Presbyterian Health Plan http:// www. phs.
org
2002
Serving: All counties of New Mexico, except for Otero and southern
Eddy County
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:
P21 Self Only P22 Self and Family
This Plan has Commendable accreditation from NCQA. See the 2002 Guide for
more
information on accreditation
RI 73-563
For changes in benefits
see page 8.
! !! !
A Health Maintenance Organization 1
1 Page 2 3
2002 Presbyterian Health Plan 2 Table of Contents
Table
of Contents
Introduction…………………………………………………………………..........................................................................................
4
Plain
Language........................................................................................................................................................................................
4
Inspector General Advisory
....................................................................................................................................................................
4
Section 1. Facts about this HMO plan
...................................................................................................................................................
6
How we pay
providers...........................................................................................................................................................
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................................................................................................................................................................
10
Hospital
care.................................................................................................................................................................
11
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 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..................... 26
(c) Services provided by a hospital or other facility, and
ambulance services .................................................. 31
(d) Emergency services/
accidents......................................................................................................................
36
(e) Mental health and substance abuse
benefits.................................................................................................
39
(f) Prescription drug benefits
............................................................................................................................
41 2
2 Page 3 4
2002 Presbyterian Health Plan 3 Table of Contents
(g) Special Features ……………………………………………………………… ...........……………………
45
Flexible Benefit Options
(h) Dental benefits…………………………………………………………………
.......................................... 46
(i) Non-FEHB benefits available to Plan
members………………………………………………………….. 47
Section 6. General
exclusions --things we don't
cover........................................................................................................................
48
Section 7. Filing a claim for covered
services......................................................................................................................................
49
Section 8. The disputed claims
process................................................................................................................................................
50
Section 9. Coordinating benefits with other
coverage
.........................................................................................................................
52
When you have…
Other health
coverage....................................................................................................................................................
52
Original
Medicare..........................................................................................................................................................
52
Medicare managed care plan
........................................................................................................................................
54
TRICARE/ Workers' Compensation/ Medicaid
...................................................................................................................
55
Other Government agencies
................................................................................................................................................
55
When others are responsible for
injuries.............................................................................................................................
55
Section 10. Definitions of terms we use in this
brochure...................................................................................................................
56
Section 11. FEHB facts
....................................................................................................................................................................
57
Coverage
information........................................................................................................................................................
57
No pre-existing condition
limitation..........................................................................................................................
57
Where you get information about enrolling in the
FEHB
Program...........................................................................
57
Types of coverage available for you and your family
...............................................................................................
57
When benefits and premiums start
............................................................................................................................
58
Your medical and claims records are confidential
....................................................................................................
58
When you
retire........................................................................................................................................................
58
When you lose benefits
.....................................................................................................................................................
58
When FEHB coverage ends
......................................................................................................................................
58
Spouse equity
coverage............................................................................................................................................
58
Temporary Continuation of Coverage (TCC)
..........................................................................................................
58
Converting to individual coverage
...........................................................................................................................
59
Getting a Certificate of Group Health Plan
Coverage..............................................................................................
59
Long-term care insurance is coming later in 2002
................................................................................................................................
60
Index
.........................................................................................................................................................................................
61
Summary of benefits
.............................................................................................................................................................................
62
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Presbyterian Health Plan 4 Introduction/ Plain Language/
Advisory
Introduction
Presbyterian Health Plan 2501 Buena
Vista SE
Albuquerque, NM 87106 Or
PO Box 27489 Albuquerque, NM
87125-7489
This brochure describes the benefits of Presbyterian Health Plan under our
contract (CS2627) with the Office of Personnel Management (OPM), as authorized
by the Federal Employees Health Benefits law. This brochure is the official
statement of
benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and exclusions of this brochure.
If you are enrolled
in this Plan, you are entitled to the benefits described in this brochure. If
you are enrolled for Self and Family coverage, each eligible family member is
also entitled to these benefits. You do not have a right to benefits that were
available
before January 1, 2002, unless those benefits are also shown in
this brochure.
OPM negotiates benefits and rates with each plan annually.
Benefit changes are effective January 1, 2002, and 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 Presbyterian Health
Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of
this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the
Office of Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900 E Street, NW, Washington, DC
20415-3650.
Inspector General Advisory
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 800/ 356-2219 and explain the situation.
If we do not
resolve the issue, call or write
Stop health care fraud! 4
4 Page 5 6
2002 Presbyterian
Health Plan 5 Introduction/ Plain Language/ Advisory
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 ID card
if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your
agency may also take
administrative action against you. 5
5 Page 6 7
2002 Presbyterian Health Plan 6 Section 1
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, coinsurance, and deductibles 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. Our Fee schedule is
based
on the Resource Base Relative Value Scale (RBRVS). The RBRVS method
was designed by physicians to fairly compensate themselves based on (1) a
nationally uniform relative value for service (2) geographic adjustment factor
and (3) a nationally uniform
conversion factor for service. This method has
been adopted by our Federal Centers for Medicare and Medicaid Services for
Medicare reimbursement.
The RBRVS pays higher for evaluation and management services and lower for
procedures. All physicians receive reimbursement for both evaluation and
management services and procedures. The effect upon the individual physician
will vary depending upon how
much time they spend in office-based services
as compared to procedural-based services. Typically, physicians such as primary
care physicians, internists, pediatricians, rheumatologists, and pulmonologists
spend more time in office-based services, and physicians
such as surgeons,
and cardiologists spend more time in procedure-based services. Although this fee
schedule is both provider and health plan based, it results in a high quality
health plan for you and your families.
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. Some of the required information is listed
below.
Presbyterian Health Plan is owned by Presbyterian Healthcare
Services, which has been providing quality care for New Mexicans since 1908
Presbyterian Health Plan has 15 years' experience in improving the health of
individuals, families and communities
Customer Satisfaction Measures
Networks and Providers
If you want more information about us, call 800/
356-2219 or write to Presbyterian Health Plan, PO Box 27489 Albuquerque, NM
87125-7489. You may also contact us by fax at 505/ 923-8163 or visit our website
at www. phs. org.
Service Area 6
6 Page
7 8
2002 Presbyterian Health Plan 7
Section 1
To enroll in this Plan, You must live or work in our
Service Area. This is where our providers practice. Our service area is all
counties of New Mexico, except for Otero County and southern Eddy County.
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. Full-Time
dependent students attending school outside Presbyterian Health Plan's service
area can receive care at a Student Health Center without a referral from their
Primary Care Physician. Services provided
outside of the Student Health
Center are for medically necessary services for the initial care or treatment of
an Emergency or Urgent Care situation. 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. 7
7 Page 8 9
2002 Presbyterian
Health Plan 8 Section 2
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 speech therapy benefits by removing the requirement that services
must be required to restore functional speech. (Section 5( a).
