+-----------------------------------------------------------------------+
| > 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 or condition.**
>
> *\[\[Alternate ending for plans with precertification/prior
> approval:\]\]* . . . or condition and we agree, as discussed under
> *What Services Require Our Prior Approval* on page xx.
>
> 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
    {*plan specific---can vary; discuss with contract specialist }*;

-   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.

*{{Insert other "**Genera**l Exclusions" from your 2000 brochure---your
contract specialist will help you edit for plain language and necessity
-- BE SURE TO PUT "; or" after the next to last entry and then a period
after the last entry}}*

  -----------------------------------------------------------------------
  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 xxx.

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 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;

```{=html}
<!-- -->
```
-   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: {{*insert Plan address}}***

**Prescription drugs** {*Insert Plan-specific process; if same as above,
change the header in the above to "Medical, Hospital and Drug
benefits"*}

> **Submit your claims to:** *{{insert plan address}}*

**Other supplies or services** {*Insert Plan-specific process, such as
dental, DME, vision, chiropractic; if same as above, don't put this
header in}*}

> **Submit your claims to: {{***insert plan address}}*

**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.

  -----------------------------------------------------------------------
  Section 8. The disputed claims process

  -----------------------------------------------------------------------

*{NOTE: For step numbers below, sample below is 16pt Tahoma. But as long
as the numbers stand out and look balanced, it won\'t matter what type
face you use.} {RV 5/11}*

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:

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: {{Plan address}}; and            |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or 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 medical provider for more information. If we |
|   |     ask your provider, we will send you a copy of our            |
|   |     request---go to step 3.                                      |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | 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 xx, P.O. Box 436,         |
|   | Washington, D.C. 20044-0436.                                     |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review different claims, you must       |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must provide a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | If you do not agree with OPM's decision, your only recourse is   |
| * | to sue. If you decide to sue, you must file the suit against OPM |
| 6 | in Federal court by December 31 of the third year after the year |
| * | in which you received the disputed services or supplies. This is |
| * | the only deadline that may not be extended.                      |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

> **NOTE: If you have a serious or life threatening condition** (one
> that may cause permanent loss of bodily functions or death if not
> treated as soon as possible), and

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at xxx and we will
    expedite our review; or *{RV 6-16}*

(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 xx at
> 202/606-xxxx between 8 a.m. and 5 p.m. eastern time.

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

  -----------------------------------------------------------------------

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

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

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

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay more than our allowance. *{{plan
specific---negotiate differences with contracting officer}}*

**•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-State Renal Disease (permanent kidney failure
> requiring dialysis or a transplant).

Medicare has two parts:

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

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

If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.
*{RV 5/12}*

**•Original Medicare** The Original Medicare Plan is available
everywhere in the United States. It is the way most people get their
Medicare Part A and Part B benefits. You may go to any doctor,
specialist, or hospital that accepts Medicare. Medicare pays its share
and you pay your share. Some things are not covered under Original
Medicare, like prescription drugs. *{RV 5/12}*

When you are enrolled in this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. {*Plan
specific... Your care must continue to be authorized by your Plan PCP,
or precertified as required*.}

*{Plan specific **--** We will not waive any of our copayments,
coinsurance, and deductibles. Or: We will waive some copayments,
coinsurance, and deductibles, as follows: {insert brief description}.}*

> **(Primary payer chart begins on next page.)**
>
> The following chart illustrates whether Original Medicare or this Plan
> should be the primary payer for you according to your employment
> status and other factors determined by Medicare. It is critical that
> you tell us if you or a covered family member has Medicare coverage so
> we can administer these requirements correctly.

