
A
physician
or
other
covered
provider
acting
within
the
scope
of
their
license.
You
may
fill
the
prescription
at
an
AdvancePCS
participating
pharmacy,
a
non-
AdvancePCS
pharmacy
or
by
mail
for
certain
drugs.
We
pay
a
higher
level
of
benefits
when
you
use
an
AdvancePCS
participating
pharmacy.
–
Present
your
Plan
identification
card
at
an
AdvancePCS
participating
Network
pharmacy
to
purchase
prescription
drugs.
Call
1-
800-
410-
7778
to
locate
the
nearest
network
pharmacy.
You
must
have
the
pharmacy
file
the
claim
electronically
for
you
in
order
to
receive
the
network
pharmacy
level
benefit.
–
You
may
purchase
prescriptions
at
pharmacies
that
are
not
part
of
our
network.
You
pay
full
cost
and
must
file
a
claim
for
reimbursement.
See
When
you
have
to
file
a
claim.
–
To
obtain
more
information
about
the
mail
order
drug
program,
call
the
Plan
at
1-
800-
410-
7778
or
visit
our
web
site
at
www. mhbp.
com
.
If
your
physician
believes
a
brand
name
drug
is
necessary
or
there
is
no
generic
available,
your
physician
may
prescribe
a
brand
name
drug
from
a
formulary
list.
This
formulary
list
is
our
preferred
brand.
This
is
a
list
of
drugs
selected
to
meet
patients
needs
at
a
lower
cost.
To
order
a
prescription
drug
brochure,
call
1-
800-
410-
7778.
A
generic
equivalent
will
be
dispensed
if
it
is
available,
unless
your
physician
specifically
requires
a
brand
name.
If
you
receive
a
brand
name
drug
when
a
Federally-
approved
generic
drug
is
available,
and
your
physician
has
not
specified
"dispense
as
written"
for
the
brand
name
drug,
you
have
to
pay
the
difference
in
cost
between
the
brand
name
drug
and
the
generic.
All
prescriptions
will
be
limited
to
a
90
day
dispensing
amount.
Also,
in
most
cases,
refills
cannot
be
obtained
until
75%
of
the
drug
has
been
used.
In
addition
to
the
general
dispensing
limitations
described
above,
there
are
restrictions
on
certain
types
of
drugs.
The
Plan
requires
prior
authorization
for
the
following
drugs:
growth
hormones,
acne
medications,
antiemetics
(antinausea
drugs),
migraine
medications,
drugs
used
to
treat
Attention
Deficit
Disorder
and
narcolepsy.
The
Plan
may
further
limit
the
dispensing
quantities
for
some
categories
of
drugs.
These
categories
include
drugs
to
treat
migraine
headaches,
medications
used
for
nausea
and
the
medications
to
treat
influenza.
A
generic
drug
is
the
therapeutic
equivalent
to
a
brand
name
drug,
yet
it
costs
much
less.
Choosing
generic
drugs
rather
than
brand
name
drugs
can
reduce
your
out-
of-
pocket
expenses.
The
U.
S
Food
and
Drug
Administration
sets
quality
standards
for
generic
drugs
to
ensure
that
these
drugs
meet
the
same
standards
of
quality
and
strength
as
brand
name
drugs.
They
must
contain
the
same
active
ingredients,
be
equivalent
in
strength
and
dosage,
and
meet
the
same
standards
for
safety,
purity
and
effectiveness
as
the
original
brand
name
product.
you
If
you
purchase
prescriptions
at
a
non-
network
pharmacy,
mail
your
prescription
receipts
to:
AdvancePCS
,
Attn:
MHBP
Claims,
P.
O.
Box
52151,
Phoenix,
AZ
85072-
2151.
Receipts
must
include
the
prescription
number,
name
of
drug,
prescribing
doctor's
name,
date,
charge
and
name
of
drugstore. 49
49 Page
50 51
2002
Mail
Handlers
Benefit
Plan
50
Section
5(
f)
.
Some
of
the
drug
classes
that
are
not
available
are:
all
injectables
(except
for
diabetic
supplies
and
multiple
sclerosis
agents
Betaseron,
Avonex,
and
Copaxone),
narcotics,
hospital
solutions
and
certain
drugs
such
as
antipsychotic
agents
and
AIDS
therapies
and
other
drugs
for
which
state
or
federal
laws
or
medical
judgement
limit
the
dispensing
amount
to
less
than
90
days.
However,
these
excluded
drugs
are
covered
under
the
retail
prescription
drug
program.
This
Plan
has
two
levels
of
reimbursement
for
retail
prescription
drug
claims.
One
is
for
prescriptions
filled
at
a
network
pharmacy
or
for
prescriptions
filled
by
foreign
pharmacies.
The
second
is
for
prescriptions
filled
at
a
non-
network
pharmacy
or
other
vendor
or
when
you
choose
to
submit
a
paper
claim
to
the
Plan.
It
is
in
your
best
interest
to
have
your
prescription
filled
at
a
network
pharmacy.
If
you
do
not
and
do
not
live
overseas,
your
reimbursement
will
be
reduced.
If
you
submit
a
paper
claim
for
drugs
dispensed
by
a
network
pharmacy,
the
Plan
will
reduce
your
benefits
to
50%
of
the
allowable
charges.
Remember
to
show
your
Mail
Handlers
Benefit
Plan
ID
card
with
the
AdvancePCS
logo
to
receive
increased
benefits.
In
addition,
the
claims
will
be
filed
electronically
for
you.
You
may
purchase
the
following
medications
and
supplies
prescribed
by
a
physician
from
either
a
pharmacy
or
by
mail
(for
certain
prescription
drugs):
Drugs
and
medicines
that
by
Federal
law
of
the
United
States
require
a
doctor's
written
prescription,
including
chemotherapy
and
drugs
used
to
treat
the
side
effects
of
chemotherapy Disposable needles
and
syringes,
and
alcohol
swabs
(if
purchased
at
a
pharmacy).
Insulin
and
related
testing
material
Hormone
based
contraceptives,
including
Norplant
(Norplant
insertions
are
covered
under
Surgical
Benefits)
Diaphragms Smoking deterrents
Network
pharmacies
or
prescriptions
filled
by
foreign
pharmacies:
30%
of
the
Plan's
allowance
for
the
prescription Non-network
pharmacies:
50%
of
the
Plan's
allowance
for
the
prescription Paper claims for prescriptions
filled
at
a
network
pharmacy:
50%
of
the
Plan's
allowance
for
the
prescription Mail Order:
$10
per
generic/$
40
per
preferred
brand/$
55
per
non-
preferred
brand
drug
Mail
Order
Medicare:
$10
per
generic/$
40
per
preferred
brand/$
55
per
non-
preferred
brand
drug
(No
deductible)
Network
pharmacies
or
prescriptions
filled
by
foreign
pharmacies:
25%
of
the
Plan's
allowance
for
the
prescription Non-network
pharmacies:
50%
of
the
Plan
allowance
for
the
prescription. Paper claims for prescriptions
filled
at
a
network
pharmacy:
50%
of
the
Plan's
allowance
for
the
prescription Mail Order:
$10
per
generic/$
30
per
preferred
brand/$
45
per
non-
preferred
brand
drug
Mail
Order
Medicare:
$10
per
generic/$
30
per
preferred
brand/$
45
per
non-
preferred
brand
drug
(No
deductible) Covered medications
and
accessories
–
continued
on
next
page 50
50 Page
51 52
2002
Mail
Handlers
Benefit
Plan
51
Section
5(
f)
(continued) Not covered: Drugs and supplies
for
cosmetic
purposes
Prescriptions
written
by
a
non-
covered
provider
Drugs
that
do
not
require
a
prescription
Not
medically
necessary
vitamins
and
food
supplements
Vitamins,
nutrients
and
food
supplements
that
do
not
require
a
prescription
even
if
a
physician
prescribes
or
administers
them
Nonprescription
medicines
Anorexiants/
appetite
suppressants
or
prescription
drugs
for
weight
loss
Drugs
prescribed
for
sexual
dysfunction
or
sexual
inadequacies Drugs and supplies
when
another
insurance
plan
or
payer
provides
benefits
for
these
services/
supplies
except
Medicare
Part
B
covered
diabetic
supplies
Any
amount
in
excess
of
the
cost
of
a
generic
drug
when
a
generic
is
available
and
the
physician
has
not
specified
that
the
pharmacist
dispense
the
brand
name
drug
only
All
charges
All
charges 51
51 Page 52 53
2002
Mail
Handlers
Benefit
Plan
52
Section
5g
Flexible
benefits
option
Under
the
flexible
benefits
option,
we
determine
the
most
effective
way
to
provide
services. We may
identify
medically
appropriate
alternatives
to
traditional
care
and
coordinate
other
benefits
as
a
less
costly
alternative
benefit.
