This Plan has commendable accreditation
from the NCQA.
See the 2002 Guide for
more information on accreditation.
KeystoneBlue http:// www. highmark. com
2002
A Health Maintenance Organization
Serving: The Pittsburgh, Altoona and Erie, Pennsylvania areas
Enrollment in this Plan is limited; You must live or
work in our Geographic service area to enroll. See page 7 for requirements.
Enrollment codes for this Plan:
EF1 Self Only
EF2 Self and Family
RI 73-484
For changes
in benefits
see page 8. 1
1 Page 2 3
Table of Contents
Introduction ...................................................................................................................................................................
4
Plain Language................................................................................................................................................................
4
Inspector General Advisory ............................................................................................................................................
5
Section 1. Facts about this HMO plan...........................................................................................................................
6
How we pay providers..................................................................................................................................
6
Who provides my health care .......................................................................................................................
6
Your Rights ...................................................................................................................................................
6
Service Area..................................................................................................................................................
7
Section 2. How we change for 2002..............................................................................................................................
8
Program-wide changes..................................................................................................................................
8
Changes to this Plan......................................................................................................................................
8
Section 3. How you get care..........................................................................................................................................
9
Identification
cards........................................................................................................................................
9
Where you get covered care
.........................................................................................................................
9
Plan
providers.........................................................................................................................................
9
Plan facilities
..........................................................................................................................................
9
What you must do to get covered care
.........................................................................................................
9
Primary
care............................................................................................................................................
9
Specialty
care..........................................................................................................................................
9
Hospital
care.........................................................................................................................................
10
Circumstances beyond our control..............................................................................................................
11
Services requiring our prior approval .........................................................................................................
11
Section 4. Your costs for covered services ..................................................................................................................
12
Copayments
..........................................................................................................................................
12
Deductible.............................................................................................................................................
12
Coinsurance
..........................................................................................................................................
12
Your catastrophic protection out-of-pocket
maximum...............................................................................
12
Section 5. Benefits .......................................................................................................................................................
13
Overview.....................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other
health care professionals............. 14
(b) Surgical
and anesthesia services provided by physicians and other health care
professionals ......... 24
(c) Services provided by a
hospital or other facility, and ambulance services ....................................... 28
(d) Emergency
services/ accidents ............................................................................................................
31
(e) Mental health and substance abuse benefits.......................................................................................
33
2002 KeystoneBlue 2 Table of Contents 2
2 Page 3 4
(f) Prescription drug benefits...................................................................................................................
35
(g) Special features...................................................................................................................................
38
Flexible benefits option
...................................................................................................................
38
Reciprocity benefit/ travel
................................................................................................................
38
(h) Dental benefits....................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members ................................................................................
40
Section 6. General exclusions things we don't cover ...........................................................................................
41
Section 7. Filing a claim for covered services .........................................................................................................
42
Section 8. The disputed claims process....................................................................................................................
43
Section 9. Coordinating benefits with other coverage .............................................................................................
45
When you have
Other health
coverage.......................................................................................................................
45
Original
Medicare.............................................................................................................................
45
Medicare managed care plan ............................................................................................................
47
TRICARE/ Workers' Compensation/ Medicaid........................................................................................
48
Other Government
agencies....................................................................................................................
48
When others are responsible for
injuries.................................................................................................
48
Section 10. Definitions of terms we use in this brochure..........................................................................................
49
Section 11. FEHB facts ..............................................................................................................................................
50
Coverage information..............................................................................................................................
50
No pre-existing condition
limitation.................................................................................................
50
Where you get information about enrolling in the FEHB
Program................................................. 50
Types of
coverage available for you and your
family...................................................................... 50
When benefits and premiums start ...................................................................................................
51
Your medical and claims records are
confidential............................................................................
51
When you retire
................................................................................................................................
51
When you lose benefits ...........................................................................................................................
51
When FEHB coverage ends..............................................................................................................
51
Spouse equity coverage
....................................................................................................................
51
Temporary Continuation of Coverage
(TCC)...................................................................................
51
Converting to individual coverage ...................................................................................................
52
Getting a Certificate of Group Health Plan Coverage......................................................................
52
Long term care insurance is coming later in 2002 .......................................................................................................
53
Index..............................................................................................................................................................................
54
Summary of benefits ....................................................................................................................................................
55
Rates................................................................................................................................................................
Back cover
2002 KeystoneBlue 3 Table of Contents 3
3 Page 4 5
Introduction
Keystone Health Plan West, Inc., d. b. a.
KeystoneBlue
Fifth Avenue Place
120 Fifth Avenue
Pittsburgh, PA
15222
This brochure describes the benefits of KeystoneBlue under its contract
(CS2340) with the Office of Personnel
Management (OPM), as authorized by the
Federal Employees Health Benefits (FEHB) law. This brochure is the
official
statement of benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and exclusions
of this brochure.
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 premiums with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 8. Rates
are shown at the end of this brochure.
Plain Language
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. For instance,
"you" means the enrollee or family member; "we" means KeystoneBlue.
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.
2002 KeystoneBlue 4 Introduction/ Plain Language/ Advisory 4
4 Page 5 6
Inspector General Advisory
Stop health care
fraud! Fraud increases the cost of health care for everyone. If you suspect
that a physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If
the provider does not resolve the matter, call us at 1-800/ 421-0959 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, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an identification card if the person tries to
obtain services for a
person who is not an eligible family member, or is no
longer enrolled in the
Plan and tries to obtain benefits. Your agency may
also take administrative
action against you.
2002 KeystoneBlue 5 Introduction/ Plain Language/ Advisory 5
5 Page 6 7
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other
providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the
copayments, and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure.
These Plan providers accept a negotiated payment from us, and you will only
be responsible for your copayments
or coinsurance.
Who provides my health care?
KeystoneBlue is an Individual
Practice Prepayment (IPP) model HMO, offering you a choice of more than 2,600
primary care doctors. Federal employees, annuitants, and their dependents
enrolled in this Plan will need to select a
personal doctor from a list of
our participating primary care doctors. A primary care doctor is a doctor who
has been
specially trained in the areas of Family Practice, General
Practice, Internal Medicine, or Pediatrics.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about
us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of
information that we must make available to you.
If you want more information about us call 1-800/ 421-0959, or write to
KeystoneBlue, 1800 Center Street,
P. O. Box 890037, Camp Hill, PA
17089-0037, or visit our website at www.
highmark. com.
2002 KeystoneBlue 6 Section 1 6
6
Page 7 8
Service
Area
To enroll in our Plan, you must live or work in our Service Area.
This is where our providers practice. Our service area
is Western
Pennsylvania which includes the following areas:
Greater Pittsburgh: The Pennsylvania counties of Allegheny, Armstrong,
Beaver, Butler, Fayette, Greene, Lawrence,
Washington and Westmoreland.
Erie: The Pennsylvania counties of Clarion, Crawford, Erie, Forest,
McKean, Mercer and Venango.
Altoona: The Pennsylvania counties of
Bedford, Blair, Cambria, Cameron, Clearfield, Elk, Huntingdon, Indiana,
Jefferson, Potter, Somerset and Warren.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care benefits. We will not pay for any other health care services out of our
service area
unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-
service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do
not have
to wait until Open Season to change plans. Contact your employing or retirement
office.
