Prudential HealthCare HMO Pennsylvania 1999 Prudential Health Care Plan, Inc.
A Health Maintenance Organization
Serving: Philadelphia/ Lehigh Valley Area Enrollment in this Plan is limited; see page 9 for requirements.
Enrollment code: VV1 Self only VV2 Self and family
This plan has full accreditation from the NCQA. See the FEHB Guide
for more information on NCQA. Visit the OPM website at http:// www. opm. gov/ insure
and this Plans website at http:// www. prudential. com/ healthcare
For changes in benefits
see page 22
United States Office of Personnel Management
RI 73- 622
Authorized for distribution by the:
Prudential HealthCare HMO - Pennsylvania
The Prudential Health Care Plan, Inc., 250 Gibraltar Road, Suite 300, Horsham, Pennsylvania 19044 has entered into a contract (CS2685) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called Prudential HealthCare HMO, or the Plan.
This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.
Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on the inside back cover of this brochure.
Table of Contents
Page
Inspector General Advisory on Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Confidentiality; If you are a new member; If you are hospitalized; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage; Certificate of Creditable Coverage)
Facts about Prudential HealthCare HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Information you have a Right to know; Who provides care to Plan members?; Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Experimental/ investigational determinations; Other considerations; The Plans service area
General Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Important notice; Circumstances beyond Plan control; Other sources of benefits
General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits
Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Dental care; Vision care
Non- FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 How Prudential HealthCare HMO Changes January 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Rate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2
Inspector General Advisory: Stop Health Care Fraud!
Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to obtain FEHB benefits or increase the amount of FEHB benefits, is subject to prosecution for FRAUD. This could result in CRIMINAL PENALTIES. Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital or pharmacy, charged your plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:
Call the provider and ask for an explanation - sometimes the problem is a simple error. If the provider does not resolve the matter, or if you remain concerned, call your plan at 1- 800- 648- 4478 (within the service area)
or 1- 800- 526- 2963 (outside the service area) and explain the situation. If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:
THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300
The Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, N. W., Room 6400 Washington, D. C. 20415
The inappropriate use of membership identification cards, e. g., to obtain services for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.
General Information Confidentiality Medical and other information provided to the Plan, including claim files, is kept confidential and
will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan research or education, coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.
If you are a Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you
new member receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter
from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.
If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.
If you are a new member of this Plan, benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on pages 16 through 17. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 4.
FEHB plans may not refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.
3
General Information continued
If you are If you change plans or options, benefits under your prior plan or option cease on the effective
hospitalized date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care
setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.
Your responsibility It is your responsibility to be informed about your health benefits. Your employing office or retirement system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.
Things to keep The benefits in this brochure are effective on January 1 for those already enrolled in this Plan;
in mind if you changed plans or plan options, see If you are a new member above. In both cases, however, the Plans new rates are effective the first day of the enrollees first full pay period
that begins on or after January 1 (January 1 for all annuitants). Generally, you must be continuously enrolled in the FEHB Program for the last five years
before you retire to continue your enrollment for you and any eligible family members after you retire.
The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.
An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits.
You will not be informed by your employing office (or your retirement system) or your Plan when a family member loses eligibility.
You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.
An employee, annuitant or family member enrolled in one FEHB plan is not entitled to receive benefits under any other FEHB plan.
Report additions and deletions, including divorces, of covered family members to the Plan promptly.
If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.
4
General Information continued
Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.
You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.
Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program; nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).
Coverage after When an employees enrollment terminates because of separation from Federal service or when a
enrollment ends family member is no longer eligible for coverage under an employee or annuitant enrollment, and the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a
free 31- day extension of coverage. The employee or family member may also be eligible for one of the following:
Former spouse When a Federal employee or annuitant divorces, the former spouse may be eligible to elect
coverage coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employees employing office (personnel office) or retirees retirement system to get more facts about electing coverage.
Temporary If you are an employee whose enrollment is terminated because you separate from service, you
continuation of may be eligible to temporarily continue your health benefits coverage under the FEHB Program
coverage (TCC) in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.
Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another 31- day extension of coverage when you convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.
Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31- day extension of coverage when they convert to nongroup coverage.
NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.
Notification Separating employees - Within 61 days after an employees enrollment terminates because of
and election separation from service, his or her employing office must notify the employee of the opportunity
requirements to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.
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General Information continued
Children - You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, child reaches age 22 or marries.
Former spouses - You or your former spouse must notify the employing office or retirement system of the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.
The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of qualifying court order.
Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60- day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.
Conversion to When none of the above choices are available - or chosen - when coverage as an employee or
individual coverage family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.
Certificate of Under Federal law, if you lose coverage under the FEHB Program, you should automatically
Creditable Coverage receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate, along with any certificates you receive from other FEHB plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non- FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.
Facts about Prudential HealthCare HMO
This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty care doctor can only be received by referral from the selected primary care doctor (see Referrals for Specialty Care for exceptions to this rule). There are no claim forms when Plan doctors are used.
Your decision to join an HMO should be based on your preference for the plans benefits and delivery system, not because a particular provider is in the plans network. You cannot change plans because a provider leaves the HMO.
6
Facts about this Plan continued
Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits, physical exams, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.
On April 21, 1998, Prudential HealthCare HMO received a three year full NCQA Accreditation for Pennsylvania.
Information you All carriers in the FEHB Program must provide certain information to you. If you did not
have a right to know receive information about this plan, you can obtain it by calling Prudential HealthCare at (1- 800- 648- 4468) or you may write Prudential HealthCare at 250 Gibraltar Road Suite 300
Horsham, PA 19044- 0918. You may also contact Prudential HealthCare by fax at 215- 442- 2946. Information that must be made available to you includes: Disenrollment rates for 1997. Compliance with State and Federal licensing or certification requirements and the dates met. If
noncompliant, the reason for noncompliance. Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency,
confidentiality and transfer of medical records.
Who provides care Prudential HealthCare HMO is offered by Prudential Health Care Plan, Inc., a subsidiary of The
to Plan members? Prudential Insurance Company of America. Organized as an IPA HMO in the Philadelphia/ Lehigh Valley area, the Prudential HealthCare HMO network includes approximately 6,238 primary and
specialty care physicians for a total of 9,385 physician sites. These physicians provide and arrange all health services.
Role of a primary The first and most important decision each member must make is the selection of a primary care
care doctor doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor
to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when you have been referred by your primary care doctor, with the following exceptions: a woman may see her Plan obstetrician/ gynecologist at any time without a referral; any member may obtain Mental Health/ Substance Abuse services (Merit Behavioral Care Corporation 1- 800- 251- 2422) without a referral; any member may access a network Optometrist once every twenty- four (24) months without a referral.
Choosing your The Plans Provider Directory lists primary care doctors (family practitioners, general practitioners.
doctor pediatricians, and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available
at the time of enrollment or upon request by calling the Member Services Department at 1- 800- 648- 4478 (within the Service Area) or 1- 800- 526- 2963 (outside the Service Area); you can also find out if your doctor participates with this Plan by calling this number.
If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this Plan, services (except for medical emergencies) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed. If you enroll, you will be asked to complete a primary care doctor selection form, and send it directly to the Plan, indicating the name of the primary care doctor( s) you select for you and each member of your family. If you need help in choosing a doctor, call the Plan. Members may change their doctor selection by notifying the Plan 30 days in advance.
If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you for you to be seen by another participating doctor.
7
Facts about this Plan continued
Referrals for Except in a medical emergency, or when a primary care doctor has designated another doctor to
specialty care see his or her patients (or you access a Plan OB/ GYN, mental health services or a network Optometrist), you must receive a referral form from your primary care doctor before seeing any
other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if non- Plan specialists or consultants are required, the primary care doctor will arrange appropriate referrals.
When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits. All follow- up care must be provided or authorized by the primary care doctor. Do not go to the specialist for a second visit unless your primary care doctor has arranged for, and the Plan has issued an authorization for, the referral in advance. The following benefits do not require a referral from your Primary Care Physician: unlimited visits to a network OB/ GYN, one visit every twenty- four (24) months to a network vision provider, and mental health and substance abuse services can be reached at 1- 800- 251- 2422 without a referral.