Alternative
benefits
are
subject
to
our
ongoing
review.
By
approving
an
alternative
benefit,
we
cannot
guarantee
you
will
get
it
in
the
future.
The
decision
to
offer
an
alternative
benefit
is
solely
ours,
and
we
may
withdraw
it
at
any
time
and
resume
regular
contract
benefits.
Our
decision
to
offer
or
withdraw
alternative
benefits
is
not
subject
to
OPM
review
under
the
disputed
claims
process.
Worldwide
Assistance
This
program
gives
you
help
and
follow-
up
in
medical
and
other
emergencies
100
miles
or
more
from
your
home.
A
toll-
free
number
gives
you
access
to
expert
assistance
while
traveling.
Your
ID
card
and
letter
will
contain
more
information.
Note:
Services
provided
under
this
benefit
through
Worldwide
Assistance
are
not
subject
to
the
FEHB
disputed
claims
process. 52
52 Page 53 54
2002
Mail
Handlers
Benefit
Plan
53
Section
5(
h)
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.
Be
sure
to
read
Section
4,
Your
costs
for
covered
services ,
for
valuable
information
about
how
cost
sharing
works,
with
special
sections
for
members
who
are
age
65
or
over.
Also
read
Section
9
about
coordinating
benefits
with
other
coverage,
including
with
Medicare.
High
Option
pays
actual
charges
up
to
the
amounts
specified
in
the
schedule
of
dental
allowances
for
covered
dental
procedures,
up
to
a
maximum
benefit
of
$800
per
person
and
$1,600
per
family
per
calendar
year.
There
is
no
deductible
for
High
Option
Dental
Benefits.
For
covered
dental
procedures
not
shown,
the
Plan
will
pay,
subject
to
the
limits
provided,
amounts
consistent
with
procedures
which
are
shown.
Note:
We
cover
hospitalization
for
these
dental
procedures
only
when
a
non-
dental
physical
impairment
exists
which
makes
hospitalization
necessary
to
safeguard
the
health
of
the
patient.
The
hospitalization
for
both
inpatient
and
outpatient
must
be
precertified
by
the
Plan.
Dental
PPO
—The
Plan
offers
access
to
a
network
of
dentists
who
have
agreed
to
provide
services
at
a
discounted
rate.
To
learn
of
a
preferred
dentist
in
your
area,
call
1-
888-
788-
5702
or
visit
the
Plan's
web
site
www. mhbp.
com
.
For
information
about
the
Plan's
benefits,
call
customer
relations
at
1-
800-
410-
7778
or
visit
the
Plan's
web
site.
The
Plan
is
unable
to
return
dental
X-
rays.
Remind
your
dentist
not
to
submit
X-
rays.
If
in
the
construction
of
a
denture
or
any
prosthetic
dental
appliance,
the
patient
and
the
dentist
decide
on
personalized
restoration
or
to
employ
special
techniques
as
opposed
to
standard
procedures,
the
benefit
provided
will
be
limited
to
the
amount
payable
for
the
standard
procedures.
Charges
for
crowns,
bridges,
and
dentures
are
usually
incurred
when
they
are
ordered.
The
Plan
pays
benefits
to
cover
such
charges
even
if
the
enrollee
later
rejects
the
denture
or
appliance. The following is
a
partial
schedule
of
dental
allowances.
IAGNOSTIC
00120
Periodic
oral
examination
(limit
one
per
year)
$
7.50
All
charges
above
scheduled
allowance.
00210
X-
rays,
intraoral,
complete
series
including
bitewings
(limit
one
per
year)
22.00
All
charges
above
scheduled
allowance.
00220
X-
rays,
intraoral,
periapical
—first
film
3.25
All
charges
above
scheduled
allowance.
00230
X-
rays,
intraoral,
periapical
—each
additional
film
2.25
All
charges
above
scheduled
allowance.
00240
X-
rays,
intraoral,
occlusal
film
7.50
All
charges
above
scheduled
allowance.
00270
X-
rays,
bitewing,
single
film
2.75
All
charges
above
scheduled
allowance.
00290
X-
rays,
posterior-
anterior
or
lateral
skull
and
facial
bone
survey
13.00
All
charges
above
scheduled
allowance.
00330
X-
rays,
panoramic
film
22.00
All
charges
above
scheduled
allowance.
Dental
benefits
–
continued
on
next
page 53
53 Page
54 55
2002
Mail
Handlers
Benefit
Plan
54
Section
5(
h)
(continued) REVENTIVE (dollar
amount
shown
is
limit
per
calendar
year)
01110
Prophylaxis,
adult
(age
13
and
over)
$
14.25
All
charges
above
scheduled
allowance.
01120
Prophylaxis,
child
(through
age
12)
12.00
All
charges
above
scheduled
allowance.
01203
Fluoride
application,
topical,
child
7.50
All
charges
above
scheduled
allowance.
01204
Fluoride
application,
topical,
adult
7.
50
All
charges
above
scheduled
allowance.
01351
Sealant,
per
tooth
7.50
All
charges
above
scheduled
allowance.
01510
Space
maintainer,
fixed,
unilateral
(limited
to
age
18
and
under)
34.00
All
charges
above
scheduled
allowance.
ESTORATIVE
(includes
liners,
bases
and
local
anesthesia)
02140
One
surface,
permanent
$
13.00
All
charges
above
scheduled
allowance.
02150
Two
surfaces,
permanent
20.75
All
charges
above
scheduled
allowance.
02160
Three
surfaces,
permanent
27.50
All
charges
above
scheduled
allowance.
02951
Reinforcement
pins,
each
pin
8.
25
All
charges
above
scheduled
allowance.
NDODONTICS
(includes
local
anesthesia)
03110
Pulp
cap,
direct
$
16.50
All
charges
above
scheduled
allowance.
03310
Root
canal
therapy,
one
canal
96.75
All
charges
above
scheduled
allowance.
03320
Root
canal
therapy,
two
canals
136.25
All
charges
above
scheduled
allowance.
03330
Root
canal
therapy,
three
canals
178.00
All
charges
above
scheduled
allowance.
03410
Apicoectomy
55.00
All
charges
above
scheduled
allowance.
ERIODONTICS
(includes
local
anesthesia)
04320
Provisional
splinting
$
81.25
All
charges
above
scheduled
allowance.
04341
Periodontal
scaling
and
root
planing
(per
quadrant)
13.00
All
charges
above
scheduled
allowance.
04910
Periodontal
maintenance
procedures
13.00
All
charges
above
scheduled
allowance.