2002 KeystoneBlue 7 Section 1 7
7
Page 8 9
Section
2. How we change for 2002
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.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will increase by 71.9% for Self Only or
56.5% for Self and Family
We now cover certain intestinal transplants; islet
cell autotransplantation; and multivisceral transplantation, which includes the
small bowel with or without the liver and one or more of the following: stomach,
duodenum, jejunum,
ileum, pancreas, and colon. (Section 5( b))
We changed speech therapy
benefits by removing the requirement that services must be required to restore
functional speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
2002 KeystoneBlue 8 Section 2 8
8
Page 9 10
Section 3. How you get care
Identification cards We will send you
an identification (ID) card when you enroll. You should carry your ID card with
you at all times. You must show it whenever you
receive services from a Plan
provider, or fill a prescription at a Plan
pharmacy. Until you receive your
ID card, use your copy of the Health
Benefits Election Form, SF-2809, your
health benefits enrollment
confirmation (for annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800/
421-0959.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance and you will not
have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in
the provider directory, which we update
periodically. The list is also on
our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is important
since your primary care physician
provides or arranges for most of your
health care. You can choose a primary
care physician from our provider
directory or from our website.
Primary care Your primary care physician can be a family practitioner,
internist, pediatrician, general practitioner, etc. Your primary care physician
will
provide most of your health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary
care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. For most types of specialty care, the referred
specialist can provide
necessary follow-up care for up to 60 days, if
needed, without an
additional referral from your primary care physician. Any
continued
treatment beyond this 60-day period needs to be authorized by your
primary care physician. However, women may see a network
gynecologist or
network nurse midwife for obstetrical or gynecological
care without a
referral.
2002 KeystoneBlue 9 Section 3 9
9
Page 10 11
Here
are other things you should know about specialty care:
If you need to see a
specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician
will develop a treatment plan that
allows you to see your specialist for
a certain number of visits without
additional referrals. Your primary
care physician will use our criteria when
creating your treatment plan
(the physician may have to get an authorization
or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does
not participate with us, you must receive treatment from a specialist
who does. Generally, we will not pay for you to see a specialist who
does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another
specialist.
You may receive services from your current specialist until
we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you
enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us or, if we drop out of
the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to
a skilled nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call our
customer service
department immediately at 1-800/ 421-0959. If you are
new to the FEHB
Program, we will arrange for you to receive care.
2002 KeystoneBlue 10 Section 3 10
10
Page 11 12
If you
changed from another FEHB plan to us, your former plan will pay
for the
hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond Under certain extraordinary circumstances, such
as natural disasters, we our control may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered,
medically necessary, and
follows generally accepted medical practice.
Care received outside of our
network, except for emergency care, is not
covered. Elective care received
outside our network is not covered.
We call this review and approval process Prior Plan Approval. Your
physician must obtain Prior Plan Approval for the following services:
Assisted fertilization procedures; Cardiac Rehabilitation; Durable medical
equipment (DME), Orthopedic and Prosthetic devices, and Respiratory
equipment and supplies; Enteral formulae; Home health aides; Physical,
speech, and occupational therapy; growth hormone therapy (GHT); and
Hysterectomy, Appendectomy, and back surgeries, etc.
2002 KeystoneBlue 11 Section 3 11
11
Page 12 13
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit. When you go in the hospital, you
pay $100 per
admission, limited to three inpatient hospital copayments
per individual,
and up to five inpatient hospital copayments per family,
per calendar year.
Deductible We do not have a deductible.
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.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay up to $200 or 50%
of the cost, whichever
is less, for infertility services.
Your catastrophic protection We do not have an out-of-pocket maximum,
except for a $300 per out-of-pocket maximum individual and $500 per
family inpatient hospital copayment limit.
for coinsurance and copayments
2002 KeystoneBlue 12 Section 4 12
12
Page 13 14
Section 5. Benefits OVERVIEW (See page 8 for how
our benefits changed this year and page 55 for a benefits summary.)
NOTE: 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/
421-0959 or at our website at www. highmark.
com.
(a) Medical services and supplies provided by physicians and other health
care professionals................................ 14
Diagnostic and treatment services Speech therapy Lab, X-ray, and other
diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic
devices Family planning Durable medical equipment (DME)
Infertility services
Home health services Allergy care Chiropractic
Treatment therapies
Alternative treatments Physical and occupational therapies Educational classes
and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ............................ 24
Surgical procedures Oral and maxillofacial surgery Reconstructive
surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services...........................................................
28
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory facility benefits
surgical center Hospice care Ambulance
(d) Emergency services/ accidents ...............................................................................................................................
31
Medical emergency Ambulance
(e) Mental health and substance abuse benefits..........................................................................................................
33
(f) Prescription drug benefits ......................................................................................................................................
35
(g) Special features ......................................................................................................................................................
38
Flexible benefits option Reciprocity benefit/ travel
(h) Dental benefits .......................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members....................................................................................................
40
Summary of benefits .....................................................................................................................................................
55
2002 KeystoneBlue 13 Section 5 13
13
Page 14 15
Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
Diagnostic and treatment services
Professional services of
physicians $10 per office visit
In physician's office
Office medical
consultation
Second surgical opinion
Professional services of physicians Nothing
In an urgent care center
During a hospital stay
In a skilled nursing facility
At home $10 per visit
Not covered: Charges for missed appointments.
All charges.
2002 KeystoneBlue 14 Section 5( a)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Benefit Description You pay 14
14 Page 15 16
Lab, X-ray and
other diagnostic tests You pay
Tests, such as: Nothing when authorized
by a Plan
Blood tests Non-routine mammograms primary care physician or
specialist.
Urinalysis Cat Scans/ MRI
Non-routine pap tests Ultrasound
Pathology Electrocardiogram and EEG
X-rays
Preventive care, adult
Routine screenings, such as: $10 per office
visit; no separate
Routine physical exams copayment for routine screenings.
Total Blood Cholesterol once every three years
Colorectal Cancer
Screening, including
Fecal occult blood test
Sigmoidoscopy,
screening every five years starting at age 50
Prostate Specific Antigen
(PSA test) one annually for men age 40 and older
Routine pap test Nothing
Routine mammogram covered for women age 35 and
older, Nothing
as follows:
From age 35 through 39, one during this five year period
From age 40 and
over, one every calendar year
Screening regardless of age when prescribed by
your primary care physician or obstetrician/ gynecologist.
Not covered: Physical exams required for obtaining or continuing All
charges.
employment or insurance, attending schools or camp, or
immunizations
for foreign travel, licensing, premarital or sports.
2002 KeystoneBlue 15 Section 5( a) 15
15 Page 16 17
Preventive care, adult (continued)
You pay
Routine immunizations, limited to: $10 per office
visit; no separate
Tetanus-diphtheria (Td) booster once every 10 years,
ages 19 and copayment for routine immunizations. over (except as provided for
under Childhood immunizations)
Influenza vaccine
annually, age 50 and over
annually, for person
at high risk, between ages 18 and 64
Pneumococcal vaccine
annually,
age 65 and over
annually, for person at high risk, between ages 18 and 64
Preventive care, children
Childhood immunizations recommended by
the American Academy $10 per office visit; no separate of Pediatrics copayment
for routine immunizations.