If you have a chronic, complex, or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.
Authorizations The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your Plan doctor must obtain the Plans definition of medical necessity before you may be hospitalized, referred for specialty care or obtain follow- up care from a specialist.
For new members Referrals are not needed to a network OB/ GYN, mental health/ substance abuse services, and network vision providers; these are direct access specialists. If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you to this specialist is now your Plan primary care doctor, you need only call to explain that you are now a Plan member and ask that you be referred for your next appointment.
If you are selecting a new primary care doctor and want to continue with this specialist, you must schedule an appointment so that the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.
Hospital care If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.
Outpatient surgical services may be performed at a participating hospital or at a participating ambulatory surgical center.
Out- of- pocket Copayments are required for a few benefits. However, copayments will not be required for the
maximum remainder of the calendar year after your total copayment charges required for services provided or arranged by the Plan reach $948.48 per Self Only enrollment or $2608.45 per Self and Family
enrollment. The copayment maximum does not include charges for prescription drugs. You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out- of- pocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.
Deductible If you changed to this Plan during open season from a plan with a deductible and the effective
carryover date of the change was after January 1, any expenses that would have applied to that plans deductible will be covered by your old plan if they are for care you got in January before the
effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective January 1.
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Facts about this Plan continued
Submit claims When you are required to submit a claim to this Plan for covered expenses, submit your claim
promptly promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred unless timely filing was
prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.
Experimental/ In making a determination as to whether a supply or service is experimental or investigational,
investigational Prudential will initiate the evaluation described below. This description is a summary. For a more
determinations complete description, please contact Member Services at 1- 800- 648- 4478 (within the service area) or 1- 800- 526- 2963 (outside the service area).
Determine if the service or supply is under study or in a clinical trial to evaluate its effectiveness for a particular diagnosis or set of indications.
Assess whether the prevailing opinion within the appropriate specialty of the United States medical profession is that the service or supply needs further evaluation for the particular diagnosis. In making this determination, Prudential relies on published reports in authoritative medical literature, and on regulations, reports, publications, and evaluations issued by government agencies such as the Agency for Health Care Policy and Research, the National Institutes of Health, and the FDA.
Determine if the provider= s institutional review board acknowledges that the use of the service or supply is experimental or investigational and requires that the patient, parent, or guardian give an informed consent stating that the service or supply is experimental or investigational, or part of a research project or study.
Determine if research protocols indicate that the service or supply is experimental or investigational, or is part of a research project or study.
Other considerations Plan providers will follow generally accepted medical practice in prescribing any course of treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.
The Plans The service area for this Plan, where Plan providers and facilities are located is described below.
service area You may enroll in this Plan if you live inside the service area or live in the geographical area described below.
The service area for this Plan includes the following areas: The Philadelphia/ Lehigh Valley, Pennsylvania area including the Pennsylvania counties of Bucks, Chester, Delaware, Lehigh, Montgomery, Northampton and Philadelphia.
This Plan accepts enrollments from these additional geographic areas: The Pennsylvania counties of Berks and Lancaster; the New Jersey counties of Burlington, Camden, Gloucester, and Mercer; or the Delaware county of New Castle.
Benefits for care outside the service area are limited to emergency services, as described on pages 15 and 16.
If you or a covered family member move outside the service area or geographic area, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.
General Limitations Important notice Although a specific service may be listed as a benefit, it will be covered for you only if, in the
judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.
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General Limitations continued
Circumstances In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant
beyond Plan number of Plan providers, complete or partial destruction of facilities, or other circumstances
control beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plan will not be responsible for any delay or failure in providing service
due to lack of available facilities or personnel.
Other sources This section applies when you or your family members are entitled to benefits from a source
of benefits other than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.
Medicare If you or a covered family member is enrolled in this Plan and Medicare Part A and/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except emergencies, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.
Group health This coordination of benefits (double coverage) provision applies when a person covered by this
insurance and Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the
automobile payment of medical and hospital costs under no- fault or other automobile insurance that pays
insurance benefits without regard to fault. Information about the other coverage must be disclosed to this Plan. When there is double coverage for covered benefits, other than emergency services from nonPlan
providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary plan.