Dental
benefits
–
continued
on
next
page 54
54 Page
55 56
2002
Mail
Handlers
Benefit
Plan
55
Section
5(
h)
(continued) ROWN AND RIDGE
(includes
local
anesthesia)
02510
Inlay,
metallic,
one
surface
$
68.00
All
charges
above
scheduled
allowance.
02710
Crown,
resin
(laboratory)
108.75
All
charges
above
scheduled
allowance.
02720
Crown,
resin
with
high
noble
metal
178.00
All
charges
above
scheduled
allowance.
02740
Crown,
porcelain
with
ceramic
substrate
136.25
All
charges
above
scheduled
allowance.
02750
Crown,
porcelain
fused
to
high
noble
metal
178.00
All
charges
above
scheduled
allowance.
02752
Crown,
porcelain
fused
to
noble
metal
178.00
All
charges
above
scheduled
allowance.
02790
Crown,
full
cast,
high
noble
metal
149.50
All
charges
above
scheduled
allowance.
02810
Crown,
cast
metallic
102.25
All
charges
above
scheduled
allowance.
02920
Recement
crown
27.50
All
charges
above
scheduled
allowance.
02952
Cast
post
and
core,
in
addition
to
crown
68.00
All
charges
above
scheduled
allowance.
02954
Prefabricated
post
and
core,
in
addition
to
crown
34.00
All
charges
above
scheduled
allowance.
02980
Crown
repair
13.00
All
charges
above
scheduled
allowance.
ONTICS
(includes
local
anesthesia)
06210
Cast
high
noble
metal
$
82.50
All
charges
above
scheduled
allowance.
06240
Porcelain
fused
to
high
noble
metal
136.25
All
charges
above
scheduled
allowance.
ENTURES
(prosthetics)
05110
Complete
denture,
maxillary
(including
necessary
adjustments
within
6
months)
$
239.75
All
charges
above
scheduled
allowance.
05120
Complete
denture,
mandibular
(including
necessary
adjustments
within
6
months)
239.75
All
charges
above
scheduled
allowance.
05130
Immediate
denture,
maxillary
272.50
All
charges
above
scheduled
allowance.
05140
Immediate
denture,
mandibular
272.50
All
charges
above
scheduled
allowance.
05211
Partial
denture,
maxillary,
resin
base
217.75
All
charges
above
scheduled
allowance.
05510
Repair,
complete
denture,
base
20.75
All
charges
above
scheduled
allowance.
05520
Repair,
complete
denture,
repair
or
replace
teeth
(each
tooth)
9.75
All
charges
above
scheduled
allowance.
05630
Repair,
partial
denture,
repair
or
replace
clasp
40.50
All
charges
above
scheduled
allowance.
05640
Repair,
partial
denture,
repair
or
replace
teeth
(each
tooth)
13.00
All
charges
above
scheduled
allowance.
05650
Add
tooth,
partial
denture
34.00
All
charges
above
scheduled
allowance.
05660
Add
clasp,
partial
denture
40.50
All
charges
above
scheduled
allowance.
05710
Rebase,
complete
denture,
maxillary
68.00
All
charges
above
scheduled
allowance.
Dental
benefits
–
continued
on
next
page 55
55 Page
56 57
2002
Mail
Handlers
Benefit
Plan
56
Section
5(
h)
(continued) RAL URGERY (includes
local
anesthesia)
04210
Gingivectomy
or
gingivoplasty
(per
quadrant)
$
102.50
All
charges
above
scheduled
allowance.
04260
Osseous
surgery,
including
flap
entry
and
closure
(per
quadrant)
137.50
All
charges
above
scheduled
allowance.
07110
Extraction
of
tooth
—first
tooth
15.00
All
charges
above
scheduled
allowance.
07120
Extraction
of
tooth
—each
additional
tooth,
same
session
12.00
All
charges
above
scheduled
allowance.
07210
Surgical
extraction
of
erupted
tooth
23.00
All
charges
above
scheduled
allowance.
07285
Biopsy
of
oral
hard
tissue
34.00
All
charges
above
scheduled
allowance.
07310
Alveoloplasty
in
conjunction
with
extraction
(per
quadrant)
44.00
All
charges
above
scheduled
allowance.
07450
Removal
of
odontogenic
cyst
or
tumor/
lesion,
up
to
1.25
cm
66.00
All
charges
above
scheduled
allowance.
07510
Incision
and
drainage
of
abscess,
intraoral
soft
tissue
13.00
All
charges
above
scheduled
allowance.
07960
Frenulectomy
(frenectomy
or
frenotomy),
separate
procedure
61.50
All
charges
above
scheduled
allowance.
ISCELLANEOUS
ERVICES
09110
Palliative
treatment
of
dental
pain,
minor
procedure
$
7.50
All
charges
above
scheduled
allowance.
09220
General
anesthesia
—first
30
minutes
8.75
All
charges
above
scheduled
allowance.
09221
General
anesthesia
—each
additional
15
minutes
4.38
All
charges
above
scheduled
allowance.
09310
Consultation
by
other
than
attending
dentist
20.75
All
charges
above
scheduled
allowance.
Note:
For
services
rendered
due
to
accidental
injury
to
sound
natural
teeth,
see
Section
5(
d).
What
is
not
covered
Charges
related
to
orthodontia
Oral
hygiene
instruction
Denture
replacements
(if
benefits
were
provided
by
this
Plan
within
the
last
five
years)
Temporary
dental
services
Dental
implants
or
related
surgical
benefits
Orthotics
and
other
occlusal
appliances
used
to
treat
temporomandibular
joint
dysfunction
and/
or
sleep
apnea
Conservative
treatment
of
temporomandibular
joint
dysfunction
(TMJ) 56
56 Page
57 58
2002 Mail Handlers Benefit Plan
57 Section 5( i)
The benefits on this page are not part of the
FEHB contract or premium
Fees you pay for these services do not count toward
FEHB deductibles or out-of-pocket maximums.
provides Plan enrollees and eligible family members the ability to obtain
eye exams, frames,
eyeglasses, and contact lenses at reduced prices from
Vision One providers. For more information concerning the Vision One
Eyecare
Program or to locate a participating Vision One center near you, visit the
Plan's web site (www. mhbp. com), or
call 1-800-804-4384.
provides Plan enrollees and eligible family members the ability to take
advantage of
discounts on Lasik laser vision correction at LCA Vision
Centers across the country. Lasik procedures are performed by board-certified
ophthalmologists experienced in laser vision correction, using the latest
equipment and technology in state-of-the-art
facilities. To find out more
about this program and learn of an LCA Vision Center near you, call
1-888-705-2020.
provides Plan enrollees and eligible family members the ability to obtain
free hearing tests and
evaluations, free counseling, free check-up and
cleaning of instruments, and a discount off of suggested retail prices of
Miracle-Ear
hearing aid products. Consult your Yellow Pages for a
Miracle-Ear Center or Sears Hearing Aid Center, or simply call the Miracle-Ear
Consumer Affairs Department at 1-800-456-6801 for the location nearest you.
Mail Handlers Benefit Plan enrollees who reside in the United States are all
eligible for supplemental plans which are underwritten by
CNA Insurance
Companies, underwriter of the Mail Handlers Benefit Plan.
offers increased dental coverage to High Option enrollees and covered
dependents. The
Dental Supplement Plan will automatically increase benefits
for covered diagnostic, preventive, and periodontal services by 60%;
benefits for all other covered services will increase by 30%. Enrollees and
covered dependents will also receive benefits for a
second annual cleaning
and exam. There is no deductible for this plan and no extra claim forms. For
more information about the
High Option Dental Supplement Plan, you may call
1-800-621-0839.
provides dental benefits for Mail Handlers Benefit Plan Standard Option
enrollees and their
eligible family members. Like the regular MHBP High
Option dental benefits, the Standard Option Dental Program pays benefits up
to a scheduled allowance for most dental procedures up to a maximum annual
benefit of $800 per person or $1,600 per family.