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
Eye exams through age 17 when
performed by primary care physician to determine the need for vision correction.
Ear exams through age 17 when performed by primary care physician to
determine the need for hearing correction.
Examinations done on the day of
immunizations (up to age 22)
Maternity care
Complete maternity
(obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will
cover other care of an infant who requires non-routine treatment
only if
we cover the infant under a Self and Family enrollment.
Nothing. Copayments are waived
for maternity care.
$10 per office visit; no separate
copayment for preventive care
screenings.
2002 KeystoneBlue 16 Section 5( a) 16
16 Page 17 18
Maternity care (continued) You
pay
Coverage is provided for one (1) maternity home health care visit,
within 48 hours of discharge when the discharge occurs prior to 48
hours of
inpatient care following a normal vaginal delivery, or 96
hours of inpatient
care following a cesarean delivery.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
Not covered: Routine sonograms to
determine fetal age, size or sex. All charges.
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover
oral contraceptives under the prescription drug benefit.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling. All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Cost of donor sperm
Note: We cover injectable
fertility drugs under medical benefits and oral fertility drugs under the
prescription drug benefit.
Not covered: All charges.
Assisted reproductive technology
(ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Medical services and supplies related to excluded ART procedures
Cost of donor egg
Up to $200 or 50% of the cost,
whichever is less. These services,
including fertility drugs, require
prior authorization by the Plan.
$10 per office visit; no separate
copayment for listed services.
Nothing. Copayments are waived
for maternity care.
2002 KeystoneBlue 17 Section 5( a) 17
17 Page 18 19
Allergy care You pay
Testing and treatment
Allergy injection
Allergy serum
Not covered: Provocative food testing, and sublingual allergy
desensitization. All charges.
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone
marrow
transplants is limited to those transplants listed under
Organ/ Tissue
Transplants on pages 26-27.
Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Enteral formulae administered on an outpatient basis either orally or through
a tube
Growth hormone therapy (GHT)
Note: Growth hormones are covered
under the prescription drug
benefit. We will only cover Enteral formulae and
GHT when we
preauthorize treatment.
Not covered: All charges.
Hair growth stimulants
Hair replacements and hair replacement surgery
Weight
reduction programs, except when medically necessary for morbid obesity
Physical and occupational therapies
60 days per condition for the
services of each of the following: Nothing
qualified physical therapists;
occupational therapists.
Note: We only cover therapy to restore bodily
function when there has
been a total or partial loss of bodily function due
to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction is covered at a Plan facility for up to 12 weeks
Not covered: All charges.
long-term rehabilitative therapy
exercise programs
$10 per office visit to specialist; no
separate copayment for treatment
therapies.
$10 per office visit; no separate
copayment for testing, injections
or serum.
2002 KeystoneBlue 18 Section 5( a) 18
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Speech therapy You pay
60 days per
condition for the services of qualified speech therapists. Nothing
Hearing services (testing, treatment, and supplies)
Diagnostic
hearing test when medically necessary
Hearing testing for children through
age 17 (see Preventive care, children)
Not covered: All charges.
all other hearing testing
hearing aids, testing and examinations for them
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment $10 per office visit
directly caused by accidental ocular injury or intraocular surgery
(such as
for cataracts)
Note: See Preventive care, children for eye exams for
children
The following benefits are provided through OptiChoice, our
Preferred
Vision Care Program. The OptiChoice In-Network Annual
Vision Benefits
Program offers affordability and paid-in-full vision
benefits on standard,
eligible services. It also offers a quality net-work
of statewide and
national vision care providers who agree to
accept program allowances as
payment in full, in accordance with
the OptiChoice benefit design. Members
are required to select
an optometrist, ophthalmologist, or optical supplier
from the
Preferred Provider Network. You can get information by calling
1-800/ 541-2039. Payment for services is limited to in-network
only
and services are eligible once a year. It also provides
discounts on
additional examinations, frames, lenses, contacts,
optical accessories, and
supplies. There is no pre-authorization or
deductible required. OptiChoice
Preferred Providers submit claims
for members and receive direct
reimbursement, completely
removing members from the paperwork process.
Following is a summary of benefits and out-of-pocket expenses.
Eye Examination and Refractive Service Nothing
Contact Lens Prescription
Fitting
Vision services (testing, treatment, and supplies) continued on next
page.
$10 per office visit; no separate
copayment for hearing screenings
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Vision services (testing, treatment, and supplies)
(continued) You pay
Post Refractive Services
Frames All charges in excess of $60
Post Refractive Services
Single Vision Lenses (Standard) Nothing
Bifocal Vision Lenses (Standard)
Trifocal Vision Lenses (Standard)
Aphakic Vision Lenses (Standard)
Post Refractive Services:
Single Vision Lenses (Non-standard)
Bifocal
Vision Lenses (Non-standard)
Trifocal Vision Lenses (Non-standard)
Aphakic/ Lenticular Vision Lenses (Non-standard)
Post Refractive Services:
Hard Contact Lenses (Standard) Nothing
Soft
Contact Lenses (Standard)
Post Refractive Services: All charges in excess of $75.
Specialty Contact
Lenses (Standard)
Post Refractive Services:
Vision Care Options (tints, contact lens
solutions, etc.)
Post Refractive Services:
Additional Post-Refractive Services
Not covered: All charges.
Eye exercises and orthoptics
Radial keratotomy
All charges in excess of the
Program's Allowance.
The cost of the items less a 10%
discount.
90% of the difference between the
normal charge and the non-standard
charge for the same type of standard
lenses.
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Foot care You pay
Routine foot care when
you are under active treatment for a metabolic $10 per office visit
or
peripheral vascular disease, such as diabetes.
See Orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
Not covered: All charges.
Cutting, trimming or removal of
corns, calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
Orthopedic and prosthetic devices
Artificial limbs and eyes;
lenses following cataract removal; $10 per office visit stump hose
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as
artificial joints, pacemakers, cochlear implants, and surgically implanted
breast implant
following mastectomy. Note: We pay internal prosthetic
devices as hospital benefits; see Section 5( c) for
payment information.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Braces
Shoes permanently attached to a brace
Custom molded foot
orthotics
Not covered: All charges.
Arch supports
Heel pads
and heel cups
Lumbosacral supports
Corsets, trusses and
other supportive devices
2002 KeystoneBlue 21 Section 5( a) 21
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Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
Nothing
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
Standard hospital beds;
Standard wheelchairs;
Crutches;
Walkers;
Blood glucose monitors;
Insulin pumps, and
Motorized wheel chairs if
authorized and medically necessary
Note: Call us at 1-800/ 421-0959 as soon
as your Plan physician prescribes
this equipment. We will arrange with a
health care provider to rent or sell
you durable medical equipment at
discounted rates and will tell you more
about this service when you call.
Not covered: All charges.