Changes to this Plan
Your share of the non-Postal premium will
increase by 11. 2% for Self Only or 11. 2% for Self and Family.
We clarified
that there is not an additional copay for a mammogram; the mammogram is included
in the office visit copay.
The benefit for all rehabilitative therapies of
physical and occupational will decrease up to two months per condition. A $15
per visit copay applies. 8
8 Page
9 10
2002 Presbyterian Health Plan
9 Section 3
Section 3. How you get care
Identification
cards We will send you an identification (ID) card when you enroll. You
should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan
provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health Benefits
Election Form, SF-2809, your health benefits enrollment
confirmation (for
annuitants), or your Employee Express confirmation letter.
If you do not
receive your ID card within 30 days after the effective date of your enrollment,
or if you need replacement cards, call us at 1-800/ 356-2219.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and 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 obtain, verify, review and evaluate
practitioners' competencies and qualifications on an ongoing basis to determine
whether
they can participate as providers in our Plan. Providers we
credential include Medical Doctors, Specialists, Physician Assistants, Certified
Nurse Practitioners, Licensed Social
Workers, and licensed Professional
counselors.
We list Plan providers in the provider directory, which we
update periodically. The list is also on our website. The listings are first
organized by region within New Mexico –
Central New Mexico, Northern New
Mexico, and Southern New Mexico. Each region, physicians, other providers and
facilities are organized by Physician directed Teams,
Primary Care
Physicians are listed as Family Practice, General Practice, Internal Medicine,
Pediatrics and OB/ GYN's acting as PCPs.
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. Presbyterian Health Plan's
provider directory has a section that lists all participating facilities,
hospitals and
pharmacies across the state.
It depends on the type of
care you need. First, you and each family member must choose a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care. Your must select a
primary care physician from the provider directory who is closest to home or
work. Locations and
telephone numbers of the participating doctors are
listed in the provider directory or can be obtained by calling the member
Services Department 505/ 923-5678 or 1-800/ 356-
2219. By selecting a PCP who
belongs to the plan, members are selecting their corresponding network of
specialists, hospitals and other providers to serve their
healthcare needs.
A PCP selection form is in your packet. Select your provider by the 5-digit
provider number and mail it in the return envelope.
Primary care Your primary care physician can be a family Practice,
General Practice, Internal Medicine, Pediatrics and OB/ GYN acting a Primary
Care Physician. 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.
What you must do to get covered care 9
9
Page 10 11
2002
Presbyterian Health Plan 10 Section 3
Specialty care Your
primary care physician will refer you to a specialist for needed care. When you
receive a referral from your primary care physician, you must return to the
primary care
physician after the consultation, unless your primary care
physician authorized a certain number of visits without additional referrals.
The primary care physician must provide or
authorize all follow-up care. Do
not go to the specialist for return visits unless your primary care physician
gives you a referral. However, you may see a woman's healthcare
provider who
has been credentialed by Presbyterian Health Plan to provide female-related care
without a referral. Treatment for Infertility, Reproductive Endocrinology, and/
or
Gynecological Oncology may require pre-authorization. You do not need a
referral from your PCP or Specialist for an evaluation from behavioral health
services; however, you
must call 505/ 923-5470 (Albuquerque area or 1-800/
453-4347 (Outside Albuquerque) to access services.
Except in a medical emergency, or when a primary care doctor has designated
another doctor to see his or her patients, or for gynecological or maternity
care, you must receive
a referral from your primary care doctor before
seeing any other doctor or obtaining specialty services. Referral to a
participating specialist is given at the primary care
doctor's discretion,
if non-Plan specialist or consultants are required, the primary care doctor will
make arrangements for appropriate referrals. All follow-up care must be
provide or arranged by the primary care doctor.
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 issue a referral that will include
the
expiration date of the referral and the number of visits. If the consultant
suggests additional services or visits, you must first check with your primary
care doctor to
develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals. Your
primary care physician will use our criteria
when creating your treatment
plan (the physician may have to get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment
you need. If he or
she decides to refer you to a specialist, ask if you can
see your current specialist. If your current specialist does not participate
with us, you must receive treatment from a
specialist who does. Generally,
we will not pay for you to see a specialist who does not participate with our
Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for
other than cause; or
-drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new
plan. 10
10 Page
11 12
2002 Presbyterian Health Plan
11 Section 3
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
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 1-800-356-2219 or 923-5678. If you
are new to the
FEHB Program, we will arrange for you to receive care.
If
you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care.
Your primary care physician
has authority to refer you for most services. For certain services, however,
your physician must obtain approval from us. Before giving approval,
we
consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
We call this review and approval process pre-authorization. Your physician
must obtain pre-authorization for the following services: Durable Medical
Equipment, Home Health,
Hospice, Home IV/ Infusion, Acute Rehabilitation,
Outpatient Rehab, Ambulance, Skilled Nursing Facilities and Mental Health/
Substance Abuse care.
Except in a medical emergency, or when a primary care doctor has designated
another doctor to see his or her patients, or for gynecological or maternity
care, you must receive
a referral from your primary care doctor before
seeing any other doctor or obtaining specialty services. Your physician must get
our approval before sending you to a
hospital. Referral to a participating
specialist is given at the primary care doctor's discretion. If required medical
services are not available from participating providers, the
Primary Care
Physician must request and obtain written authorization from the Presbyterian
Health Plan Medical Director before the Member may receive services.
Services requiring our prior approval 11
11
Page 12 13
2002
Presbyterian Health Plan 12 Section 4
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 and when you go in the hospital, you pay nothing per admission.
Deductible We do not have a deductible.
Coinsurance
Coinsurance is the percentage of our negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 50% of our allowance for
infertility services and 20% of our allowance for durable medical equipment.
After your copayments and/ or coinsurance total $2000 per person or $4000 per
family enrollment in any calendar year, you do not have to pay any more for
covered services.
However, copayments and/ or coinsurance for the following
services do not count toward your out-of-pocket maximum, and you must continue
to pay copayments and/ or
coinsurance for these services:
Prescription
drugs
Dental services
Vision Services
Be sure to keep accurate
records of your copayments and/ or coinsurance since you are responsible for
informing us when you reach the maximum.
Your catastrophic protection out-of-pocket maximum for
coinsurance and
copayments 12
12 Page
13 14
2002 Presbyterian Health Plan
13 Section 5
Section 5. Benefits --OVERVIEW
(See
page 8 for how our benefits changed this year and page 62 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 1-800-356-2219 or
at our website at www. phs. org.