And, like the regular High
Option dental benefits, you can take advantage of Preferred Provider dentists to
reduce your out-of-pocket
costs even further. This plan has no deductible
and you are always free to see any dentist you choose. For more information
on this program, please call 1-800-621-0839.
is designed to help people cope with the potentially devastating costs
associated with long
term care. The Mail Handlers Group Long Term Care
Program lets enrollees choose the type of care they receive and where they
receive it, either in a nursing home, assisted living facility, community
setting, or at home. Long Term Care benefits are typically
not provided by
regular group health insurance, and Medicare benefits are limited, so coverage
for long term care expenses can be
an important financial decision. Complete
information on the Mail Handlers Group Long Term Care Program, including a full
explanation of rates and benefits, can be requested by visiting the MHBP web
site (www. mhbp. com) or a kit can be requested by
calling 1-800-522-0100.
This program is underwritten by Continental Casualty Company, a CNA company.
(Not available in MD)
provides daily cash benefits for hospitalization. Cash payments of up to
$100 per day are paid directly to
enrollees when they or a covered family
member are hospitalized for any covered sickness or accident. If confinement is
for
intensive care, benefits of up to $200 per day are paid. The money is
paid directly to the enrollee and may be spent in any way. For
additional
information concerning the Hospital Money Plan, you may call 1-800-621-0839.
provides $150 a week when an enrollee is totally disabled by an off-work
injury. The
program also provides up to $25,000 for accidental death
benefits. If the enrollee has children, up to $10,000 in educational benefits
for each eligible child is provided if death occurs as a result of a covered
injury. For more information about the Off-Work
Accident Disability Plan,
you may call 1-800-621-0839.
provides up to $500 or $1,000 per month to enrollees to replace lost income
for a
period of up to 12 or 24 months as a result of a disability due to a
covered illness, injury, or complications of pregnancy. The
benefit choice
and period is up to the enrollee. All enrollees under the age of 60 are
guaranteed acceptance in this plan as long as
they actively work at least 30
hours a week and have not been hospitalized in the last six months. For more
information about this
program, call 1-800-621-0839. 57
57 Page 58 59
2002 Mail Handlers Benefit Plan 58 Section 6
The exclusions in this section apply to all benefits.
We do not
cover the following:
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 in the United
States;
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 and supplies for which there would be no charge if the covered
individual had no health insurance coverage;
Services, drugs, or supplies
related to sex transformations, sexual dysfunction or sexual inadequacy, penile
prosthesis;
Services, drugs, or supplies you receive from a provider or
facility barred from the FEHB Program;
Services and supplies furnished
without charge while in active military service; or required for illness or
injury sustained on or after the effective date of enrollment (1) as the result
of an act of war within the Unites States, its territories or possessions, or
(2) during
combat;
Services and supplies furnished by household members or immediate
relatives, such as spouse, parents, grandparents, children, brothers or sisters
by blood, marriage or adoption;
Services and supplies furnished or billed by a non-covered facility, except
that medically necessary prescription drugs are covered;
Services, drugs and
supplies associated with care that is not covered, though they may be covered
otherwise (e. g., Inpatient Hospital Benefits are not payable for non-covered
cosmetic surgery);
Any portion of a provider's fee or charge ordinarily due from the enrollee
but that has been waived. If a provider routinely waives (does not require the
enrollee to pay) a deductible, copayment or coinsurance, the Plan will calculate
the actual provider fee or
charge by reducing the fee or charge by the
amount waived;
Charges which the enrollee or Plan has no legal obligation to
pay, such as excess charges for an annuitant age 65 or older who is not covered
by Medicare Parts A and/ or B (see page 14), doctor's charges exceeding the
amount specified by the Department of Health
& Human Services when benefits are payable under Medicare (limiting
charge) (see page 15), or State premium taxes however applied;
Services, drugs and supplies for weight control or treatment of obesity,
except surgery for documented morbid obesity;
Educational, recreational or
milieu therapy, whether in or out of the hospital;
Services and supplies for
cosmetic purposes, except as provided under Surgical Benefits/ Reconstructive
Surgery;
Biofeedback;
Cardiac rehabilitation;
Eyeglasses, contact
lenses and hearing aids, except as provided under Section 5( a);
Orthotics
and appliances used to treat temporomandibular joint dysfunction and/ or sleep
apnea;
Custodial care (see definition) or domiciliary care;
Travel, even
if prescribed by a doctor, except as provided under the Ambulance Benefit;
Handling Charges/ Administrative Charges or late charges, including
interest, billed by providers of care; and
Services and/ or supplies not
listed as covered in this brochure. 58
58 Page 59 60
2002 Mail
Handlers Benefit Plan 59 Section 7
To obtain claim forms or other
claims filing advice or answers about our benefits, contact us at
1-800-410-7778, or visit our web site at www. mhbp. com
In most cases,
providers and facilities file claims for you. Your physician must file on the
form HCFA-1500, Health Insurance Claim Form. Your facility will file on the
UB-92 form. All claims
should be completed in ink or type that is readable
by an optic scanner. For claims questions and assistance, call us at
1-800-410-7778.
When you must file a claim —such as for overseas claims or when another group
health plan is primary —submit it on the HCFA-1500 or a claim form that includes
the information shown
below. Claims should be itemized and show:
Name of
patient and relationship to enrollee;
Plan identification number of the
enrollee;
Name, address and provider or employer tax identification of
person or firm providing the service or supply;
Dates that services or supplies were furnished;
Diagnosis;
Type of
each service or supply; and
The charge for each service or supply.
Note:
Canceled checks, cash register receipts, or balance due statements are not
acceptable substitutes for itemized bills.
In addition:
You must send a copy of the explanation of benefits (EOB)
from any primary payer, such as the Medicare Summary Notice (MSN), with your
claim.
Bills for home nursing care must show that the nurse is a registered or
licensed practical nurse and must include nursing notes.
Claims for rental
or purchase of durable medical equipment; private duty nursing; and physical,
occupational, and speech therapy require a written statement from the patient's
attending
physician specifying the medical necessity for the service or
supply and the length of time needed.
Claims for overseas (foreign) services should include an English translation.
The Plan applies the exchange rate for the date the services were rendered.
All foreign claim payments will be made directly to the enrollee except for
services rendered to beneficiaries of the Department of Defense third party
collection program.
Canceled checks, cash register receipts, or balance due
statements are not acceptable.
After completing a claim form and attaching
proper documentation, send medical and dental claims to:
Mail Handlers Benefit Plan P. O. Box 45118
Jacksonville, FL 32232-5118
Claims for prescription drugs and supplies that are not ordered through the
Mail Service Prescription Drug Program or purchased from and filed with an
AdvancePCS network pharmacy
must include receipts that include the prescription number, name of drug or
supply, prescribing physician's name, date, and charge.
After completing a claim form and attaching proper documentation send
prescription claims to:
AdvancePCS MHBP Claims
P. O. Box 52151 Phoenix, AZ 85072-2151
If all the required information is not included on the claim, the claim may
be delayed or denied. 59
59 Page 60 61
2002 Mail
Handlers Benefit Plan 60 Section 7
Keep a separate record of the
medical expenses of each covered family member as deductibles and maximum
allowances apply separately to each person. Save copies of all medical bills,
including
those you accumulate to satisfy a deductible. In most instances
they will serve as evidence of your claim. We will not provide duplicate or
year-end statements.
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. Once we pay benefits, there is a three-year limitation on
the
reissuance of uncashed checks.