Motorized wheelchairs that are not
authorized and not medically necessary
Electric hospital beds
Home health services
Home health care ordered by your primary care
physician and Nothing provided by a registered nurse (R. N.), licensed practical
nurse
(L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.
Not covered: All charges.
Nursing care requested by, or for the
convenience of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative;
Homemaker services, and
Food or home delivered meals
Chiropractic
Limited to spinal manipulation Nothing
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Alternative treatments You pay
Acupuncture
by a doctor of medicine or osteopathy for: anesthesia, $10 per office visit
pain relief.
Not covered: All charges.
naturopathic services
hypnotherapy
biofeedback
Educational classes and programs
Coverage includes, but is not
limited to: Nothing
Diabetes self-management
Congestive heart failure
self-management
Chronic obstructive pulmonary disease (COPD) self-management
Smoking cessation class (see Section 5( i))
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other
health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other cover-age,
including with Medicare.
The amounts listed below are for the charges
billed by a physician or other health care professional for your surgical care.
Any costs associated with the facility charge
(i. e. hospital, surgical center, etc.) are covered in Section 5 (c).
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR ALL INPATIENT PROCEDURES AND
SOME OUTPATIENT SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3.
Surgical procedures
A comprehensive range of services, such as:
Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of
amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see
reconstructive surgery)
Surgical treatment of morbid obesity a condition
in which an individual weighs 100 pounds or 100% over his or her
normal weight according to current underwriting standards;
eligible
members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns
Note: Generally, we pay
for internal prostheses (devices) according to
where the procedure is done.
For example, we pay Hospital benefits
for a pacemaker and Surgery benefits
for insertion of the pacemaker.
Surgical procedures continued on next page.
2002 KeystoneBlue 24 Section 5( b)
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Surgical
procedures (continued) You pay
Not covered: All
charges.
Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
Correction of
myopia or hyperopia by means of corneal microsurgery such as keratomileusis,
keratophakia and
radial keratotomy
Reconstructive surgery
Surgery to correct a functional defect
Nothing
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by
such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements
(see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have this procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure. Member is eligible for 1 (one) home health care visit,
as determined by the member's physician and received within 48 hours
after discharge. The discharge must occur within 48 hours after the
admission for a mastectomy.
Not covered: All charges.
Cosmetic surgery any surgical
procedure (or any portion of a procedure) performed primarily to improve
physical appearance through change in
bodily form, except repair of accidental injury
Surgeries
related to sex transformation
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Oral and maxillofacial surgery You pay
Oral
surgical procedures, limited to: Nothing
Reduction of fractures of the jaws
or facial bones;
Surgical correction of cleft lip, cleft palate or severe
functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures;
Procedures adjacent to the oral cavity or sinuses (such as excision of tumors
and cysts);
Extractions of impacted third molars when partially or totally
covered by bone;
Extraction of teeth in preparation for radiation therapy,
and
Other surgical procedures that do not involve the teeth or their
supporting structures.
Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involving temporomandibular joint (TMJ) pain dysfunction
syndrome
Organ/ tissue transplants
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung:
Single-Double
Pancreas
Skin and tissue
Small bowel
Small bowel/
liver
Multivisceral which includes the small bowel with or without the liver
and one or more of the following: stomach, duodenum, jejunum, ileum,
pancreas and colon.
Islet cell autotransplantation
Allogeneic (donor)
bone marrow transplants
Organ/ tissue transplants continued on next page.
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Organ/ tissue transplants (continued)
You pay
Autologous bone marrow transplants (autologous stem
cell and Nothing
peripheral stem cell support) for the following conditions:
acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma;
breast cancer; multiple myeloma; epithelial
ovarian cancer; and testicular,
mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas.
Limited Benefits Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when
we
cover the recipient.
Not covered: All charges.
Donor screening tests and donor
search expenses, except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
Anesthesia
Professional services provided in Nothing
Hospital (inpatient)
Hospital outpatient department
Skilled nursing
facility
Ambulatory surgical center
Office
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Section 5 (c). Services provided by a hospital or
other facility, and
ambulance services
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other
coverage,
including with Medicare.
The amounts listed below are for the charges billed
by the facility (i. e., hospital or surgical center) or ambulance service for
your surgery or care. Any costs associated with the
professional charge (i. e., physicians, etc.) are covered in Sections 5( a)
or (b).
Inpatient hospital
Room and board, such as
ward, semiprivate,
or intensive care accommodations;
general nursing care; and
meals and
special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced
Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any
covered items billed by a hospital for use at home.
Inpatient hospital continued on next page.
$100 copay per admission up to a
maximum of $300 per individual
and
$500 per family per calendar
year.
2002 KeystoneBlue 28 Section 5( c)
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Inpatient hospital (continued)
You pay
Not covered: All charges.
Custodial
care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber
services, guest meals and beds
Private nursing care
Storage of blood, except when done in
preparation for a scheduled surgical procedure.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Nothing
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 oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and
supplies related to dental
procedures when necessitated by a non-dental
physical impairment.
We do not cover the dental procedures.
Not covered: All charges.
Storage of blood, except when done in
preparation for a scheduled surgical procedure
2002 KeystoneBlue 29 Section 5( c) 29
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Extended care benefits/ skilled nursing care
facility benefits You pay
Skilled nursing facility (SNF): Nothing
The Plan provides a comprehensive range of benefits for up to 100 days
per calendar year when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor. All necessary services are covered
including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a
Plan doctor.
Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for a terminally ill member is covered in
Nothing
the home or hospice facility. Services include inpatient and
outpatient care,
and family counseling; these services are provided under
the direction
of a Plan doctor who certifies that the patient is in the
terminal stages
of illness, with a life expectancy of approximately six
months or less.
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate Nothing and
ordered or authorized by a Plan doctor.
2002 KeystoneBlue 30 Section 5( c) 30
30 Page 31 32
Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other cover-age,
including with Medicare.
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or injury that you believe endangers your
life, including a pregnant woman or her unborn child, or could result in
serious injury or disability, and requires
immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly, they might
become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability to
breathe. There are many other acute conditions that we may determine are
medical emergencies what they all
have in common is the need for quick
action.
What to do in case of emergency:
Emergencies within our service area:
In the event that you or a covered dependent requires emergency care, all
charges for such covered services will be paid. No prior authorization is
required for emergency care.
Either the member or a family member should, if possible, notify the Primary
Care Physician within 48 hours of
the emergency care or as soon as
reasonably possible to facilitate follow-up care.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify the Plan within that time. If you are hospitalized
in non-Plan
facilities and Plan doctors believe care can be better provided
in a Plan hospital, you will be transferred when
medically feasible with any
ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan
provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan
or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify the Plan within that time. If a Plan doctor
believes care
can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance
charges covered in
full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan
or provided by Plan providers.
Emergency benefits begin on the next page
2002 KeystoneBlue 31 Section 5( d)
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Emergency within our service area
Emergency
care at a doctor's office $10 per office visit
Emergency care at an urgent
center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services.
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office $10 per office visit
Emergency care at an urgent center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
Not covered: All charges.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
Ambulance
Professional ambulance service, including air ambulance,
when Nothing
medically appropriate.