(a) Medical services and supplies provided by physicians and other health
care professionals. ................................................ 14-27
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Treatment therapies Physical
and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision
services (testing, treatment, and supplies) Foot care
Orthopedic and
prosthetic devices Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals.......................................... 26-30
Surgical
procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other
facility, and ambulance services
....................................................................... 31-35
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents
...........................................................................................................................................
36-38 Medical emergency Ambulance
(e) Mental health and substance abuse benefits
......................................................................................................................
39-40
(f) Prescription drug benefits
..................................................................................................................................................
41-44
(g) Special Features…………………………………………………………………………………………………………………… 45
Flexible Benefit Option
Services for deaf and hearing impaired
High
risk pregnancies
(h) Dental
Benefits…………………………………………………………….....…………………………………………………… 46
(i) Non-FEHB
benefits available to Plan members…………………………………………………….....…………………………. 47
Summary of benefits.
............................................................................................................................................................................
62 13
13 Page 14
15
2002 Presbyterian Health Plan 14 Section
5( a)
Section 5 (a). Medical services and supplies provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deducible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
$10 per office visit
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility: Admission must be
arranged and preauthorized by the Plan. Skilled Nursing facility care is
provided for
up to 60 days per member, per calendar year.
For office medical
consultations
For second surgical opinion
$10 per office visit
$10 in Service Area
$15 out of Service Area
Nothing
Nothing
$10 per office visit
$10 per office visit
At home $10 per visit
Diagnostic and treatment services --continued on next page 14
14 Page 15 16
2002 Presbyterian Health Plan 15 Section 5(
a)
Lab, X-ray and other diagnostic tests You pay
Tests, such
as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services during your office visit; otherwise,
$10 per office
visit
Preventive care, adult
Routine screenings, such as:
Preventive
physical exam
Office based health education
Glaucoma Testing
Family
Planning
Blood lead level – One annually
Total Blood Cholesterol – once
every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening – every five years
starting at age 50
Chlamydial infection Prostate Specific Antigen (PSA test)
– one annually for men age 40 and
older
$10 per office visit
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see Diagnosis and Treatment, above. $10 per
office visit
Preventive Care -Adult --continued on next page 15
15 Page 16 17
2002 Presbyterian Health Plan 16 Section 5(
a)
Preventive care, adult (continued) You pay
Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
You pay nothing for charges. Additional mammograms are covered when
determined to be medically necessary by a participating provider.
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care
(under age 22)
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (under age 22)
$10 per office visit 16
16 Page 17 18
2002
Presbyterian Health Plan 17 Section 5( a)
Maternity care You
pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 33 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
$10 per office visit up to a maximum of $100 per pregnancy
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
Norplant (a surgically implanted
contraceptive) and intrauterine devices (IUDs). Note: Devices are covered
under 5 (a).
NOTE: We cover oral contraceptives under the prescription drug benefit.
50% of all charges
50% of all charges-insertion
$10 per visit-removal
50% of all charges
50% of all charges
$10 per visit
50% of all
charges
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges. 17
17 Page 18 19
2002
Presbyterian Health Plan 18 Section 5( a)
Infertility services
You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination: intravaginal insemination (IVI)
intracervical insemination (ICI) intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under the medical benefits. Artificial
insemination is
covered up to 3 inseminations.
50% of all charges
50% of all charges
Not covered:
Assisted reproductive technology (ART) procedures,
such as: in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT Zygote transfer
Services and supplies related to excluded ART procedures
Cost
of donor sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges. 18
18 Page 19 20
2002 Presbyterian Health Plan 19 Section 5(
a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous
bone marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 29.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we
preauthorize the treatment. Growth Hormone is covered for children with growth
potential who
have total or partial growth hormone deficiency (idiopathic or organic). The
diagnosis of growth hormone deficiency must be confirmed by at
least two
stimulation tests. Growth hormone injections are specifically excluded for
Turner's syndrome or Down's syndrome, unless growth
hormone deficiency can
be documented, and when preauthorized by us. For adults, growth hormone is
covered only for non-functioning or
surgically removed pituitary glands with
demonstrated low levels of growth hormone. Growth hormone injections are
excluded for chronic
renal failure or other chronic disease regardless of
stimulated growth hormone levels.
We will ask that your physician submit information that establishes that the
GHT is medically necessary. Ask us to authorize GHT before you
begin
treatment; otherwise, we will only cover GHT services from the date you submit
the information. If you do not ask or if we determine
GHT is not medically
necessary, we will not cover the GHT or related services and supplies. See
Services requiring our prior approval in
Section 3. Continuation of
therapy using any drug is dependent upon its demonstrable efficacy.
$10 per office visit
Note: 10% of all charges for Recombinant DNA and
Purified Biological Products.
Not covered: All charges. 19
19 Page 20 21
2002
Presbyterian Health Plan 20 Section 5( a)
Physical and
occupational therapies You Pay
Provided in-patient or out-patient up to
2 months per condition if significant improvement is expected for the services
of each of the
following:
qualified physical therapists; and
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. In-patient or out-patient
therapy may be extended 2
additional months if significant improvement is expected to continue and must be
preauthorized by PHP
This benefit is not renewable each calendar year. Cardiac
rehabilitation following a heart transplant, bypass surgery or a
myocardial
infarction is provided for up to 12 sessions with continuous electrocardiogram
(ECG) monitoring or up to 24 sessions with intermittent
ECG monitoring at an
approved facility.
$15 per visit
Not covered: Long-term rehabilitative therapy
(Any therapy
beyond 6 months is defined as long term therapy.) Exercise programs All
charges.
Speech therapy Speech Therapy is covered for up to 2 months when
provided by a licensed or
certified speech therapist subject to the
following:
Speech Therapy is medically necessary
Speech Therapy must
be preauthorized by us.
Following the initial 2 months of treatment,
in-patient or outpatient Speech Therapy may be extended for a period not to
exceed 2 additional 2-month
periods.
$15 per visit
Not covered: Speech Therapy beyond 6 consecutive months. All
charges. 20
20 Page
21 22
2002 Presbyterian Health Plan
21 Section 5( a)
Hearing services (testing, treatment, and
supplies) You pay
First hearing aid and testing only when necessitated
by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
20% of all charges
Eye exam to determine the need for vision correction for children through age
17 (see Preventive care, children)
Screening performed to determine the need
for vision correction. This does not include routine eye exams or refractions
performed by
eye care specialists.
$10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
Eye exercises and orthopedics
Radial keratotomy and other
refractive surgery
Replacement of all items referenced in this section due to wear, loss, or
damage
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges. 21
21 Page 22 23
2002
Presbyterian Health Plan 22 Section 5( a)
Orthopedic and
prosthetic devices You Pay Artificial limbs and eyes; stump hose
Orthotic appliances including braces and other external devises used to
correct a body function. Benefits will be provided if medically
necessary
and preauthorized.