Claims for inhospital confinements that are submitted by the hospital will be
paid directly to the hospital (with the exception of foreign claims). You may
authorize direct payment to any other
provider of care by signing the
assignment of benefits section on the claim form, or by using the assignment
form furnished by the provider of care. The provider of care's Tax
Identification
Number must accompany the claim. The Plan reserves the right
to make payment directly to you, and to decline to honor the assignment of
payment of any health benefits claim to any person or
party.
Claims
submitted by PPO hospitals and medical providers will be paid directly to the
hospital or provider.
Note: Benefits for services provided at Department of Defense, Veterans
Administration or Indian Health Service facilities will be paid directly to the
facility.
Please reply promptly when we ask for additional information. We may delay
processing or deny your claim if you do not respond.
The Plan, its medical
staff and/ or an independent medical review, determines whether services,
supplies and charges meet the coverage requirements of the Plan (subject to the
disputed claims
procedure described in Section 8. The disputed claims
process). We are entitled to obtain medical or other information —including an
independent medical examination —that we feel is necessary
to determine
whether a service or supply is covered. 60
60
Page 61 62
2002
Mail Handlers Benefit Plan 61 Section 8
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/ prior approval.
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:
Mail Handlers Benefit Plan, P. O. Box 45118, Jacksonville, FL 32232-5118; 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.
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.
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.
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 2, 1900 E Street NW, Washington, D. C. 20415-3620.
Send OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control. 61
61 Page 62 63
2002 Mail Handlers Benefit Plan 62 Section 8
(continued)
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.
If you do not agree with OPM's decision, your only
recourse is to sue. If you decide to sue, you must file the suit against OPM in
Federal court by December 31 of the third year after the year in which you
received the disputed services, drugs or
supplies or from the year in which
you were denied precertification or prior approval. This is the only deadline
that may not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, Federal law governs your lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to
uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
(one that may cause permanent loss
of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 1-800-410-7778 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 2 at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 62
62
Page 63 64
2002
Mail Handlers Benefit Plan 63 Section 9
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. The combined payment from both plans may not equal the entire
amount billed by the provider.
The provision applies whether or not a claim is filed under the other
coverage. When applicable, authorization must be given to this Plan to obtain
information about benefits or services available
from the other coverage, or
to recover overpayments from other coverages.
Medicare is a Health Insurance Program for: People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with
End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a Federal employee on January
1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or
older, you may be able to buy it.
Contact 1-800-MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check
or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan choices available to Medicare
beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of Medicare+ Choice plan you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the
United States. It is the way everyone used to get Medicare benefits and is the
way most people get their Medicare Part
A and Part B benefits now. You may
go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.
When you are
enrolled in Original Medicare along with this Plan, you still need to follow the
rules in this brochure for us to cover your care.
—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 the Original Medicare Plan is the primary payer, Medicare
processes your claim first. In most cases, your claims will be coordinated
automatically and we will consider the balance of
covered charges. You will not need to do anything. To find out if you need to
do something about filing your claims, call us at 1-800-410-7778 or check www.
mhbp. com. 63
63 Page
64 65
2002 Mail Handlers Benefit Plan
64 Section 9
continued
—When Original
Medicare is the primary payer, we will waive some out-of-pocket costs, as
follows:
We limit our payment to an amount that supplements the benefits
that Medicare would pay under Part A (Hospital insurance) and Part B (Medical
Insurance), regardless of whether Medicare pays.
Note: We pay our regular
benefits for emergency services to an institutional provider, such as a
hospital, that does not participate with Medicare and is not reimbursed by
Medicare.
If you are covered by Medicare Part B and it is primary, your out-of-pocket
costs for services both we and Medicare Part B cover depend on whether your
physician accepts Medicare assignment for
the claim.
When Medicare Part
A is primary, all or part of your Plan deductibles and coinsurance will be
waived as indicated below:
When Medicare Part A is primary, the Plan will waive applicable per-admission
copayments and coinsurance for Inpatient Hospital Benefits and Inpatient Mental
Conditions/ Substance Abuse
Benefits.
When Medicare Part B is primary,
the Plan will waive applicable deductibles, copayments and coinsurance for
surgical and medical services billed by physicians, durable medical equipment,
orthopedic and prosthetic appliances and ambulance services.
When
Medicare Part B is primary, the Plan will waive the calendar year deductible
(but not the coinsurance) for nursing benefits and outpatient mental conditions
and substance abuse benefits.
When Medicare Parts A and B are primary, the Plan will waive the deductible
for prescription drugs purchased through the mail order prescription drug
program.
Note: The Plan will not waive the deductible and coinsurance for
retail prescription drugs.
A physician may ask you to sign a private contract agreeing that you can be
billed directly for services ordinarily covered by Original Medicare. Should you
sign an agreement, Medicare will
not pay any portion of the charges, and we
will not increase our payment. We will still limit our payment to the amount we
would have paid after Original Medicare's payment. We will not waive
any
deductibles, coinsurance or copayments when paying these claims. 64
64 Page 65 66
2002 Mail Handlers Benefit Plan 65 Section 9
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.
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.)
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,
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
65
65 Page 66
67
2002 Mail Handlers Benefit Plan 66
Section 9
If you are eligible for Medicare, you may choose to enroll
in and get your Medicare benefits from another type of Medicare+ Choice plan – a
Medicare managed care plan. These are health care
choices (like HMOs) in
some areas of the country. In most Medicare managed care plans, you can only go
to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans
provide all the benefits that Original Medicare covers.
Some cover extras, like prescription drugs. To learn more about enrolling in a
Medicare managed care plan, contact Medicare at 1-800-
MEDICARE
(1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare
managed care plan, the following options are available to you:
: You may
enroll in another plan's Medicare managed care plan and also remain enrolled in
our FEHB plan. We will still provide
benefits as your secondary payer 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,
coinsurance, or deductibles. If you
enroll in a Medicare managed care plan, tell us. We will need to know whether
you are in Original Medicare or in a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.
: If you are an annuitant
or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
managed care
plan, eliminating your FEHB premium. (OPM does not contribute to your
Medicare managed care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next Open Season unless
you involuntarily lose coverage or move out of the Medicare managed
care
plan's service area.
If you do not have one or both parts of Medicare, you can still be covered
under the FEHB program. We will not require you to enroll in Medicare Part B
and, if you can't get premium-free
Part A, we will not ask you to enroll in
it.
TRICARE 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. If you are
enrolled in the Uniformed Services Family Health Plan, the Mail Handlers
Benefit Plan is primary.
We do not cover services that:
You need because of a workplace-related
illness or injury that the Office of Workers' Compensation Programs (OWCP) or a
similar Federal or State agency determines they must
provide; or
OWCP or a similar agency pays for through a third party
injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care.
When you have this Plan and Medicaid, we pay first.
We do not cover
services and supplies when a local, State, or Federal Government agency directly
or indirectly pays for them. 66
66 Page 67 68
2002 Mail
Handlers Benefit Plan 67 Section 9
If you or any covered member
of your family suffer injuries in an accident, or become ill, because of the
actions of another person, and you thereafter receive compensation, either from
that person
or from your own or other insurance, for the injuries or
illness, you will be required to reimburse the Plan for any services and
supplies the Plan paid for out of the compensation you receive. This
is
known as the Plan's right of reimbursement, and is also sometimes referred to as
subrogation. You will have this obligation to reimburse the Plan even if the
compensation you receive is not
sufficient to compensate you fully for all
of the damages which resulted from the accident or illness. In other words, the
Plan is entitled to be reimbursed for all expenditures it has made on
your
behalf even if you are not "made whole" for all of your damages by the
compensation you receive. The Plan's right to reimbursement is also not subject
to reduction for attorney's fees under
the "common fund" doctrine without
the Plan's written consent. The Plan enforces this right of reimbursement by
asserting a lien against any and all compensation you receive, whether by court
order or out-of-court settlement. You must cooperate with the Plan in its
enforcement of this right of reimbursement by telling the Plan whenever you or a
covered member of your family has filed a
claim for compensation resulting
from an accident or illness. You must also accept the Plan's lien for the full
amount of the benefits it has paid; you must agree to assign any proceeds from
third
party claims or your own insurance to the Plan when asked to do so;
and you must sign a Reimbursement Agreement for this purpose when asked by the
Plan to do so. We will not pay
benefits until this agreement is signed. The
Plan's right to full reimbursement applies even if the Plan has paid benefits
before we know of the accident or illness, and before we have asked you to
sign a Reimbursement Agreement. Unless the Plan agrees in writing to accept
less than 100% of the Plan's lien amount, the Plan is entitled to be reimbursed
for all the benefits it has paid on
account of the accident or illness. If
you would like more information about the subrogation process and how it works,
please call the Plan's Third Party Recovery Services unit at
301-610-0919.