See 5( c) for non-emergency service.
$50 per visit (waived if admitted,
but the inpatient copay applies).
$50 per visit (waived if admitted,
but the inpatient copay applies).
2002 KeystoneBlue 32 Section 5( d)
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Section 5 (e).
Mental health and substance abuse benefits
When you get our approval for
services and follow a treatment plan we approve, cost-sharing
and
limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
Mental health and substance abuse benefits
All diagnostic and
treatment services recommended by a
Plan provider and contained in a
treatment plan that we
approve. The treatment plan may include services,
drugs,
and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine
the care is
clinically appropriate to treat your condition
and only when you receive the
care as part of a treatment
plan that we approve.
Professional services, individual or group $10 per office visit therapy by
providers such as psychiatrists,
psychologists, or clinical social workers
Medication management
Mental health and substance abuse benefits continued on next page.
Your cost sharing responsibilities are no
greater than for other
illnesses or
conditions.
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Mental health
and substance abuse benefits (continued) You pay
Diagnostic tests
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial hospitalization and substance abuse
residential treatment facilities
Not covered: Services we have not approved 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.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow the network authorization process:
You
must obtain approval from our mental health administrators prior to
treatment for any mental health or substance abuse condition. Please call
1-800/ 258-9808, for preauthorization.
Limitation We may limit your benefits if you do not obtain a treatment
plan.
$100 copay per admission up to a
maximum of $300 per individual and
$500 per family per calendar year
$10 per specialist office visit; no sep-arate
copayment for diagnostic
tests.
2002 KeystoneBlue 34 Section 5( e) 34
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Section 5 (f). Prescription drug benefits
Here
are some important things to keep in mind about these benefits:
We cover
prescribed drugs and medications, as described in the chart beginning on the
next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
There are important features you should be aware of. These include:
Who can write your prescription. A Plan or referral doctor or
licensed dentist must write the prescription.
Where you can obtain them.
You must fill the prescription at a Plan pharmacy or by mail for a
maintenance medication.
We use a formulary. The formulary is an extensive list of Food &
Drug Administration (FDA) approved prescription drugs selected for their
quality, safety and effectiveness. It includes products in every major
therapeutic category. The formulary was developed by Highmark Pharmacy and
Therapeutics Committee made up
of clinical pharmacists and physicians. Your
program includes coverage for both formulary and non-formulary
drugs at the
specific copay listed on page 36.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no generic available, your physician may prescribe a name
brand drug from a formulary list. This list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower
cost. To order a prescription drug brochure,
call 1-800/ 421-0959.
These are the dispensing limitations:
Prescription drugs
prescribed by a Plan or referral doctor or licensed dentist and filled at a Plan
pharmacy will be
dispensed for up to a maximum 34-day supply. Generic drugs
may be dispensed when substitution is permissible.
When generic drugs are available and the prescribing doctor requires the use
of a name brand drug, you will pay a
higher copayment per prescription or
refill.
When generic drugs are available and the prescribing doctor does not require
the use of a name brand drug, but
you request the name brand drug, you will
pay a higher copayment per prescription or refill, plus the price
difference
between the generic and name brand drug.
A mail order program is available to provide up to a 90-day supply of
maintenance drugs. For more information on
mail order prescription drugs
call 1-800/ 903-6228.
If you attempt to refill a prescription too soon, it will be denied; however,
your pharmacist will be given the
eligible date for refill and will pass
that information on to you. If your supply has run out because your
doctor
increased your dosage, your doctor must write a new prescription to cover the
increased amounts.
Continued on next page.
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Important features you should be aware of
(continued):
Why use generic drugs? Generic drugs are
lower-priced drugs that are the therapeutic equivalent to more expensive name
brand drugs. They must contain the same active ingredients and must be
equivalent in strength
and dosage to the original name brand product. Generics cost less than the
equivalent name brand product. 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 name brand drugs.
You can save money by using generic drugs. However, you and your physician
have the option to request a name brand if a generic option is available. Using
the most cost-effective medication saves money.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is available, and your physician has not
specified Dispense as Written for the name brand drug, you have to pay the
difference in cost between the name
brand drug and the generic
When you have to file a claim. Mail your completed form and receipts
to: Paid Prescriptions, LLC, P. O. Box 1258, Lees Summit, MO 64063-8258. Please
complete a separate form for each covered person. You can obtain a claim
form by calling Member Service at 1-800/ 421-0959.
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan
or referral physician, or
licensed dentist, and obtained from a Plan
pharmacy or through our mail
order program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as
Not covered.
All FDA approved contraceptive drugs. (Up to a
three-cycle supply of oral contraceptive drugs may be obtained for a single
copayment charge
through the mail order program)
Insulin
Insulin syringes, needles,
and/ or disposable diabetic testing materials; supplies will be included under
the same copayment as the insulin
Disposable needles and syringes needed to inject covered prescribed
medication
Prenatal vitamins
Fluoride vitamins
Fertility drugs
(require prior authorization by the Plan)
Drugs for sexual dysfunction are
subject to dosage limits set by the Plan. Contact the Plan for details.
Intravenous fluids and medications for home use and some covered injectable
drugs are covered under home health services at no charge
Growth Hormone
Therapy requires prior authorization by the Plan
FDA approved drugs to
assist with smoking cessation
Prescription drug benefits continued on next page.
Retail pharmacy for up to a
34-day supply:
$8 copay for generic drugs
$14 copay for physician required
use of
name brand drugs
Mail order pharmacy for up to a
90-day supply for maintenance
medications for a single copay:
$8 copay for generic drugs
$14 copay for physician required
use of
name brand drugs
Note: If there is no generic
equivalent available, you will still
have to pay the $14 name brand
copayment.
If generic drug is available but you
request a name brand drug you pay
the $14 name brand copay plus the
difference between the generic
and
name brand drug.
2002 KeystoneBlue 36 Section 5( f)
Benefit Description You pay 36
36 Page 37 38
Covered
medications and supplies (continued) You pay
Not
covered: All charges.
Drugs and supplies for cosmetic purposes
Vitamins, and nutritional supplements that can be purchased without a
prescription, except for enteral formulae (See above and
Section 5( a) Treatment therapies)
Nonprescription medicines
and over-the-counter drugs
Weight loss drugs, except when medically
necessary in the treatment of Morbid Obesity
Drugs obtained at a non-Plan pharmacy except out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs
to enhance athletic performance
2002 KeystoneBlue 37 Section 5( f) 37
37 Page 38 39
Section 5 (g). Special Features
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.
Obtaining care while away from home:
If you are away from home,
you can obtain urgent and follow-up care
through the Blue Cross Blue Shield
Association's BlueCard program. The
BlueCard program, gives you access to
the largest network of providers in
the United States. The benefits are the
same as if you were receiving care
at home.
If you have an unexpected illness or injury that cannot wait to be treated
until you return home, you can arrange urgent care by calling the
BlueCard Provider Finder number at 1-800/ 810-BLUE; it is available 24
hours a day. You will be given the names of three local Blue Cross Blue
Shield participating physicians you can call to schedule an appointment
that is convenient for you. You can also find a provider online at
www. bcbs. com. You do not need to contact your
primary care physician
for the urgent visit. However, if the out-of-area
physician you seek care
from recommends any additional visits or refers you
to another physician
or facility for other services, you must coordinate
this subsequent care
with your primary care physician before receiving
services.