Externally worn breast prostheses and surgical bras,
including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant following
mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see
Section 5 (c) for payment information. See 5( b) for
coverage of the surgery
to insert the device.
Corrective orthopedic appliances for non-dental
treatment of tempormanibular joint (TMS) pain dysfunction syndrome.
Prosthetics devices are covered only when they replace a limb or other part
of the body after accidental or surgical removal and/ or when the body's
growth necessitates replacement.
For diabetics, covered services include
foot appliances, including therapeutic molded or depth-inlay shoes, functional
orthotics, custom
molded inserts, replacement inserts, preventive devices
and shoe modifications for prevention and treatment.
Penile Prosthesis is limited to the reasonable charge for semi-rigid or
flexible rod prosthesis. Benefits for inflatable penile prosthesis may be
provided when medically necessary.
Prosthetic Devices will be provided
when determined to be medically necessary by the plan physician. Prosthetic
devices must be
preauthorized by us.
20% of all charges
Not covered:
orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
speech synthesis devices
All charges. 22
22 Page 23 24
2002
Presbyterian Health Plan 23 Section 5( a)
Durable medical
equipment (DME) You Pay
Rental or purchase, at our option, including
repair and adjustment, of durable medical equipment prescribed by your Plan
physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs (non-motorized);
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
20% of all charges
Not covered: deluxe equipment such as motor driven wheelchairs,
chair lifts, or
beds, when standard equipment is available and adequate.
motorized wheel chairs
All charges.
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen
therapy, intravenous therapy and medications.
Recombinant DNA and Purified
Biological Products
Nothing
10% of all charges
Not covered: nursing care
requested by, or for the convenience of, the patient or
the patient's
family;
Home Care primarily for personal assistance does not include
a medical component and is not diagnostic, therapeutic or
rehabilitative.
All charges. 23
23 Page 24 25
2002
Presbyterian Health Plan 24 Section 5( a)
Chiropractic You Pay
Chiropractic Services – 18 visits per year if medically necessary.
Preauthorization is required.
Your plan physician must determine in consultation with us that your
treatment will result in significant improvement in your condition
within 2
months.
Following the initial evaluation and 6 sessions, inpatient or
outpatient chiropractic treatment may be extended for a period not to exceed 2
additional 6-session periods when:
preauthorized by us, and
the plan physician certifies that the therapy is
medically necessary and is resulting in significant improvement. The
determination of
significant improvement will be established if the member
has met all therapy goals for the preceeding 6 sessions as documented on the
therapy record.
Chiropractic treatment is specifically limited to
treatment by means of manual manipulation, by the use of hands, and ultrasound
therapy.
Subluxation must be documented by chiropractic examination and documented in
the chiropractic records.
Chiropractic x-rays are only covered if
preauthorized. Preauthorization for x-rays performed by a chiropractor will be
considered for the
following clinical situations, unless clinically relevant
x-rays already exist:
Acute trauma with a suspected fracture, such as motor vehicle accidents or
slip and fall accidents
Clinical evidence of significant osteoporosis:
recent fracture of the spine, wrist or hip; loss of height over inch, or spine
curvature
consistent with osteoporotic fractures; or
Abnormal neurologic or orthopedic findings suggesting spinal nerve
impingement.
$15 per office visit
Chiropractic --continued on next page 24
24
Page 25 26
2002
Presbyterian Health Plan 25 Section 5( a)
Chiropractic
(continued) You Pay
Not covered:
Chiropractic treatment for chronic subluxation of rheumatoid arthritis,
allergy muscular dystrophy, multiple sclerosis, pneumonia, or chronic lung
disease, and other diseases/ conditions.
Diagnostic or therapeutic
service furnished by a chiropractor including magnetherm, or any other
mechanical form of treatment
Rolfing
Massage therapy
Naturopathic services
Hynotherapy
Biofeedback
All charges.
Alternative treatments
Acupuncture/ Meridian Therapy – 20 visits
per year if determined medically necessary by a doctor of medicine or
osteopathy, chiropractor
or doctor of Oriental Medicine acting within the scope of his/ her license
for anesthesia or chronic or acute pain relief. Both a referral is required
from your plan physician and preauthorization from us.
Treatment of
other medical conditions using acupuncture or meridian therapy will be covered
only if the following conditions are met:
There is evidence-based medical literature that clearly supports the safety,
efficacy and appropriateness of this treatment for the specific
medical
condition for which authorization is requested.
Acupuncture or meridian
therapy must be part of a coordinated plan of care
$15 per office visit
Not covered: naturopathic services
hypnotherapy
biofeedback
Educational classes and programs
No Benefit. All charges.
25
25 Page 26
27
2002 Presbyterian Health Plan 26 Section
5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which
services require precertification and
identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: 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
$10 per office visit – Outpatient
Nothing – Inpatient 26
26 Page 27 28
2002 Presbyterian Health Plan 27 Section 5(
b)
Surgical procedures (continued) You pay
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.
Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All
charges.
Reconstructive surgery Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if: the condition
produced a major effect on the 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.
Nothing
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas; breast
prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
See above.
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges. 27
27 Page 28 29
2002
Presbyterian Health Plan 28 Section 5( b)
Oral and
maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
Nothing
Not covered: Oral implants and transplants
Procedures
that involve the teeth or their supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
All charges. 28
28 Page 29 30
2002 Presbyterian Health Plan 29 Section 5(
b)
Organ/ tissue transplants You pay
Limited to: Cornea
Heart Heart/ lung
Lung Kidney
Kidney/ Pancreas Liver
Lung: Single
–Double Pancreas
Pancreas islet cell infusion Allogeneic (donor) bone marrow
transplants
Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors Intestinal transplants (small
intestine) and the small intestine with
the liver or small intestine with
multiple organs such as the liver, stomach, and pancreas
National Transplant
Program (NTP) – All organ transplants must be medically necessary. Transplants
will be performed as a site
approved by us.
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. The plan will pay reasonable and
customary charges for
hospital, surgical, laboratory and x-ray services for a donor who is not
entitled to benefits under any other health benefit
plan or policy. Donor
charges must result from the medically necessary covered transplant of an organ
or body tissue to a member of the plan.
Limited travel benefits are available for the transplant recipient and one
other person. Transportation costs will be covered only if out-of-state
travel is required. Reasonable expenses for lodging and meals will be
covered for both out-of-state and in-state, up to a maximum of $150 a
day
for both combined. All benefits for transportation, lodging and meals are
limited to a maximum of $10,000.
All transplant benefits, including travel, are limited to a lifetime maximum
of $500,000 (including immunosuppressive drugs).