67
67 Page 68 69
2002 Mail Handlers Benefit Plan 68 Section
10
The period from entry (admission) into a hospital or other covered
facility until discharge. In counting days of inpatient care, the date of entry
and the date of discharge are counted as the same
day.
An authorization by an enrollee or spouse for the Plan to issue payment of
benefits directly to the provider. The Plan reserves the right to pay the member
directly for all covered services.
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.
Coinsurance is the percentage of our allowance
that you must pay for your care. You may also be responsible for additional
amounts. See page 11.
A condition existing at or from birth which is a
significant deviation from the common form or norm. For purposes of this Plan,
congenital anomalies include protruding ear deformities, cleft
lips, cleft
palates, birthmarks, webbed fingers or toes, and other conditions that the Plan
may determine to be congenital anomalies. In no event will the term congenital
anomaly include
conditions relating to teeth or intraoral structures
supporting the teeth.
A copayment is a fixed amount of money you pay when you receive covered
services. See page 11.
Services we provide benefits for, as described in this brochure.
The Plan
determines what services are custodial in nature. For instance, the following
are considered custodial services:
Help in walking; getting in and out of
bed; bathing; eating (including help with tube feeding or gastrostomy)
exercising and dressing
Homemaking services such as making meals or special
diets
Moving the patient
Acting as companion or sitter
Supervising
medication when it can be self administered; or
Services that anyone with
minimal instruction can do, such as taking a temperature, recording pulse,
respiration or administration and monitoring of feeding systems.
A deductible is a fixed amount of covered expenses you must incur for certain
covered services and supplies before we start paying benefits for those
services. See page 11. 68
68 Page 69 70
2002 Mail
Handlers Benefit Plan 69 Section 10
A drug, device, or biological
product is Experimental or investigational if the drug, device, or biological
product cannot be lawfully marketed without approval of the U. S. Food and Drug
Administration (FDA) and approval for marketing has not been given at the
time it is furnished. Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product is
Experimental or investigational if 1) reliable evidence shows that it is the
subject of ongoing phase I, II, or III
clinical trials or under study to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or
its efficacy as compared with the standard means of treatment or diagnosis; or
2)
reliable evidence shows that the consensus of opinion among experts
regarding the drug, device, or biological product or medical treatment or
procedure is that further studies or clinical trials are
necessary to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or
its efficacy as compared with the standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the
authoritative medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol( s)
of another
facility studying substantially the same drug, device, biological product, or
medical treatment or procedure; or the written informed consent used by the
treating facility or by another
facility studying substantially the same
drug, device, biological product, or medical treatment or procedure.
If you wish additional information concerning the experimental/
investigational determination process, please contact the Plan.
Health care coverage that a member is eligible for because of employment, by
membership in, or connection with, a particular organization or group that
provides payment for hospital, medical, or
other health care services or
supplies, or that pays a specific amount for each day or period of
hospitalization if the specified amount exceeds $200 per day, including
extension of any of these
benefits through COBRA.
A formal program directed by a doctor to help care for a terminally ill
person. The services may be provided through either a centrally-administered,
medically-directed, and nurse-coordinated
program that provides primarily
home care services 24 hours a day, seven days a week by a hospice team that
reduces or abates mental and physical distress and meets the special stresses of
a terminal
illness, dying and bereavement, or through confinement in a
hospice care program. The hospice team must include a doctor and a nurse (R. N.)
and also may include a social worker,
clergyman/ counselor, volunteer,
clinical psychologist, physical therapist, or occupational therapist.
Services, drugs, supplies, or equipment provided by a hospital or covered
provider of health care services that the Plan determines:
1) are
appropriate to diagnose or treat the patient's condition, illness, or injury;
2) are consistent with standards of good medical practice in the United
States;
3) are not primarily for the personal comfort or convenience of the
patient, the family, or the provider;
4) are not a part of or associated with the scholastic education or
vocational training of the patient; and,
5) 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.
A condition in which an individual weighs 100 pounds or 100% over his or her
normal weight (in accordance with current underwriting standards). Eligible
members must be age 18 or over.
Any fitted external device used to support,
align, prevent, or correct deformities, or to restore or improve function. 69
69 Page 70 71
2002 Mail Handlers Benefit Plan 70 Section
10
Our Plan allowance is the amount we use to determine our payment and
your coinsurance for covered services. Fee-for-service plans determine their
allowances in different ways. We
determine our allowance as follows:
PPO
allowance: an amount that we negotiate with each provider or provider group who
participates in our network. For these PPO allowances, the PPO provider has
agreed to accept the negotiated
reduction and you are not responsible for the discounted amount. In these
instances, the benefit we pay plus any applicable deductible, copayment or
coinsurance you are responsible for, equals
payment in full.
Managed
In-Network allowance: a negotiated amount the mental health/ substance abuse
provider has agreed to accept as the negotiated reduction and you are not
responsible for the discounted
amount. In these instances, the benefit we pay plus any applicable
deductible, copayment or coinsurance you are responsible for, equals payment in
full.
Non-PPO allowance: the amount the Plan will consider for services provided by
non-PPO or non-Managed In-Network providers. Non-PPO allowances are determined
as follows:
If you live in an area that has a fully developed PPO network
(one in which you have adequate access to a network provider), but you do not
use a PPO network provider the Plan's allowance will
be reduced to a rate
that the Plan would have paid had you used a PPO provider. This non-PPO
allowance is based upon a fee schedule that represents an average of the PPO fee
schedules for a
particular service in a particular geographic area. In
industry terms, this is a called a "blended" fee schedule.
Note: For those members who do not have adequate access to a network provider
(in terms of distance from where you live to a network provider) or those
members receiving emergency care,
the Plan's non-PPO allowance will be based
on the reasonable and customary charge (as described below), not the "blended"
fee schedule.
If you live in an area that does not have a fully developed network, and use
a non-PPO provider, the non-PPO allowance is the reasonable and customary
allowance for your medical or mental
health/ substance abuse services based
on the reasonable and customary charge. This is generally the lesser of either
(a) the usual charge made by the provider for the service or supply in the
absence of insurance or, (b) the charge that the Plan determines to be in
the 80th percentile of the prevailing charges made for the service or supply in
the geographic area in which it is furnished.
The prevailing charge data is
collected by the Plan's underwriter. For certain services, exceptions to the
general method of determining reasonable and customary may exist.
If you receive services from a MultiPlan participating provider, the Plan's
allowance will be the amount that the provider has negotiated and agreed to
accept for the services and or supplies.
Benefits will be paid at non-PPO
benefit levels, subject to the applicable deductibles and copayments.
For more information, see Differences between our allowance and the bill
in Section 4. 70
70 Page
71 72
2002 Mail Handlers Benefit Plan
71 Section 10
An artificial substitute for a missing body part
such as an arm, eye, or leg. This appliance may be used for a functional or
cosmetic reason, or both.