+------------------------------------------------+------------+--------+
| > **Primary Payer Chart**                      |            |        |
+------------------------------------------------+------------+--------+
| **A. When either you \-- or your covered       | **Then the |        |
| spouse \-- are age 65 or over and ...**        | primary    |        |
|                                                | payer      |        |
|                                                | is...**    |        |
+------------------------------------------------+------------+--------+
|                                                | **Original | **This |
|                                                | Medicare** | Plan** |
+------------------------------------------------+------------+--------+
| 1)  Are an active employee with the Federal    |            | >     |
|     government (including when you or a family |            |        |
|     member are eligible for Medicare solely    |            |        |
|     because of a disability),                  |            |        |
+------------------------------------------------+------------+--------+
| 2)  Are an annuitant,                          | >         |        |
+------------------------------------------------+------------+--------+
| 3)  Are a reemployed annuitant with the        | ..         |        |
|     Federal government when...                 | ......... |        |
|                                                |            |        |
| ```{=html}                                     |            |        |
| <!-- -->                                       |            |        |
| ```                                            |            |        |
| a)  The position is excluded from FEHB, or     |            |        |
|     *{RV 6-16}........................*        |            |        |
+------------------------------------------------+------------+--------+
| b)  The position is not excluded from FEHB {RV | ......     | ....   |
|     6-16}...................                   | .......... | ..... |
|                                                | .......... |        |
| > Ask your employing office which of these     |            |        |
| > applies to you.                              |            |        |
+------------------------------------------------+------------+--------+
| 4)  Are a Federal judge who retired under      | ######    |        |
|     title 28, U.S.C., or a Tax Court judge who |            |        |
|     retired under Section 7447 of title 26,    |            |        |
|     U.S.C. (or if your covered spouse is this  |            |        |
|     type of judge),                            |            |        |
+------------------------------------------------+------------+--------+
| 5)  Are enrolled in Part B only, regardless of |           |       |
|     your employment status,                    |            |        |
|                                                | (for Part  | (for   |
|                                                | B          | other  |
|                                                | services)  | ser    |
|                                                |            | vices) |
+------------------------------------------------+------------+--------+
| 6)  Are a former Federal employee receiving    |           |        |
|     Workers' Compensation and the Office of    |            |        |
|     Workers' Compensation Programs has         | (except    |        |
|     determined that you are unable to return   | for claims |        |
|     to duty,                                   | related to |        |
|                                                | Workers'   |        |
|                                                | Comp       |        |
|                                                | ensation.) |        |
+------------------------------------------------+------------+--------+
| > **B. When you \-- or a covered family member |            |        |
| > \-- have Medicare based on end stage renal   |            |        |
| > disease (ESRD) and...**                      |            |        |
+------------------------------------------------+------------+--------+
| ###### Are                                     |            |       |
| within the first 30 months of eligibility to r |            |        |
| eceive Part A benefits solely because of ESRD, |            |        |
+------------------------------------------------+------------+--------+
| 1)  Have completed the 30-month ESRD           |           |        |
|     coordination period and are still eligible |            |        |
|     for Medicare due to ESRD,                  |            |        |
+------------------------------------------------+------------+--------+
| 2)  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                            | ......... |        |
|                                                |            |        |
| ```{=html}                                     |            |        |
| <!-- -->                                       |            |        |
| ```                                            |            |        |
| a)  Are an annuitant,                          |            |        |
|     or...........                              |            |        |
| .............................................. |            |        |
+------------------------------------------------+------------+--------+
| b)  Are an active employee... *{RV             | .........  | ..     |
|                                                | .......... | ..... |
|  6-16}*....................................... | .......... |        |
+------------------------------------------------+------------+--------+

{Insert *Plan specific information as to whether claim filing will be
necessary*. *For example, Please note, if your Plan physician does not
participate in Medicare, you will have to file a claim with Medicare
{Follows is sample FFS language you may adapt:}{RV 5/12}*

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

-   When we are the primary payer, we process the claim first.

-   When 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
    \_\_\_\_\_\_\_\_\_\_\_\_.\[web too, etc\]

**We waive some costs when you have Medicare \--** When Medicare is the
primary payer, we will waive some out-of-pocket costs, as follows:
*\[also plan specific: primary payer\] \[Alt: "In this case we do not
waive any out-of-pocket costs."\] \[plan specific list; sample below\]*

-   Medical services and supplies provided by physicians and other
    health care professionals. If you are enrolled in Medicare Part B,
    we will waive*..... \[plan specific\--show each type of benefit you
    waive for\] {RV 5/12}*

**• Medicare managed care plan** If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from a Medicare
managed care plan. These are health care choices (like HMOs) in some
areas of the country. In most Medicare managed care plans, you can only
go to doctors, specialists, or hospitals that are part of the plan.
Medicare managed care plans cover all Medicare Part A and B benefits.
Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at
[www.medicare.gov](http://www.medicare.gov/). If you enroll in a
Medicare managed care plan, the following options are available to you:
*{RV 5/12}*