$10 per visit – Outpatient
Nothing – Inpatient
Organ/ Tissue Transplants – continued on next page 29
29 Page 30 31
2002 Presbyterian Health Plan 30 Section 5(
b)
Organ/ tissue transplants (Continued) You pay
Not covered: Donor screening tests and donor search expenses,
except those
performed for the actual donor Implants of artificial organs
Transplants not listed as covered
Non-human organ transplants,
except for porcine (pig) heart valves
All charges.
Anesthesia
Professional services provided in –
Hospital
(inpatient) Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
$10 per office visit 30
30 Page 31 32
2002
Presbyterian Health Plan 31 Section 5( c)
Section 5 (c).
Services provided by a hospital or other facility, and ambulance services
I
M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
The amounts listed below are for the charges
billed by the facility (i. e., hospital or surgical center) or ambulance service
for your surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
Hospital
Service must be preauthorized by us.
YOUR PHYSICIAN MUST GET
PRECERTIFICATION OF HOSPITAL STAYS
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
Ward, semiprivate, or intensive care accommodations;
General nursing
care; and
Meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 31
31 Page 32 33
2002 Presbyterian Health Plan 32 Section 5(
c)
Inpatient hospital (continued) You pay
Other
hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed
drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
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
Nothing
Not covered:
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
All charges. 32
32 Page 33 34
2002
Presbyterian Health Plan 33 Section 5( c)
Outpatient hospital
or ambulatory surgical center You Pay
Operating, recovery, and other
treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and
pathology services
Administration of blood, blood plasma, and other
biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): 60 days per member per calendar year
Note: Room and board and other necessary services are provided when you
require skilled nursing care of the type provided by the
facility. Admission
to the facility must be arranged by your Primary Care Physician or a physician
to whom you are referred
and must be preauthorized by Presbyterian Health
Plan.
Nothing
Not covered: custodial care or domiciliary care All charges. 33
33 Page 34 35
2002 Presbyterian Health Plan 34 Section 5(
c)
Hospice care You Pay
The following services are covered
for in-patient and in-home hospice benefits:
Inpatient hospice care
Physician visits by plan hospice physicians
Home health care by approved
home health care personnel
Physical therapy
Medical supplies
Drugs
and medication for the terminally ill patient
Respite care for a period not
to exceed five continuous days for every 60 days of hospice care. Only two
respite cares are available
during a hospice benefit period
Benefits are provided for in a
participating hospice or facility approved by the plan physician and
preauthorized by the plan.
The hospice benefit period must begin while you are covered with this
benefit, and coverage through the plan must be continued throughout the
benefit period in order for hospice benefits to continue.
The hospice
benefit period is defined as:
Beginning on the date the plan physician
certifies that you are terminally ill with a life expectancy of six months or
less; and ending six months after it
began, or upon death.
If you require an extension of the hospice benefit
period, the hospice must provide a new treatment plan and the plan physician
must recertify your
medical condition to us. No more than one additional hospice benefit period
will be preauthorized by us.
Nothing
Not covered:
Food, housing and delivered meals
Volunteer services
Comfort items
Homemaker and
housekeeping services
Private duty nursing
Pastoral and
spiritual counseling and
Bereavement counseling
All charges. 34
34 Page 35 36
2002
Presbyterian Health Plan 35 Section 5( c)
Ambulance You Pay
Local professional ambulance service when medically appropriate.
Ground Ambulance
Air Ambulance
$50 copay per occurrence
$100
copay per occurrence 35
35 Page
36 37
2002 Presbyterian Health Plan
36 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year
deductible.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies
because, if not treated promptly, they might become more serious; examples
include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what they all have in
common is the need for quick action.
What to do in case of emergency:
If you need emergency care you
should call 911 or seek treatment at the nearest emergency room. If in need of
urgent care, you should seek treatment at an urgent care center that is open and
available for business. Please note that some urgent care
centers are not
open after 8: 00 p. m. In such circumstances, you may need to use an emergency
room for care that is needed on an urgent basis.
Acute emergency medical care is covered 24 hours per day, seven days per week
for services needed immediately to prevent jeopardy to your health. If you
cannot reasonably access a plan facility, we will make arrangements to cover
your care that is
needed on an urgent basis.
Coverage for services will
continue until you are medically suitable, do not require critical care, and can
be safely transferred to a hospital in our plan network.
We will provide reimbursement when you, acting in good faith, obtain
emergency care for what appears to you acting as a reasonable lay person, to be
an acute condition that requires immediate medical attention, even if your
condition is
subsequently determined to be non-emergent.
In determining
whether you acted as a "reasonable layperson" we will determine the following
factors:
Your belief that the circumstances required immediate medical care
that could not wait until the next working day or the next available appointment
The time of day the care was provided
The presenting symptoms
Any
circumstance that prevented you from using our established procedures for
obtaining emergency care.
We will not deny a claim for emergency care when
you are referred to the emergency room by a plan doctor or the plan.
No
prior authorization is required for emergency care. 36
36 Page 37 38
2002 Presbyterian Health Plan 37 Section 5(
d)
If your emergency care results in a hospitalization directly from the
emergency room the emergency co-payment is waived.
Emergencies within our
service area: You should seek medical treatment from plan providers whenever
possible. Follow up care from plan or non-plan providers
within the service
area requires a referral from a plan provider.
Out-of-network emergency care
will be provided to you without additional cost. The reasonable lay person
standard from above will apply to determine if out of network care was
appropriate.
________________________________________________________________________________________________
Emergencies outside our service area:
You may seek services from
the nearest facility where emergency treatment can be provided. Non-emergent
follow up care outside the service area is not covered unless transfer to a plan
provider would be medically inappropriate and a risk to your
health. Non-emergent follow-up care outside of our service area is not
covered for convenience or preference. 37
37
Page 38 39
2002
Presbyterian Health Plan 38 Section 5( d)
Benefit Description
You pay
Emergency within our service area
Emergency care at a
doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient
or inpatient at a hospital, including doctors' services
$10 per visit
$15 per visit
$25 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$10 per visit
$15 per visit
$25 per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Ground Ambulance
Air Ambulance
$50 per occurrence
$100 per occurrence
Inter-Facility Transfer:
Ground Ambulance
Air Ambulance
Nothing
$100 per occurrence
Not covered: Inter-Facility Transfer Services if not preauthorized All
charges. 38
38 Page
39 40
2002 Presbyterian Health Plan
39 Section 5( e)
Section 5 (e). Mental health and substance
abuse benefits
I M
P O
R T
A N
T
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.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All Diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
" Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
" Medication management
$10 per visit
Mental health and substance abuse benefits -continued on next page 39
39 Page 40 41
2002 Presbyterian Health Plan 40 Section 5(
e)
Mental health and substance abuse benefits (continued)
You pay
" Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial hospitalization, half-way house,
residential treatment, full-day
hospitalization, facility-based intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
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.