On-going routine services (follow-up care) that you require when you are
away from home must be coordinated with your primary care physician
prior to leaving. You can arrange follow-up care through the same process
as urgent care and make your appointment at a time and place that is
convenient for you.
You can also obtain services outside the U. S. by contacting BlueCard
Worldwide.
Call Member Service at 1-800/ 421-0959 for information or logon
to
www. bcbs. com to access the BlueCard
Worldwide data base.
Reciprocity benefit/ travel
Flexible benefits option
2002 KeystoneBlue 38 Section 5( g)
Feature Description 38
38 Page 39 40
Section 5 (g).
Special Features
Note: The procedure for emergency services has
not changed. When you
need emergency services, you should seek care
immediately and
coordinate any needed follow-up care with your primary care
physician.
You do not need to call your primary care physician or the
BlueCard
telephone number before seeking emergency care.
Your reciprocity benefit also includes a guest membership feature. This
feature is for members who will be living outside western Pennsylvania
for an extended period of time (for example, a child away at school or
when business takes you temporarily to another location.) Through this
program, you can apply for a guest membership in another area of the
country that has a Blue Cross and Blue Shield HMO plan. The guest
membership is designed to serve members who plan to be out of the
KeystoneBlue area for 90 to 180 days. The temporary residence can be for
either work-related or personal reasons. Your dependents covered by
KeystoneBlue can also apply for an unlimited length of time, as long as
the application is renewed yearly. As a guest member of another "Blue"
HMO plan, you or your dependents would choose a primary care doctor at
that plan and have the benefits offered by that HMO. For care coordinated
by that plan's primary care physician, you would be responsible only for
any applicable copayments or deductibles for that HMO. You need to
apply
for a guest membership at least 30 days before you would like the
guest
membership to become effective.
Section 5 (h). Dental benefits
Here are some important things to keep
in mind about these benefits:
Please remember that all benefits are
subject to the definitions, limitations, and exclusions in this brochure and are
payable only when we determine they are medically necessary.
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health
of the patient; we do not cover the dental procedure unless it is
described
below.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage, including with Medicare.
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair Nothing
(but not replace) sound
natural teeth. The need for these services must
result from an accidental
injury.
Dental benefits
We have no other dental benefits.
Reciprocity benefit/ travel
(continued)
2002 KeystoneBlue 39 Section 5( g) and Section 5( h) 39
39 Page 40 41
Section 5 (i). Non-FEHB benefits available to Plan
members
The benefits on this page are not part of the FEHB contract or
premium, and you cannot file an
FEHB disputed claim about them. Fees
you pay for these services do not count toward FEHB
deductibles or
out-of-pocket maximums.
KeystoneBlue also offers members these Distinct Health Enhancement
Opportunities:
Dental coverage All KeystoneBlue members may
take advantage of special discounts through our Healthy Lifestyle
Program. By simply presenting your Plan ID card at participating Healthy
Lifestyle providers you
will receive a 10% to 30% discount off the cost of
most dental services. Some dental providers also
offer KeystoneBlue members
free or discounted initial exams, x-rays, and cleanings.
Healthy Lifestyle Programs All KeystoneBlue members may take
advantage of discounts available at more than 500 area
establishments which promote "healthy lifestyle" choices. By simply
presenting your KeystoneBlue
membership card at the time of purchase at
participating establishments, you may take advantage of
discounts on health
club memberships, sporting goods, fitness equipment, and nutritional items.
Also, KeystoneBlue members may take advantage of free lifestyle improvement
classes on such
topics as nutrition and weight loss, smoking cessation,
stress management, and prepared childbirth.
These classes are offered at
least three times a year at various locations in the Western Pennsylvania
area.
Blues On Call SM 1-888/ BLUE-428 Blues On Call provides all
KeystoneBlue members with 24-hour access 7 days a week to health
information and personalized support for health decisions. The program helps
you get more involved
in your care by providing a reliable source for
current medical information. Blues On Call promotes
the philosophy of Shared
Decision Making by helping you share with your physicians in the task of
choosing treatment options that take into account your values and
preferences. Blues On Call also
supports physicians by encouraging patient
adherence to treatment plans. Enhanced Blues On Call
integrates the
previously offered services with disease management to provide a comprehensive
approach to total patient care. This integration supports overall patient
management and will allow
members access to services through one source,
regardless of the condition that they have.
2002 KeystoneBlue 40 Section 5( i) 40
40 Page 41 42
Section 6. General exclusions things we don't
cover
The exclusions in this section apply to all benefits. Although
we may list a specific service as a benefit, we
will not cover it unless
your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your
illness, disease, injury, or condition and we agree, as discussed
under What Services Require Our Prior Approval
on page
11.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency benefits);
Services, drugs, or supplies you receive while you are not enrolled in
this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program.
2002 KeystoneBlue 41 Section 6 41
41
Page 42 43
Section 7. Filing a claim for covered services
When you see Plan
physicians, receive services at Plan hospitals and facilities, or fill your
prescription drugs
at Plan pharmacies you will not have to file claims. Just
present your ID card and pay your copayments or coinsurance.
You will only need to file a claim when you receive emergency services from
non-Plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance
Claim Form. Facilities will file on the UB-92 form. For claims
questions and assistance, call us at 1-800/ 421-0959.
When you must file a claim such as for out-of-area care
submit it on
the HCFA-1500 or a claim form that includes the
information shown below.
Bills and receipts should be itemized
and show:
Covered member's name and ID number;
Name and address of the physician or
facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer such as
the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your
claims to: KeystoneBlue, 1800 Center Street,
P. O. Box 890037, Camp Hill, PA
17089-0037
Prescription drugs Mail your completed form and receipts to: Paid
Prescriptions, LLC, P. O. Box 1258, Lees Summit, MO 64063-8258. Please
complete a separate form for each covered person. You can obtain
a claim
form by calling Member Service at 1-800/ 421-0959.
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after you
received the service, unless timely filing was prevented by
administrative operations of Government or legal incapacity,
provided
the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do
not respond.
2002 KeystoneBlue 42 Section 7 42
42
Page 43 44
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your
claim or request for services, drugs, or supplies
including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Keystone Health Plan West, Member Grievance
and Appeal Department,
P. O. Box 2717, Pittsburgh, PA 15230.
(c) Include a statement about why you believe our initial decision was wrong,
based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you
or your provider for more information. If we ask your provider, we will send you
a copy of our
request go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the information was
due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in
some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of
Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, D.
C. 20415-3630.
2002 KeystoneBlue 43 Section 8 43
43
Page 44 45
The
Disputed Claims process (continued)
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 represen-tative,
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.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed
services, drugs, or supplies 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.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or
death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
1-800/ 421-0959 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 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time.
2002 KeystoneBlue 44 Section 8 44
44
Page 45 46
Section 9. Coordinating benefits with other coverage
When you have
other You must tell us if you are covered or a family member is covered
under health coverage another group health plan or have automobile
insurance that pays health care
expenses without regard to fault. This is
called "double coverage."