One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners. When benefits are payable under automobile insurance, including no- fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.
CHAMPUS If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.
Medicaid If you are covered by both this Plan and Medicaid, this Plan will pay benefits first.
Workers The Plan will not pay for services required as the result of occupational disease or injury for
compensation which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers compensation (under section 8103 of title 5, U. S. C.) or by
a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers compensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP (or the agency).
10
General Limitations continued
DVA facilities, Facilities of the Department of Veterans Administration, Department of Defense, and the Indian
DoD facilities, and Health Service are entitled to seek reimbursement from the Plan for certain services and supplies
Indian Health Service provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.
Other Government The Plan will not provide benefits for services and supplies paid for directly or indirectly by any
agencies other local, State, or Federal Government agency.
Liability insurance If a covered person is sick or injured as a result of the act or omission of another person or party,
and third party the Plan requires that it be reimbursed for the benefits provided in an amount not to exceed the
actions amount of the recovery, or that it be subrogated to the persons rights to the extent of the benefits received under this Plan, including the right to bring suit in the persons name. If you need more
information about subrogation, the Plan will provide you with its subrogation procedures.
General Exclusions
All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness or condition, and the Plan agrees, as discussed under Authorizations on page 8. The following are excluded:
Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits);
Expenses incurred while not covered by this Plan; Services furnished or billed by a provider or facility barred from the FEHB Program; Services not required according to accepted standards of medical, dental, or psychiatric practice; Procedures, treatments, drugs or devices that are experimental or investigational; Procedures, services, drugs and supplies related to sex transformations; and Procedures, services, drugs and 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.
Medical and Surgical Benefits What is covered A comprehensive range of preventive, diagnostic and treatment services is provided by Plan
doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit copay, but no additional copay for laboratory tests and X- rays. Within the service area, house calls will be provided if, in the judgement of the Plan doctor, such care is necessary and appropriate; you pay $5 for a doctors house call and nothing for home visits by nurses and health aides.
The following services are included and are subject to the office visit copay unless stated otherwise: Preventive care, including hearing and vision screenings (hearing screenings are limited to
children through age 17), well- baby care and periodic check- ups Mammograms for women are covered as follows: for women under age 40, mammograms as
recommended by your primary care doctor; age 40 and older, one mammogram every year or as recommended by your primary care doctor. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness.
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
11
Medical and Surgical Benefits continued
Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and
postnatal care by a Plan doctor. No referrals are needed for network OB/ GYN visits. The office visit copay applies to the first obstetrical visit only. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage has ended under the Plan. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment.
Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye Allergy testing and treatment, including testing and treatment materials (such as allergy serum) The insertion of internal prosthetic devices, such as pacemakers and artificial joints Cornea, heart, heart/ lung, lung (single/ double), kidney, liver and pancreas transplants; 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 Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan.
Patients who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
Dialysis Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Orthopedic devices, such as braces; foot orthotics Prosthetic devices, such as artificial limbs and lenses following cataract removal (initial
eyeglasses or lenses to replace the loss of the natural lens are also covered) Durable medical equipment, such as crutches, wheelchairs, hospital beds, oxygen and rental of
oxygen equipment Home health services of nurses and health aides, including intravenous fluids and medications,
when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need
Chiropractic and acupuncture services with a referral All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including any dental care involved in the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
12
Medical and Surgical Benefits continued
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance and if the condition can reasonably be expected to be corrected by such surgery.
Short- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to 90 days per condition if significant improvement can be expected within 90 days; you pay a $5 copay per outpatient session. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.
Diagnosis and treatment of infertility is covered: you pay a $5 copay per office visit. The following types of artificial insemination are covered: intravaginal insemination (IVI), intracervical insemination (ICI), and intrauterine insemination (IUI); cost of donor sperm is not covered. Fertility drugs are covered. Other assisted reproductive technology (ART) procedures such as in vitro fertilization and embryo transfer are not covered.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided on an outpatient basis for up to 90 days if such care is necessary and appropriate in the judgment of the Plan doctor and has been authorized by the Plan. You pay a $5 copay per outpatient session.