All charges.
Preauthorization To be eligible to receive these enhanced mental
health and substance abuse benefits you must follow your treatment plan and all
the following authorization processes:
To access mental health services,
simply contact the Presbyterian Health Plan Behavioral Health Unit at 923-5470
or 1-800-453-4347 to receive a referral to a
behavioral health provider. The
behavioral health provider is responsible for any authorizations.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 40
40 Page
41 42
2002 Presbyterian Health Plan 41 Section 5( f)
Section 5
(f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T There are important features you should
be aware of. These include:
Who can write your prescription. A
participating plan healthcare provider must write the prescription. Where you
can obtain them. You may fill the prescription at a plan pharmacy, (except
for out-of-area emergencies), or
by mail for a maintenance medication. Mail
order medications are available through the Mail Service Pharmacy identified in
the Doctors and Facilities Directory. Order forms are available from the Plan's
customer service department.
We use a formulary. We cover
non-formulary drugs prescribed by a Plan doctor. Prescription medications are
prescribed by a Plan healthcare provider and dispensed in accordance with the
Plan's drug formulary. The formulary is a
list of generic and brand name
medications that we selected to meet patient needs for quality treatment at a
lower cost. You may request a copy of this formulary by calling Member Services
at 1-800-356-2219 or 923-5678. An on-line
version of our formulary is also
available at our web site – www. phs. org (under Services & MDS-Pharmacy).
These are the dispensing limitations. 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. 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
Member Service at 505-923-5678 or 1-800-356-2219.
An on-line version of our formulary is available on our web site – www. phs. org
(under Services and MDs – Pharmacy).
Prescription medications
prescribed by a Plan healthcare provider and obtained at a Plan pharmacy
will be dispensed for up to a 30 day supply or 100-unit supply, whichever is
less, or one commercially prepackaged unit i. e. one inhaler, one
vial
ophthalmic drops, one vial of insulin). Any amount of medication beyond these
quantity limits, even if necessary to obtain a months supply, will be associated
with multiple copays (for example 200 tablets of a medication or 2
prepackaged inhalers, necessary for a months supply, will be associated with
payment of two copays for that medication).
Maintenance formulary
medications purchased through the mail order option will be for a 90-day supply
or 300-units, whichever is less, or 3 commercially prepackaged units.
Non-formulary medications are not available through the mail
order option.
If you or your healthcare provider request a brand name drug in place of the
generic, you pay the difference in price between the brand and generic, plus the
applicable generic copay.
Brand name drugs will be associated with a brand
copay, even if a generic equivalent is not available. Prescription refill
requests through a Plan pharmacy or the mail order option will be processed at
or near the expected
time at which the original supply of medication would
be exhausted. Requests for early refills can be made to the Plan pharmacy, who
can then request approval from the Plan. Replacement prescriptions resulting
from loss, theft, or
destruction are not a covered benefit. Why use
geneic drugs? Generic drugs contain the same active ingredients and are
equivalent in strength and dosage to
the original brand name product.
Generic drugs cost you and your Plan less money that a name-brand drug. 41
41 Page 42 43
2002 Presbyterian Health Plan 42 Section 5(
f)
When you have to file a claim.
In-Network
No claims
filing is necessary. You are responsible for paying the copayment or
coinsurance.
Out-of-Network
For services provided by out-of-network providers, you may
be required to file a claim if the provider does not do so. To file a claim,
complete all questions on the claim form (see sample), sign it, and attach an
itemized statement from the
provider. Be sure the statement includes all of
the following:
Patient's Name Diagnosis
Date of Service Procedure Code
Price for each procedure Name and address
of the provider.
A separate claim form is required for each family member.
If the
provider's office uses a universal claim form (HCFA-1500), that form may be
submitted in lieu of the Presbyterian Health Plan claim form as long as the
patient and insured information is completed.
If a charge is made to you for covered pharmacy benefits, you must provide
proof of such charge with a copy of the pharmacy receipt with the name of the
drug, quantity dispensed, and National Drug Code (NDC) number. Any charge shall
be paid only upon receipt of proof satisfactory to the Plan of the
occurrence, character and extent of the event and services for which claim is
made.
Mail proof to:
Presbyterian Health Plan Attention: Pharmacy
P. O. Box 27489 Albuquerque, NM 87125-7489 42
42
Page 43 44
2002
Presbyterian Health Plan 43 Section 5( f)
Benefit Description
You pay
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan physician and obtained from a Plan
pharmacy 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.
Insulin, with a copay charge applied to each vial
Diabetic
supplies, including insulin syringes, needles, blood test strips, urine test
tape, and acetone test tablets. (Glucose monitors
are covered as durable
medical equipment, see under DME section)
All FDA-approved oral and
injectable contraceptive drugs and contraceptive devices
Disposable needles and syringes for the administration of covered medication
Drugs for sexual dysfunction (see Prior authorization below)
Fertility
drugs, oral or injectable, including those provided in a physician's office.
Injectable drugs or products (recombinant DNA & Purified Bilological
Products)
$5 per generic – 30 day supply or 100 units whichever is less
$15 per
brand – 30 day supply or 100 units whichever is less
Mail order
$10 per generic – 90 day supply or 300 units whichever
is less.
$30 per brand – 90 day supply or 300 units whichever is less
Note: If there is no generic equivalent available, you will still have to pay
the
brand name copay.
50% of all charges for Fertility Drugs
10% of all charges for DNA &
Purified biological Products
Covered medications and supplies --continued on next page 43
43 Page 44 45
2002 Presbyterian Health Plan 44 Section 5(
f)
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:
A generic equivalent will be dispensed if it is available, unless
your physician specifically requires a name brand. If you receive a name
brand drug when a Federally-approved generic drug is available, and your
physician has not specifically Dispense as Written for the name
brand drug,
you have to pay the difference in cost between the name brand drug and the
generic.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a
non-Plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients and food supplements that can be purchased without a
prescription
Replacement prescriptions resulting from loss, theft, or
destruction
Drugs from which there is a nonprescription equivalent
available
Medical supplies such as dressings and antiseptics
Smoking cessation drugs and medication, including nicotine patches
Nonprescription medicines
All charges. 44
44 Page 45 46
2002
Presbyterian Health Plan 45 Section 5( g)
Section 5 (g).
Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Services for deaf and hearing impaired Contact Member services at
1-800-356-2219 or 505-923-5678 and indicate that you require services.