When you have double coverage, one plan normally
pays its benefits in full as
the primary payer and the other plan pays a
reduced benefit as the secondary
payer. We, like other insurers, determine
which coverage is primary according
to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our
regular
benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with
End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a
transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. 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
show how we coordinate benefits with Medicare, depending
on the type of
Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere (Part A or Part B) 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 pays its share and you pay your share. Some things are not
covered
under Original Medicare, like prescription drugs.
(Primary payer chart begins on next page.)
2002 KeystoneBlue 45 Section 9 45
45
Page 46 47
2002
KeystoneBlue 46 Section 9
The following chart illustrates whether
the Original Medicare Plan 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.
P rimary Payer Chart
Then the primary payer is A. When either you
or your covered spouse are age 65 or over and
Original Medicare This Plan
1) Are an active employee with the
Federal government (including
when you or a family member are eligible for
Medicare solely
because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for
Part B
services)
(for other
services)
6) Are a former Federal employee receiving
Workers' Compensation
and the Office of Workers' Compensation Programs has
determined
that you are unable to return to duty,
(except for claims
related to Workers'
Compensation.)
B. When you or a covered family member have Medicare based
on end
stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant,
or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare,
you will have to file a claim with Medicare. 46
46
Page 47 48
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.
We will not waive any of our copayments or coinsurance.
Claims process
when you have the Original Medicare Plan You probably will
never have to
file a claim form when you have both our Plan and the Original
Medicare
Plan.
When we are the primary payer, we process the claim first.
When Original
Medicare is the primary payer, Medicare processes your claim first. In most
cases, your claims will be coordinated automatically. We will
process your claims for secondary payment based on usual and customary
allowances, rather than Medicare allowances. If there is a remaining
balance,
an explanation of benefits will be sent to you detailing how the
claim was
processed and showing you any amounts that are your
responsibility. To find out
if you need to do something about filing your
claims, call us at 1-800/ 421-0959.
We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your benefits from a Medicare managed care plan.
These are health care choices
(like HMOs) in some areas of the country. In
most Medicare managed care
plans, you can only go to doctors, specialists,
or hospitals that are part of the
plan. Medicare managed care plans 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:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan.
In
this case, we do not waive any of our copayments or coinsurance for your
FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll
in another plan's Medicare managed care plan and also remain enrolled
in our
FEHB plan. We will still provide benefits when your Medicare managed
care plan
is primary, even out of the managed care plan's network and/ or
service area (if
you use our Plan providers), but we will not waive any of
our copayments, or
coinsurance. If you enroll in a Medicare managed care
plan, tell us. We will need
to know whether you are in the Original Medicare
Plan or in a Medicare managed
care plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage
to enroll in a Medicare managed care plan, eliminating your FEHB
premium.
(OPM does not contribute to your Medicare managed care plan
premium.) For
information on suspending your FEHB enrollment, contact your
retirement office.
If you later want to re-enroll in the FEHB Program,
generally you may do so only
at the next open season unless you
involuntarily lose coverage or move out of the
Medicare managed care plan's
service area.
2002 KeystoneBlue 47 Section 9 47
47
Page 48 49
If
you do not enroll in If you do not have one or both Parts of Medicare, you
can still be covered Medicare Part A or Part B 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
TRICARE is the health care program for eligible dependents of military
per-sons, and retirees of the military. TRICARE includes the CHAMPUS program.
If both TRICARE and this Plan cover you, we pay first. See your TRICARE
Health Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related 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. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital for injuries care for injuries or illness caused
by another person or organization, you must
reimburse us for all expenses we
paid. This is called subrogation. We will cover
the cost of treatment based
on your benefit plan, but we do have the right to be
repaid from the money
that you received in the settlement.
If you do not seek damages, we can attempt to recover the benefits we paid on
your behalf. You may be asked to assist us in our recovery efforts. If you
need
more information, contact us for our subrogation procedures.
2002 KeystoneBlue 48 Section 9 48
48
Page 49 50
Section 10. Definitions of terms we use in this brochure
Calendar year
January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Coinsurance Coinsurance is the
percentage of our allowance that you must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money
you pay when you receive covered services. See page 12.
Covered
services Care we provide benefits for, as described in this brochure.
Experimental or The use of any treatment, service, procedure,
facility, equipment, drug, Investigational services device or supply
(intervention) that is not determined by the Plan or its
Designated Agent to
be medically effective for the condition being treated. The
Plan or its
Designated Agent will consider an intervention to be
Experimental/
Investigative if:
The intervention does not have FDA approval to market for the specific
relevant indication( s); or
Available scientific evidence does not permit conclusions concerning the
effect of the intervention on health outcomes; or
The intervention is not
proven to be as safe or as effective in achieving an outcome equal to or
exceeding the outcome of alternative therapies; or
The intervention is not
proven to be applicable outside the research setting. If an intervention as
defined above is determined to be Experimental/ Investigative at
the time of
service, it will not receive retroactive coverage if, at some future
date,
medical opinion changes.
Medically necessary and Those services or medical supplies that based
on the opinion of your appropriate primary care physician and/ or
KeystoneBlue, are determined to be:
Appropriate for the symptoms and
diagnosis or treatment of your condition, illness, disease, or injury; and
Provided for the diagnosis, or the direct care and treatment of your
condition, illness, disease, or injury; and
In accordance with standards of
good medical practice; and
Not primarily for your convenience, or your
provider; and
The most appropriate supply or level of service that can
safely be provided to you. When applied to hospitalization, this further means
that you require acute
care as an inpatient due to the nature of the services rendered or your
condi-tion,
and that you cannot receive safe or adequate care as an
outpatient.
Us/ We Us and we refer to KeystoneBlue
You You refers to
the enrollee and each covered family member.
2002 KeystoneBlue 49 Section 10 49
49
Page 50 51
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition before
you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing
or retirement office about enrolling in the can answer your questions,
and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot
change your enrollment status without information from your employing
or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, your for you and your family 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
enroll-ment
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 enroll-ment
begins on the first day of the pay period in which
the child is born or
becomes an eligible family member. When you change to
Self and Family because
you marry, the change is effective on the first day
of the pay period that begins
after your employing office receives your
enrollment form; benefits will not be
available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is
no longer eligible to receive health benefits, nor will we. Please
tell us immediate-ly
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.
2002 KeystoneBlue 50 Section 11 50
50
Page 51 52
When
benefits and The benefits in this brochure are effective on January 1. If
you joined this premiums start 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.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when coordinating benefit
payments and subrogating claims;
Law enforcement officials when
investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal
service. If you do not meet this requirement, you
may be eligible for other forms
of coverage, such as temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are
a family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of
Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you may be
eligible for your own FEHB coverage under the spouse equity law. If you are
recently divorced or are anticipating a divorce, contact your ex-spouse's
employing
or retirement office to get RI 70-5, the Guide to Federal
Employees Health
Benefits Plans for Temporary Continuation of Coverage and
Former Spouse
Enrollees, or other information about your coverage
choices.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no longer qualify of Coverage (TCC) 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 job, if you are a covered
depen-dent
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.