Institutes of Quality (IQ) Program: The IQ program provides coverage for sophisticated medical treatments and procedures offered by a network of hospitals and physicians known for their demonstrated accomplishments in patient outcomes. This Program includes a nationwide network for organ transplants, bone marrow transplants, and brain and spinal cord injury rehabilitation. Under the Program, the persons primary care doctor must initiate a referral to an institute of quality for covered procedures. Participation is subject to approval by Prudential HealthCare and candidates must meet pre- screening criteria. Contact the Plan for further information on the IQ Program.
Medical foods are covered if they are medically necessary and critical to the well being of individuals afflicted with rare hereditary genetic metabolic disorders. The disorders are as follows: Phenylketonuria (PKU), branched- chain ketonuria, galactosemia and homocystinuria. There is no copay. However, this treatment must be precertified by a participating Plan provider.
What is not Physical examinations that are not necessary for medical reasons, such as those required for
covered obtaining or continuing employment or insurance, attending school or camp, or travel Reversal of voluntary, surgically- induced sterility
Plastic surgery primarily for cosmetic purposes Transplants not listed as covered Blood and blood derivatives replaced by the member Hearing aids; exams to determine the need for hearing aids, or the need to adjust them Long- term rehabilitative therapy Homemaker services Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as
nearsightedness (myopia), farsightedness (hyperopia) and astigmatism Cochlear implants for prelingually deafened adults and for children less than two years of age,
(unless authorized by the Plan).
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
13
Hospital/ Extended Care Benefits What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing. All necessary services are covered, including:
Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care
Specialized care units, such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with up to 100 days per condition for all such confinements which are due to the same or related causes and which are separated by less than three months. Coverage is provided when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay nothing. All necessary services are covered, including:
Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor.
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility up to a reasonable cash value of $7,400 per period of care. Services include inpatient and outpatient care, and counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less. Counseling services within 3 months of the death of the patient will be furnished for the patients family up to a reasonable cash value of $200.
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor.
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis,
detoxification treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 17 for nonmedical substance abuse benefits.
What is not Personal comfort items, such as telephone and television
covered Blood and blood derivatives replaced by the member Custodial care, rest cures, domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
14
Emergency Benefits What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you
medical emergency? 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 the Plan may determine are medical emergencies - what they all have in common is the need for quick action.
Emergencies within If you are in an emergency situation, please call your primary care doctor. In extreme emergencies,
the service area if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency
room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours (unless it was not reasonably possible to do so). It is your responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non- Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non- Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan and provided by Plan providers.
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.
You pay $25 per hospital emergency room visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency room copay is waived.
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area because of injury or unforeseen illness. If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan or provided by Plan providers.
Plan pays... Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers.
You pay... $25 per hospital emergency room visit; $5 per urgent care center visit for emergency services that are covered benefits of this Plan. (Urgent care services rendered outside the service area must be coordinated through the Prudential HealthCare National Service Hotline in order for the $5 copay to apply.) You may contact the National Service Hotline at 1- 800- 526- 2963, as found on the reverse side of your ID card. If the emergency results in admission to a hospital, the emergency room copay ($ 25) is waived.
What is covered Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctors services Ambulance service approved by the Plan
15
Emergency Benefits continued
What is not Elective care or non- emergency care
covered 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
Filing claims With your authorization, the Plan will pay benefits directly to the providers of your emergency
for non- Plan care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim
providers form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.
Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on pages 21 through 22.
Portability If you are away from home and require medical care other than routine physical exams,
(Reciprocity) immunizations and non- emergency maternity care, you can use any Prudential HealthCare network facility in the area you are visiting. You will receive this care at the maximum benefit
level as if you were at home, free of bills and claim forms. To obtain these benefits, you must do one of two things: Contact your primary care doctor at home to obtain permission for out- of- area care. In lifethreatening emergencies, we recommend that you seek appropriate treatment immediately.
However, you or a family member must notify your primary care doctor within 48 hours concerning the emergency care you received.