High risk pregnancies PRESiouis Beginnings is a statewide program that
determines high risk pregnancies and offers care management, literature and use
of videos. Peri-Natal nurses are available for questions Monday through Friday
8: 30A to
5: 00P to assist with high-risk pregnancy questions. For
additional information, call 1-505-724-6500 45
45
Page 46 47
2002
Presbyterian Health Plan 46 Section 5( h)
Section 5 (h).
Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year
deductible.
We cover hospitalization for dental procedures only when a
nondental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient; we do not cover the dental procedure unless
it is
described below.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair (but not replace) sound natural teeth.
The need for these services must
result from an accidental injury.
$10 per visit
Dental benefits (Limited) Limited dental services will be provided
when preauthorized by us.
Services include but are not limited to the
following:
Accidental injury to sound natural teeth. Oral surgery Medically
Necessary to treat infections or abscess of
the teeth that involve the fascia or have spread beyond the dental space.
Removal of infected teeth in preparation for certain surgeries or radiation
therapy of the head and neck.
Temporomandibular Joint Disorders (TMJ) The treatment of
Temporomandibular Joint disorders (TMJ) are subject
to the same conditions
and limitations as are applicable to treatment of any other joint in the body.
Orthodontics are not covered unless the
TMJ disorder is the result of an
injury.
$10 per visit 46
46 Page
47 48
2002 Presbyterian Health Plan
47 Section 5( i)
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.
Dental Source Dental Plan, inc. is a discount referral dental
plan available to you if you are enrolled in our plan. You select a dentist from
a list of participating dentists throughout the community. Copayments are paid
at the
Dental Office at the time services are received.
The Dental
Source Dental Plan features no deductibles, no claims forms, no waiting periods,
no maximums, and no pre-existing condition exclusions. It is a comprehensive
plan including preventive and diagnostic service
restoratives, dentures,
oral surgery, endodontists, periodontists, and orthodonics for adults and
children. For additional information and customer service call 1-888-862-8659.
ECCA Managed Vision Care is a discount referral vision plan that is
automatically available to you if you are enrolled in our Plan through the FEHB
Program. It is available at no additional cost and allows for discounts on
Annual Wellness Exams and materials. Services are provided by Eye-Master and
other select providers throughout New Mexico. For additional information and
customer service call 1-800-340-0129.
A four week health education class on diabetes (including diet) is free to
you and $23 for non-members. Preregistration is required. Call 505/ 823-8408. 47
47 Page 48 49
2002 Presbyterian Health Plan 48 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, 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. 48
48 Page
49 50
2002 Presbyterian Health Plan
49 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment, coinsurance, or deductible.
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 1-800-356-2219.
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:
Presbyterian Health Plan
PO Box 27489 Albuquerque, NM 87125-7489
Prescription drugs If a charge is made to you for covered pharmacy
benefits, you must provide proof of such charge with a copy of the pharmacy
receipt with the name of the drug, quantity dispensed,
and National Drug
Code (NDC) number. Any charge shall be paid only upon receipt of proof
satisfactory to the Plan of the occurrence, character and extent of the event
and
services for which claim is made.
Submit your claims to:
Presbyterian Health Plan
Attn: Pharmacy PO Box 27489
Albuquerque, NM
87125-7489
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service, unless timely
filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 49
49 Page
50 51
2002 Presbyterian Health Plan
50 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for 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: PO Box 27489 Albuquerque, NM
87125-7489; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letter, 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, DC 20415-3630. 50
50 Page 51 52
2002 Presbyterian Health Plan 51 Section 8
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
representative, such as medical providers, must include a copy of your specific
written consent with the review
request.
Note: The above deadlines may be extended if you show that you
were unable to meet the deadline because of reasons beyond your control.
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 800/ 356-2219 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/ 606-0737
between 8 a. m. and 5 p. m. eastern time. 51
51
Page 52 53
2002
Presbyterian Health Plan 52 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays 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 shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay
your share. Some things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be
authorized by your Plan PCP, or precertified as
required. (Primary payer chart begins on next page.)
The Original Medicare Plan (Part A or Part B) 52
52 Page 53 54
2002 Presbyterian Health Plan 53 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.
Primary Payer Chart
A. When either you --or your covered spouse --are age 65 or over and …
Then the primary payer is…
Original Medicare This Plan
1) Are anactiveemployeewith
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability), #
2) Are an annuitant, #
3) Are a reemploy annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The
position is not excluded from FEHB
#
#
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 53
53
Page 54 55
2002 Presbyterian Health Plan 54 Section 9
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 and we
will pay the balance of covered charges. You will not need to do anything. To
find out if you
need to do something about filing your claims, call us at 800/ 356-2219.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or hospitals that are
part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
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, coinsurance,
or deductibles 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, but we will
not waive any of our copayments, coinsurance, or deductibles. You must use our
provider network to receive secondary benefits from us. 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.
If you do not enroll in If
you do not have one or both parts of Medicare, you can still be covered under
Medicare Part A or Part B 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. 54
54 Page 55 56
2002
Presbyterian Health Plan 55 Section 9
TRICARE TRICARE is
the health care program for eligible dependents of military persons and retirees
of the military. TRICARE includes the CHAMPUS program. If both TRICARE
and
this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if
you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related 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, or Federal Government are responsible for your care
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries or for injuries illness caused
by another person, you must reimburse us for any expenses we paid.
However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 55
55 Page
56 57
2002 Presbyterian Health Plan
56 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same
year.
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.
Custodial care Care provided primarily for maintenance of
the patient and designed essentially to assist in meeting the patient's daily
activities. It is not provided for its therapeutic value in the
treatment of
an illness, disease, accidental injury, or condition. Custodial Care includes,
but is not limited to, help in walking, bathing, dressing, eating, preparation
of special
diets, and supervision over self-administation of medication not
requiring the constant attention of trained medical personnel.
The plan evaluates any new procedures, drug therapies, treatments, devices,
etc. To determine if they are experimental/ investigational in nature. This
evaluation includes
review of current literature published in peer review
journals and appropriate information from governmental regulatory bodies, such
as the FDA. We also utilize reliable evidence
(consensus of opinion in the
medical community) to determine if the procedure, drug therapies, treatments,
devices, etc. is contraindicated for the particular indication which it
has
been prescribed. Please contact the plan for a more detailed explanation of this
evaluation process.
Medical necessity Appropriate or necessary services as determined by
our plan doctor in consultation with the plan, which are given to you for any
covered condition requiring, according to
generally accepted principles of
good medical practice, the diagnosis or direct care and treatment of an illness,
injury, or medical condition, and are not services provided only as a
convenience.
Plan allowance Plan allowance is the amount we use to
determine our payment and your coinsurance for covered services. Fee-for-service
plans determine their allowances in different ways. We
determine our
allowance as follows: Total allowable charges for plan providers may not exceed
the amount the provider service and for non-plan providers, the total allowable
charges may not exceed the plan allowance as determined by the plan for a
service.