A power-operated vehicle (chair or cart) with a
base that may extend beyond the edge of the seat, a tiller-type control
mechanism which is usually center mounted and an adjustable seat that may or
may not swivel.
Us and we refer to the Mail Handlers Benefit Plan.
An enrollee does not
have a vested right to the benefits in this brochure in 2003 or later years and
does not have a right to benefits available prior to 2002 unless those benefits
are in this brochure.
You refers to the enrollee and each covered family member. 71
71 Page 72 73
2002 Mail Handlers Benefit Plan 72 Section
11
We will not refuse to cover the treatment of a condition that you had
before you enrolled in this Plan solely because you had the condition before you
enrolled.
See www. opm. gov/ insure. Also, your employing or retirement
office can answer your questions, and give you a Guide to Federal Employees
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.
Self Only coverage is for you alone. Self and Family coverage is for 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 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.
The benefits in this brochure are effective on January 1. If you joined this
Plan during Open Season, your coverage begins on the first day of your first pay
period that starts on or after January
1. Annuitants' coverage and premiums
begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage. 72
72 Page 73 74
2002 Mail Handlers Benefit Plan 73 Section
11
We will keep your medical and claims information confidential. Only
the following will have access to it:
OPM, this Plan, and subcontractors
when they administer this contract;
In an effort to improve healthcare
quality and patient safety, the Plan may disclose information about a member's
prescription drug use, including the names of the doctors who prescribed the
drugs to any of your treating physician or any pharmacy who is dispensing the
drug;
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, 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).
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.
If you are divorced from a Federal employee or annuitant, you may not
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.
If you leave Federal service, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for Temporary Continuation of
Coverage (TCC). For example, you
can receive TCC if you are not able to
continue your FEHB enrollment after you retire, if you lose your Federal job, if
you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
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. 73
73 Page
74 75
2002 Mail Handlers Benefit Plan
74 Section 11
You may convert to a non-FEHB individual policy if:
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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose
employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this
certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods, limitations,
or exclusions for health related conditions based on the
information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in
other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the FEHBP web
site (http:// www. opm. gov/ insure/ health), and
refer to the "TCC and HIPAA" frequently asked questions. These highlight
HIPAA rules, such as the requirement that federal employees must exhaust any TCC
eligibility as one condition for
guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies you
can contact for more information. 74
74 Page 75 76
2002 Mail
Handlers Benefit Plan 75 Long Term Care Insurance
Many FEHB
enrollees think that their health plan and/ or Medicare will cover their
long-term care needs.
Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality
long-term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or
age-related disease such as Alzheimer's.
LTC insurance can provide broad,
flexible benefits for nursing home care, care in an assisted living facility,
care in your home, adult day care, hospice care, and more. LTC can supplement
care provided by family members, reducing the burden you place on them.
Welcome to the club!
76% of Americans believe they will never need long
term care, but the facts are that about half of them will. And it's not just old
folks. About 40% of people needing long term care are under
age 65. They may need chronic care due to a serious accident, a stroke,
developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan,
just in case. Many people now consider long term care insurance to be vital
to their financial and retirement
planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before inflation!
Long term care can exhaust your savings. Long
term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of
your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted living facility or a continuing need
for a home health aid to help
get you in and out of bed and with other activities of daily living. Limited
stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day
limit.
Medicaid covers long term care
for those who meet their state's poverty guidelines, but has restrictions on
covered services and where they can be received.
Long term care insurance can provide choices of care and preserve your
independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you
can learn more about the program on our web site at www. opm. gov/ insure/ ltc.
75
75 Page 76 77
2002 Mail Handlers Benefit Plan 76
Department of Defense/ FEHB Demonstration Project
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, 2002.
DoD and OPM have set up some
special procedures to implement the
Demonstration Project, noted below. Otherwise, the provisions described in this
brochure apply.
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.
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 area Coffee County, GA area
You may enroll under the FEHB/ DoD
Demonstration Project during the 2001 Open Season, November 12, 2001, through
December 10, 2001. Your coverage will begin January 1, 2002. 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 Open Season. Your coverage will begin January 1, 2002.
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.
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 2002 Guide to Federal Employees Health Benefits Plans
Participating in the DoD/ FEHB Demonstration Project," on the OPM web site
at www. opm. gov.
See Section 11, FEHB Facts; it explains temporary
continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the
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.
The 31-day extension of coverage and right to
convert do not apply to the DoD/ FEHB Demonstration Project. 76
76 Page 77 78
2002 Mail Handlers Benefit Plan 77 Index
Do not rely on this page; it is for your convenience and may not show
all pages where the terms appear.
ccidental injury
.......................... 44-45
Allergy care
........................................ 23
Alternative
treatment.......................... 31
Ambulance........................ 39,
43, 45, 58
Anesthesia .................. 21, 38, 40, 42, 56
Assistant
surgeon................................ 34
iopsy........................................... 32, 56
Birthing
center.......................... 8, 21, 39
Blood or blood plasma
................. 40, 42
Blood tests
.......................................... 18
Breast cancer
...................................... 37
Breast prostheses
................................ 27
Breast
reconstruction.......................... 35
ast......................................... 32, 40, 42
CAT
Scans.......................................... 18
Catastrophic
protection................. 12-13
Changes for
2002.................................. 6
Chemotherapy ............ 17-18,
24, 38, 40
Chiropractic ........................................ 30
Cholesterol test ................................... 19
Claims..................................... 59-62, 73
Coinsurance
....................... 5, 11-15, 58, 64, 66, 68, 70
Colorectal cancer screening................ 19
Congenital anomalies
............. 32, 35, 68
Contraceptive.......................... 22, 33, 50
Coordination of benefits............... 63-66
Covered providers
............................. 7-8
eductible ........ 6, 11-15, 58, 60, 68,
70
Definitions .................................... 68-71
Dental
............... 5, 10, 13, 36, 42, 53-56
Diabetic supplies
................................ 50
Disputed claims
............................ 61-62
Donor............................................ 37, 38
Durable medical
equipment.......... 28-29
ducational classes............................. 31
Effective date of enrollment ...................
Emergency.............................. 10, 44-45
Experimental or
investigational .............................................. 5, 58, 69
Eyeglasses .............................. 26, 57, 58
amily planning
................................. 22
Fecal occult blood
.............................. 19
Flexible benefits option
...................... 52
Foot care
............................................. 27
Freestanding ambulatory facility ......... 8
eneral Exclusions
............................ 58
earing services
................................ 26
Home health services
......................... 30
Hospice .................................... 8,
43, 69
Hospital.......................... 8-10, 39-42, 57
Hospital
beds...................................... 28
mmunizations
............................. 19, 20
Infertility
............................................ 22
Inpatient Hospital Benefits
........... 39-41
Insulin ................................................
50
ab, X-ray, and other diagnostic tests............................... 18
Long term care insurance............. 57, 75
ail order drug program ..