Contact the Prudential HealthCare office in the city you are visiting or the Prudential National Hotline (1- 800/ 526- 2963) to obtain a referral to a local participating doctor. This toll free number is also located on the back of your member ID card and is available 24 hours a day.
You pay a $5 office visit copay for urgent care services received out of your service area at the local participating doctors office.
Your home plan is responsible for reimbursing the providers in the out- of- area Prudential HealthCare HMO Plan. You will not be asked to make payments, except for applicable copays, or file a claim unless you receive authorized treatment from a Non- Prudential HealthCare provider.
Mental Conditions/ Substance Abuse Benefits You must call the Merit Behavioral Care Corporation 1- 800- 251- 2422 prior to services being rendered. Merit Behavioral Care Corporation will determine and authorize the appropriate number of visits. A referral from your Primary Care Physician is not required.
Mental conditions What is covered To the extent shown below, the Plan provides the following services necessary for the
diagnosis and treatment of acute psychiatric conditions, including the treatment of mental illness or disorders:
Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
16
Mental Conditions/ Substance Abuse Benefits Outpatient care Up to 20 outpatient visits to Plan doctors, consultants or other psychiatric personnel each calendar
year; you pay a $15 copay for each covered visit - all charges thereafter.
Inpatient care Up to 30 days of hospitalization each calendar year; you pay nothing for the first 30 days - all charges thereafter.
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short- term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short- term psychiatric condition
Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the
medical, non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition, and, to the extent shown below, the services necessary for diagnosis and treatment.
Outpatient care Up to 30 outpatient visits/ partial hospitalization sessions to Plan providers for treatment each calendar year (120 visits/ sessions per lifetime). You pay nothing for each covered visit/ session all charges thereafter.
An additional 30 outpatient visits/ partial hospitalization sessions may be exchanged on a 2 for 1 basis to allow up to 15 additional inpatient residential care days per calendar year.
Inpatient care Up to 30 days per calendar year (90 days per lifetime) for treatment in an Alcoholism or Drug Abuse Addiction Treatment Center. You pay nothing for each covered day - all charges thereafter.
What is not covered Treatment that is not authorized by a Plan doctor.
Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor 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 prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin). You pay a $5 copay per prescription unit or refill for generic drugs, a $10 copay for prescription unit or refill for brand name drugs, regardless of generic availability. However, in no event will the copay exceed the cost of the prescription.
Maintenance medications and oral contraceptives prescribed by a plan or referral doctor can also be obtained via a mail order drug program for up to a 90 day supply per refill for a single copay.
You pay a $5 copay per prescription unit or refill for generic drugs, and a $10 copay for a prescription unit or refill for brand name prescription drugs.
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary. Nonformulary drugs will be covered when prescribed by a Plan doctor.
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
17
Prescription Drug Benefits continued
Formulary The Prudential Health Care Drug Formulary was developed and is maintained by the Prudential
development: HealthCare National Pharmacy and Therapeutics committee (P& T) with the understanding that a well constructed formulary enhances quality of care. The P& T committee evaluates the clinical
use of drugs and develops policies and procedures for developing new drug therapies and managing the formulary. The P& T is also responsible for conducting therapeutic class reviews and analyzing new drugs as they enter the market. The formulary reflects our medical and pharmaceutical experience in formulary management and rigorous reviews of individual clinical studies.
Non- Formulary In order to request coverage for a non- formulary drug, the patients doctor may call our toll- free Drug Requests: unit or fax a request form to the plans Drug Request Unit. After obtaining all of the required information, the request will be evaluated. The physician will be notified within one business day after the Drug Request Unit has made the decision. A copy of the decision will be faxed and mailed to your doctor.
Covered medications and accessories include: Drugs for which a prescription is required by law Oral contraceptive and maintenance drugs - up to a 90- day supply per refill may be obtained;
copay applies to each 30- day supply refill obtained at the pharmacy Injectable contraceptive drugs Diaphragms Implanted time- release medications, such as Norplant Fertility drugs, injectables are covered under Medical and Surgical Benefits Insulin and syringes with a copay charge applied to each 10 milliliter vial Diabetic supplies including needles, glucose test tablets and test tape, Benedicts solution or
equivalent and acetone test tablets - copay does not apply Disposable needles and syringes needed to inject covered prescribed medication Intravenous fluids and medications for home use, implantable drugs, and some injectable drugs
are covered under Medical and Surgical Benefits.