2002 KeystoneBlue 51 Section 11 51
51
Page 52 53
Enrolling in TCC. 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. It explains what you
have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law
ends (If you canceled your
coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse
equity law.
If you leave Federal service, your employing office will notify
you of your right to
convert. You must apply in writing to us within 31 days
after you receive this
notice. However, if you are a family member who is
losing coverage, the employ-ing
or retirement office will not notify
you. You must apply in writing to us with-in
31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however,
you will not have to answer questions about your health, and we
will not impose a
waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a Group Health Plan Coverage
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 FEHB website
(www. opm. gov/ insure/ health);
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.
2002 KeystoneBlue 52 Section 11 52
52
Page 53 54
Long Term Care Insurance Is Coming Later in 2002!
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:
What is long term care It's
insurance to help pay for long term care services you may need if you (LTC)
insurance? can't take care of yourself because of an extended illness or
injury, or an 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. It can supplement care provided by family members, reduc-ing
the burden you place on them.
I'm healthy. I won't need Welcome to the club! long term care. Or
will I? 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 the 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, or 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.
Is long term care expensive?
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 easily exhaust your
savings. Long term care insurance can protect your savings.
But won't my FEHB plan, Not FEHB. Look at the "Not covered"
blocks in sections 5( a) and 5( c) Medicare or Medicaid cover of your
FEHB brochure. Health plans don't cover custodial care or a stay
my long
term care? in an assisted living facility or a continuing need for a home
health aide to help you get 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.
When will I get more information Employees will get more information
from their agencies during the on how to apply for this new LTC open
enrollment period in the late summer/ early fall of 2002.
insurance coverage? Retirees will receive information at home.
How can I find out more Our toll-free teleservice center will begin
in mid-2002. In the meantime, you
about the program NOW? can learn more about the program on our web
site at www. opm. gov/ insure/ ltc.
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.
2002 KeystoneBlue 53 Long Term Care Insurance 53
53 Page 54 55
Accidental injury 31
Allergy tests 18
Allogeneic (donor) bone marrow
transplant 26
Alternative treatment 23
Ambulance 32
Anesthesia 27
Autologous bone marrow
transplant 27
Biopsies 24
Blood and
blood plasma 28
Breast cancer screening 15
Casts 28
Changes for 2002
8
Chemotherapy 18
Childbirth
16
Chiropractic 22
Cholesterol tests 15
Claims 42
Coinsurance 12
Colorectal
cancer screening 15
Congenital anomalies 25
Contraceptive devices and drugs 17
Coordination of benefits 45
Covered charges 9
Covered providers 9
Crutches 22
Definitions 49
Dental
care 39
Diagnostic services 14
Disputed claims review 43
Donor expenses
(transplants) 27
Dressings 28
Durable medical equipment
(DME) 22
Educational classes and programs 23
Effective date of enrollment 51
Emergency 31
Experimental or investigational 49
Eyeglasses 19
Family planning 17
Fecal occult blood test
15
General Exclusions 41
Hearing services 19
Home health
services 22
Hospice care 30
Home nursing care 22
Hospital 28
Immunizations 16
Infertility 17
In hospital physician care 28
Inpatient Hospital Benefits 28
Insulin 36
Laboratory and pathological
services 15
Long term care insurance 53
Machine diagnostic tests 15
Magnetic Resonance
Imagings (MRIs) 15
Mail
Order Prescription Drugs 36
Mammograms 15
Maternity Benefits 16
Medicaid 48
Medically necessary 49
Medicare 45
Members 50
Mental Conditions/ Substance
Abuse Benefits 33
Newborn care 16
Non-FEHB Benefits 40
Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits 14
Oral and maxillofacial surgery 26
Orthopedic devices 21
Out-of-pocket expenses
12
Outpatient facility care 29
Oxygen 22
Pap test 15
Physical examination 15
Physical therapy 18
Physician 9
Pre-admission testing 29
Precertification 10
Preventive care, adult 15
Preventive care,
children 16
Prescription drugs 35
Preventive services 15
Prior approval 11
Prostate cancer screening 15
Prosthetic devices 21
Psychologist 33
Psychotherapy 33
Radiation therapy 18
Renal dialysis 18
Room and board 28
Second
surgical opinion 14
Skilled nursing facility care
30
Smoking cessation 23
Speech therapy 19
Splints 28
Sterilization procedures 24
Subrogation 48
Substance abuse 33
Surgery
24
Anesthesia 27
Oral 26
Outpatient 29
Reconstructive
25
Syringes 36
Temporary
continuation
of coverage 51
Transplants 26
Treatment therapies 18
Vision services 19
Wheelchairs 22
Workers' compensation 48
X-rays 15
2002 KeystoneBlue 54 Index
Index
Do not rely on this page; it is for your convenience and may
not show all pages where the terms appear. 54
54
Page 55 56
Summary of benefits for the KeystoneBlue 2002
Do not rely on
this chart alone. All benefits are provided in full unless indicated and are
subject to the definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover; for more detail,
look
inside.
If you want to enroll or change your enrollment in this Plan, be
sure to put the correct enrollment code from the cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You pay Page
Medical services provided by
physicians:
Diagnostic and treatment services provided in the office . . . .
. 14
Services provided by a hospital:
Inpatient. . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . Nothing 29
Emergency benefits:
In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 32
Out-of-area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 32
Mental health and substance abuse treatment . . . . . . . . . . . . . . .
Regular cost sharing 33
Prescription drugs . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . 35
Up to a 34-day supply per
prescription unit or refill.
Up to a 90-day supply for maintenance drugs through mail order.
Dental Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . Nothing 39
Accidental injury benefit only.
Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 19
OptiChoice In-Network Annual Benefits Program
Special features: Flexible benefits option; Reciprocity benefit/ travel
Nothing 38
Protection against catastrophic costs
(your out-of-pocket
maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . 12 We have no
out-of-pocket maximum,
except for a $300 per individual and
$500 per family inpatient hospital
copayment limit.
Nothing for most standard services
Retail Pharmacy: $8 copay for
generic drugs; $14 copay for name
brand
drugs.
Mail Order (Maintenance drugs
only): $8 copay for generic drugs;
$14
copay for name brand drugs.
$50 copay per visit (waived if
admitted)
$50 copay per visit (waived if
admitted)
$100 copay per admission up to a
maximum of $300 per individual and
$500 per family per calendar year
Office visit copay: $10 primary
care; $10 specialist
2002 KeystoneBlue 55 Summary 55
55
Page 56
2002 KeystoneBlue 56
Rates
2002 Rate Information for
KeystoneBlue
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the
FEHB Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for
United States Postal Service Employees,
RI 70-2. Different postal rates apply and special FEHB guides are
published
for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for
Postal Service Inspectors
and Office of Inspector General (OIG) employees
(see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal
employee organization. Refer to the
applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
EF1 $97.86 $47.63 $212.03 $103.20 $115.52 $29.97
EF2 $223.41 $208.21
$484.06 $451.12 $263.75 $167.87 Self and Family
Self Only 56