15, 49-50, 64
Mammograms .................................... 18
Maternity care .................................... 21
Medicaid
............................................ 66
Medically
necessary................ 9, 10, 20, 34, 39, 41, 58, 70
Medically underserved areas ......... 7, 31
Medicare
...................... 6, 10, 14-15, 28, 50, 57-59, 63-66, 75
Mental health and substance abuse ...................................... 12,
15, 46-48
MRI.................................................... 18
ewborn............................................. 20
Non-FEHB benefits
........................... 57
Nurse
Licensed practical nurse
............... 30 Nurse midwife ................................ 7
Nurse practitioner ........................... 7 Registered nurse
................. 8, 30, 69
ccupational therapy......................... 25
Ocular injury ...................................... 24
Office
visits................. 11, 22, 24-25, 43
Oral surgery
................................. 36, 56
Orthopedic ................. 15,
27, 33, 64, 69
Ostomy supplies................................. 28
Out-of-pocket expenses ................ 12-13
Outpatient facility
.............................. 42
Overseas claims
................................. 59
Oxygen............................. 24,
28, 40, 42
ap smear........................................... 19
Pathology ............................... 18, 40, 42
Physical checkups .............................. 19
Physical therapy
................................. 25
Physician ........................ 7,
9, 12, 17-18, 24, 30, 39, 44-45, 59, 64, 70
Plan Allowance .................................. 70
Precertification
.............. 9-10, 21, 32, 39
Preferred Provider Organization .......... 5
Prescription drugs.................. 11, 13, 15, 22, 24, 31, 37, 40,
49-51,58-59, 64, 73
Preventive care, adult ......................... 19
Preventive care,
children .................... 20
Prior
approval................................ 61-62
Prostate Specific Antigen
(PSA)........ 19
Prosthetic........ 27, 33, 35, 53, 55, 64, 71
Psychologist ................................... 7, 69
adiation therapy
.................... 17-18, 24
Reconstructive surgery................. 35,
58
Rehabilitative therapies .......... 25, 28, 48
Renal dialysis
....................................... 8
Room and board
........................ 9-10, 39
econd surgical opinion
..................... 17
Skilled nursing care facility................ 42
Smoking Cessation............................. 31
Social
worker.................................. 7, 69
Speech therapy
............................. 25, 59
Splints................................................. 40
Subrogation
........................................ 67
Substance
abuse........................ 8, 11-13, 46-48, 64, 71
emporary Continuation of Coverage.............................. 73, 75
Therapist
Occupational ............................. 7, 69 Physical
..................................... 7, 69
Speech............................................. 7 Transplants
........................ 24, 37-38, 40
Treatment therapy
.............................. 24
ision services
................................... 24
Voluntary sterilization.............
22, 33-34
heelchairs................................... 28-29
Workers'
Compensation.......... 65-66, 73
-rays .....................................
18, 40, 53 77
77 Page
78 79
2002 Mail Handlers Benefit Plan
78 Summary of Standard Option Benefits
All benefits 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.
Below, an
asterisk (*) means the item is subject to the $250 Calendar Year medical
deductible. And, after we pay, you generally pay any difference between our
allowance and the billed amount if you use a Non-PPO physician or other health
care professional.
Medical services provided by physicians:
Diagnostic and treatment
services provided in the office
Inpatient hospital visits
Preventive
care (see specific services)
Maternity services
Treatment therapy,
rehabilitative therapies, chiropractic, alternative therapies (subject to
applicable calendar year
maximums)
PPO: $15 copayment per office visit; $5 copayment per allergy injection; 10%*
of the Plan's allowance for
diagnostic X-rays, laboratory services and other
professional services
Non-PPO: 30% of the Plan's allowance per office visit; 30%* of the Plan's
allowance for diagnostic X-rays,
laboratory services and other professional
services
17– 31
Services provided by a hospital:
Inpatient PPO: $150 per admission
Non-PPO: $300 per admission 39-41
Outpatient
—surgical facility PPO: Nothing after the calendar year
deductible Non-PPO: 30%* of the Plan's allowance 42
—hemodialysis, chemotherapy, radiation treatment PPO: 10%* of the Plan's
allowance Non-PPO: 30%* of the Plan's allowance 24
Emergency benefits:
Accidental injury
Medical emergency
Regular benefits
Regular
benefits
44-45
45
Mental health and substance abuse treatment
Note: This benefit has a separate calendar year deductible.
In-Network:
Regular cost sharing
Out-of-Network: Benefits are limited
46-48
Prescription drugs After $600 per person ($ 1,200 per family) calendar year
prescription deductible:
Network Retail electronic: 30% of AdvancePCS
charges
Network Retail paper: 50% of AdvancePCS charges
Non-Network
Retail: 50% of AdvancePCS charges
Mail Order: $10 copayment per generic
prescription; $40 per preferred brand; $55 per non-preferred brand
49-51
Dental Care No benefit N/ A
Special features: Flexible Benefits Option;
Worldwide Assistance 52
Protection against catastrophic costs (your
out-of-pocket maximum)
There is a separate out-of-pocket maximum for Managed In-Network mental
health and substance abuse treatment
services that must be met for this
benefit to apply. This benefit does not apply to mental health and substance
abuse
treatment services provided by out-of-network providers.
Nothing after your covered expenses total $4,000 per year for PPO providers/
facilities. When you use a
combination of PPO and non-PPO providers, your
covered out-of-pocket expenses will not exceed
$4,000.
Some costs do not
count toward this protection.
12 78
78 Page
79 80
2002 Mail Handlers Benefit Plan
79 Summary of High Option Benefits
. All benefits 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.
Below, an
asterisk (*) means the item is subject to the $200 Calendar Year medical
deductible. And, after we pay, you generally pay any difference between our
allowance and the billed amount if you use a Non-PPO physician or other health
care professional.
Medical services provided by physicians:
Diagnostic and treatment
services provided in the office
Inpatient hospital visits
Preventive
care (see specific services)
Maternity services
Treatment therapy,
rehabilitative therapies, chiropractic, alternative therapies (subject to
applicable calendar year
maximums)
PPO: $15 copayment per office visit; $5 copayment per allergy injection; 10%*
of the Plan's allowance for
diagnostic X-rays, laboratory services and other
professional services
Non-PPO: 30% of the Plan's allowance per office visit; 30%* of the Plan's
allowance for diagnostic X-rays,
laboratory services and other professional
services
17-31
Services provided by a hospital:
Inpatient PPO: Nothing Non-PPO: $250
per admission 39-41
Outpatient
—surgical facility PPO: Nothing after the calendar year
deductible Non-PPO: 30%* of the Plan's allowance 42
—hemodialysis, chemotherapy, radiation treatment PPO: 10%* of the Plan's
allowance Non-PPO: 30%* of the Plan's allowance 24
Emergency benefits:
Accidental injury
Medical emergency
Regular benefits
Regular
benefits
44-45
45
Mental health and substance abuse treatment
Note: This benefit has a separate calendar year deductible.
In-Network:
Regular cost sharing
Out-of-Network: Benefits are limited
46-48
Prescription drugs After $250 per person ($ 500 per family) calendar year
prescription deductible:
Network Retail electronic: 25% of AdvancePCS
charges
Network Retail paper: 50% of AdvancePCS charges
Non-Network
Retail: 50% of AdvancePCS charges
Mail Order: $10 copayment per generic
prescription; $30 per preferred brand; $45 per non-preferred brand
49-51
Dental Care All charges above amount stated in dental schedule 53-56
Special features: Flexible Benefits Option; Worldwide Assistance 52
Protection against catastrophic costs (your out-of-pocket maximum)
There is a separate out-of-pocket maximum for Managed In-Network mental
health and substance abuse treatment
services that must be met for this
benefit to apply. This benefit does not apply to mental health and substance
abuse
treatment services provided by out-of-network providers.
Nothing after your covered expenses total $2,500 per year for PPO providers/
facilities. When you use a
combination of PPO and non-PPO providers, your
covered out-of-pocket expenses will not exceed
$4,000.
Some costs do not
count toward this protection.
12 79
79 Page
80
2002 Mail Handlers Benefit Plan 80 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.
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 (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 who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS
Share Your Share
High Option Self Only 451 $97.86 $55.08 $212.03 $119.34 $115.52 $37.42
High Option Self and Family 452 $223.41 $99.20 $484.06 $214.93 $263.75
$58.86
Standard Option Self Only 454 $76.96 $25.65 $166.74 $55.58 $91.07 $11.54
Standard Option Self and Family 455 $167.04 $55.68 $361.92 $120.64 $197.66
$25.06 80