Limited benefits Sexual dysfunction drugs have dispensing limitations. For complete details, please call the Prudential HealthCare customer service phone number shown on your ID card (1- 800- 648- 4478).
Smoking cessation aids: Nicotine replacement therapy requiring a prescription is eligible in the following circumstances: Lifetime coverage is limited to one 90 day course of treatment to be administered through the primary care doctor
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available; including over the counter smoking cessation drugs and medications
Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
18
Other Benefits Dental care
Accidental injury Restorative services and supplies necessary to promptly repair or replace sound natural teeth are
benefit covered. The need for these services must result from an accidental injury. You pay nothing.
Vision care What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases
of the eye, one eye refraction every two years (to provide a written lens prescription for eyeglasses) may be obtained from Plan providers. You pay a $15 copay per visit.
What is not covered Corrective lenses or frames (except that initial eyeglasses or lenses to replace the loss of the natural lens are covered)
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
19
Non- FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles, out- of- pocket maximum copay charges, etc. These benefits are not subject to the FEHB disputed claims procedures.
Further information may be received by contacting the Plans member services at 1- 800- 648- 4478.
Dental Program
Prudential offers a discount dental program, with more than 10,000 participating dentists across the country. These dentists have agreed to provide services to program participants at reduced rates - including periodic exams, cleanings, root canals... even orthodontia care.
You will have access to dental services at a discount and will receive a separate ID card. There is no additional charge for this program. More details about the Dental Program are included in your Prudential HealthCare open enrollment packet.
Expanded vision care
The Plan has made arrangements with independent doctors of optometry which enables you and your family members to obtain eyeglasses, frames and contact lenses at a 20% discounted price. There is no limit on quantity.
Fitness program
All employee enrollees of the Plan may take advantage of a $200 reimbursement for working out at the health club of their choice. Spouses may receive a $100 reimbursement. Visit the club 100 times over the course of a 12 month period (benefit year) obtaining evidence of your visits. Send the initialed card and receipt of payment to Prudential Healthcare; P. O. Box 4000; Millville, NJ 08332- 9052. Additional information is enclosed in your enrollment packet.
Starting Right (program)
Starting Right is a pregnancy support program designed to provide useful information on good health habits and prenatal care. Starting Right consists of these main components: assessment, education, and case management. A case coordinator will ask the expectant mother a series of questions about her health history to determine factors that may influence her pregnancy. Prudential HealthCares Starting Right provides valuable information and resources for plan members who are planning, expecting or raising a family. A baby beeper program is available during the last trimester of the pregnancy for $10 (plus tax). Starting Right coordinators will place periodic phone calls to the expectant mother throughout her pregnancy to answer any questions that she may have.
Asthma Program
Asthma Program that offers education, counseling and supportive materials for members with asthma.
Wellness Programs
Discounts on Smokenders smoking cessation courses and materials Healthy Heart Video discounts Discounts on health education classes at participating hospitals
Providing the Health & Fitness Advantage
This exclusive health and fitness program provides discounts on health and fitness equipment from some of the nations leading manufacturers. You can get discounts on bicycles, bike helmets, exercise equipment, fitness gear and apparel, home health software, self- care materials, safety equipment and more! Call 1- 800- My Health.
Health News
Prudential HealthCare plan members receive HealthSmart , our member magazine. From health updates to safety advice to diet and exercise tips, its information that can contribute to a healthy life.
Benefits on this page are not part of the FEHB contract
20
How to Obtain Benefits Questions If you have a question concerning Plan benefits or how to arrange for care, contact the Plans
Membership Service Office at 1- 800- 648- 4478 (within the service area) or 1- 800- 526- 2963 (outside the service area) or you may write to the Plan at PO Box 2022 Millville, NJ 08332- 9006. You may also contact the Plan by fax at 609- 708- 5503.