Us/ We Us and we refer to Presbyterian Health Plan
You You
refers to the enrollee and each covered family member.
Experimental or investigational services 56
56 Page 57 58
2002 Presbyterian Health Plan 57 Section 11
Section 11.
FEHB facts
No pre-existing condition We will not refuse to cover the
treatment of a condition that you had limitation before you enrolled in
this Plan solely because you had the condition before you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing
or about enrolling in the retirement office can answer your questions,
and give you a Guide to Federal
Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue
coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is
born or becomes an eligible family member. When you change to Self
and Family because you marry, the change is effective on the first day of the
pay
period that begins after your employing office receives your enrollment
form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us
immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries or
turns
22.
If you or one of your family members is enrolled in one FEHB
plan, that person may not be enrolled in or covered as a family member by
another FEHB plan. 57
57 Page
58 59
2002 Presbyterian Health Plan
58 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you joined this Plan premiums start
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 the records are confidential 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
of Coverage (TCC) qualify as 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 dependent child and you turn 22 or
marry, etc 58
58 Page
59 60
2002 Presbyterian Health Plan 59 Section 11
You may not
elect TCC if you are fired from your Federal job due to gross misconduct.
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
employing or retirement office will not notify you. You must apply in
writing to
us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we will
not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability 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 web site
(www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked question. 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. 59
59 Page 60 61
2002 Presbyterian Health Plan 60 Long Term Care Insurance
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:
It's insurance to help pay for
long term care services you may need if you can't take care of yourself because
of an extended illness or injury, or 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. LTC insurance can supplement care provided by
family
members, reducing the burden you place on them.
Welcome to
the club! 76% of Americans believe they will never need long term care, but the
facts
are that about half 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.
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. Not FEHB. Look at
the "Not covered" blocks in sections 5( a) and 5( c) of
your FEHB
brochure. Health plans don't cover custodial care or a stay in an assisted
living facility or a continuing need for a home health 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.
Employees
will get more information from their agencies during the LTC open enrollment
period in the late summer/ early fall of 2002.
Retirees will receive
information at home. Our toll-free teleservice center will begin in mid-2002. In
the meantime,
you can learn more
about the program on our web
site at www. opm. gov/ insure/ ltc.
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.
What is long term care (LTC) insurance?
I'm healthy. I won't need long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage?
How can I find out more about the program NOW?
60
60 Page 61
62
2002 Presbyterian Health Plan 61 Index
Index Do not rely on this page; it is for your convenience and
may not show all pages where the terms appear.
Accidental injury 46
Allergy tests 18
Alternative treatment 25 Allogenetic (donor) bone marrow
transplant 29
Ambulance 35 Anesthesia 30
Autologous bone marrow
transplant 29 Biopsies 26
Blood and blood plasma 33 Breast cancer
screening 15
Casts 33 Changes for 2002 8
Chemotherapy 19 Childbirth 17
Chiropractic 24 Cholesterol tests 15
Claims 49 Coinsurance 12
Colorectal cancer screening 15 Congenital anomalies 26
Contraceptive
devices and drugs 17 Coordination of benefits 52
Covered charges 56 Crutches
23
Deductible 12 Definitions 56
Dental care 46 Diagnostic
services 14
Disputed claims review 50 Donor expenses (transplants) 29
Dressings 32 Durable medical equipment (DME) 23
Educational
classes and programs 25 Emergency 36
Eyeglasses 21 Family
planning 17
Fecal occult blood test 15
General Exclusions 48 Hearing services 21
Home health
services 23 Hospice care 34
Home nursing care 23 Hospital 31
Immunizations 16 Infertility 18
Inpatient Hospital Benefits 31
Insulin 43
Laboratory and pathological services 15
Magnetic
Resonance Imagings (MRIs) 15
Mail Order Prescription Drugs 43 Mammograms 16
Maternity Benefits 17 Medicaid 55
Medically necessary 56 Medicare 52
Mental Conditions/ Substance Abuse Benefits 39
Newborn care 17 Non-FEHB
Benefits 47
Nurse Licensed Practical Nurse 23
Registered Nurse 23
Nursery charges 17
Obstetrical care 17 Occupational therapy 20
Ocular injury 21 Oral and maxillofacial surgery 28
Orthopedic devices 22
Out-of-pocket expenses 12
Outpatient facility care 33 Oxygen 23
Pap
test 15
Physical therapy 20 Physician 14
Preventive care, adult 15 Preventive
care, children 16
Prescription drugs 41 Preventive services 15
Prior
approval 11 Prostate cancer screening 15
Prosthetic devices 22 Psychologist
39
Renal dialysis 52 Room and board 31
Second surgical opinion 14
Skilled nursing facility care 33
Smoking cessation 44 Speech therapy 20
Splints 32 Sterilization procedures 17
Subrogation 55 Substance abuse 39
Surgery 26 Anesthesia 30
Oral 28 Outpatient 33
Reconstructive 27
Syringes 43
Temporary continuation of coverage 58
Transplants 29
Treatment therapies 19
Vision services 21 Well child care 16
Wheelchairs 23 Workers' compensation 55
X-rays 15 61
61 Page 62 63
2002 Presbyterian Health Plan 62 Summary
Summary of benefits for the Presbyterian Health Plan -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.............. Office visit copay: $10 primary care 14
Services provided by a hospital:
Inpatient
.......................................................................................
Outpatient.....................................................................................
Nothing
Nothing
31
33
Emergency benefits:
In-area
.........................................................................................
Out-of-area..................................................................................
$25 outpatient hospital visit
$15 urgent care center
$10 doctor's
office
38
38
Mental health and substance abuse
treatment........................................ Regular cost sharing. 39
Prescription drugs
.................................................................................
$5 formulary generic
$15 formulary brand name and non-formulary
41
Dental Care
.......................................................................................
Limited benefit.
$10 per visit
46
Vision Care
.......................................................................................
20% of all charges (materials)
$10 per office visit (eye exam for children).
21
Special Features: Flexible benefits option; Services for deaf and
Hearing
impaired, high risk pregnancies 45
Protection against catastrophic costs
(your out-of-pocket
maximum)......................................................... Nothing
after $2,000/ Self Only or $4,000/ Family enrollment per year
Some costs do not count toward this protection
12 62
62 Page 63
2002
Presbyterian Health Plan
2002 Rate Information for
Presbyterian
Health Plan
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, RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
All Counties of New Mexico, except for Otero and Southern Eddy County
Self Only P21 $81.34 $27.11 $ 176.24 $58.74 $96.25 $12.20
Self and Family P22 $212.12 $70.71 $459.60 $153.20 $251.01 $31.82 63