Disputed claims review Plan reconsideration If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and
within six months of the date of the denial, to reconsider its denial before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.) OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.
Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.
OPM review If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plans actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plans letter affirming its initial denial.
You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.
This right is available only to you or the executor of a deceased claimants estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review.
Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.
Your request must include the following information or it will be returned by OPM: A copy of your letter to the Plan requesting reconsideration; A copy of the Plans reconsideration decision (if the Plan failed to respond, provide instead (a)
the date of your request to the Plan, or (b) the dates the Plan requested and you provided additional information to the Plan);
Copies of documents that support your claim (such as doctors letters, operative reports, bills, medical records, and explanation of benefit (EOB) forms; and
Your daytime phone number. Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy Act.
Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division III, P. O. Box 436, Washington, DC 20044.
21
How to Obtain Benefits continued
You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plans decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.
Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plans benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Plans denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.
Privacy Act statement - If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.
How Prudential HealthCare HMO Changes January 1999
Do not rely on this page; it is not an official statement of benefits.
Program- wide Several changes have been made to comply with the Presidents mandate to implement the
Changes recommendations of the Patient Bill of Rights. If you have a chronic, complex, or serious medical condition that causes you to frequently see
a Plan specialist, your primary care doctor will develop a treatment plan with you and your health plan that allows you an adequate number of direct access visits with that specialist, without the need to obtain further referrals. (See page 8 for details).
A medical emergency is defined as 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. (See page 15 for details).
Coverage of drugs for sexual dysfunction are shown under the Prescription Drug benefit. See page 18.
The medical management of mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing and psychotherapy will be covered under this Plans Mental Conditions Benefits. Office visits for the medical aspects of treatment do not count towards the 20 outpatient Mental Conditions visit limit.
Changes to Cochlear Implants for pre- lingually deafened adults and for children less than two years of age,
this Plan (unless authorized by the Plans Medical Management) are not covered. See page 13.
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Summary of Benefits for Prudential HealthCare HMO 1999
Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated, subject to the limitations, and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY AND URGENT CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.
Benefits Plan pays/ provides Page Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit.
care Includes in- hospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical
supplies, use of operating room, intensive care and complete maternity care.
You pay nothing................................................................................................................... 14
Extended care All necessary services, up to 100 days per period of care. You pay nothing ..................... 14
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year. You pay nothing............................................................................................ 16
Substance abuse Up to 30 days per year in a substance abuse treatment program. You pay nothing........... 17
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury, care including specialists care; preventive care, including well- baby care, periodic check- ups and routine immunizations; laboratory tests and X- rays; complete maternity care. You pay a $5 copay per office visit; $5 per house call by a doctor ........................... 17
Home health care All necessary visits by nurses and health aides. You pay nothing...................................... 12
Mental conditions Up to 20 outpatient visits per year. You pay a $15 copay per visit .................................... 16
Emergency care Reasonable charges for services and supplies required because of a medical emergency.
You pay a $25 copay to the hospital (waived, if admitted) for each emergency room visit and any charges for services that are not covered by this Plan ................................... 16
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay
a $5 copay per prescription unit or refill for a generic drug and a $10 copay per prescription or refill for a brand name drug ........................................................................ 17
Dental care Accidental injury benefit; You pay nothing ........................................................................ 19
Vision care One refraction every two years. You pay a $15 copay per visit ......................................... 19
Out- of- pocket maximum Copayments are required for a few benefits; however, after your out- of- pocket expenses reach a maximum of $948.48 per Self Only or $2608.45 per Self and Family enrollment per calendar year, covered benefits will be provided at 100%. This copay maximum does not include charges for prescription drugs .................................................. 8
1999 Rate Information for Prudential HealthCare HMO Pennsylvania
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 most career U. S. Postal Service employees, but do not apply to non- career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.
Non- Postal Premium Postal Premium Biweekly Monthly Biweekly
Type of Code Govt Your Govt Your USPS Your Enrollment Share Share Share Share Share Share
Self Only VV1 $56.91 $18.97 $123.31 $41.10 $67.34 $8.54 Self and Family VV2 $156.51 $52.17 $339.11 $113.03 $183.29 $25.39
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