**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/do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage. {{*HMO-Add only if you have
one\--tailor waiver text*}}

**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. \[\[*Last sentence plan
specific; for instance, could be: We will waive these deductibles or
coinsurance if you receive services from providers who do not
participate in the Medicare managed care plan: {list}*.\]\]

**Suspended FEHB coverage and a Medicare managed care plan:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage and
enroll in a Medicare managed care plan. For information on suspending
your FEHB enrollment, contact your retirement office. If you later want
to re-enroll in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily lose coverage or move out of
the Medicare+Choice service area. *{RV 5/12}*

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

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

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

**Workers' Compensation** We do not cover services that:

> • you need because of a workplace-related disease or injury that the
> Office of Workers' Compensation Programs (OWCP) or a similar Federal
> or State agency determines they must provide; or
>
> • OWCP or a similar agency pays for through a third party injury
> settlement or other similar proceeding that is based on a claim you
> filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.*{RV
5/12}*

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

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

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

**When others are responsible** *\[\[Plan specific\]\]* When you receive
money to compensate you for

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

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

  -----------------------------------------------------------------------
  Section 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.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page xx. *{{Plan: the page xx is Section 4
page that explains copayment. Do not explain it again here.}}*

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page xx. *{{Plan: the page xx is Section 4
page that explains coinsurance. Do not explain it again here.}}*

**Covered services** Care we provide benefits for, as described in this
brochure.

**Custodial care** *{Insert 2000 definition, if any; put in plain
language.}*

**Deductible** A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for those services. See page xx. *{{Plan: the page xx is
Section 4 page that explains deductible. Do not explain it again
here.}}*

**Experimental or** {*Insert definition from section 3 of your 2000
brochure*}

**investigational services**

**Group health coverage** *{{Insert last year's definition, if you had
one}}*

**Medical necessity** *{Insert last year\'s definition if you had one
--plain language}}*

**Plan allowance** *{use this definition if you have coinsurance on two
or more benefits.}* 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: *{{plan, explain how you do that. Regular definition and how
you base allowance, i.e., base Plan allowance on the reasonable and
customary charge. Be sure to show that preferred providers accept the
plan allowance as payment in full!}*

*{{{NOTE to Plan: instead of URC, R&C, UC, etc, all plans will use "Plan
allowance" or "our allowance", depending on where you say it. It will be
easier for enrollees to understand and should reduce enrollee confusion
about their own meaning of R&C vs the plan's meaning. Makes it clear
this is the Plan's determination -- not open to debate -- and not a
general/commonplace determination of what is reasonable or customary.}}*

*{{Applies to HMOs too: If you have coinsurance AND use R&C or like term
in Section 5 Benefits \-- substitute "Plan allowance" or "our allowance"
for R&C or other term and describe Plan allowance here. }}*

**Us/We** Us and we refer to *{insert plan name}*

**You** You refers to the enrollee and each covered family member.

  -----------------------------------------------------------------------
  Section 11. FEHB facts

  -----------------------------------------------------------------------

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

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

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

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

**FEHB Program** *Health Benefits Plans,* brochures for other plans, and
other materials you need to make an informed decision about: *{RV 6-16}*

> • 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. *{RV 6-20}*

Your employing or retirement office will **not** *{{Plan \-- put the
word note in bold face type.}}* notify you when a family member is no
longer eligible to receive health benefits, nor will we. Please tell us
immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child under age 22 marries
or turns 22.

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

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

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

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

**records are confidential** the following will have access to it:

> • OPM, this Plan, and subcontractors when they administer this
> contract;
>
> • This Plan, and appropriate third parties, such as other insurance
> plans and the Office of Workers\' Compensation Programs (OWCP), when
> coordinating benefit payments and subrogating claims;
>
> • Law enforcement officials when investigating and/or prosecuting
> alleged civil or criminal actions;
>
> • OPM and the General Accounting Office when conducting audits;
>
> • Individuals involved in bona fide medical research or education that
> does not disclose your identity; or
>
> • OPM, when reviewing a disputed claim or defending litigation about a
> claim.

**When you retire** When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for
the last five years of your Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such as
temporary continuation of coverage (TCC). *{RV 6-20}*

**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. *{RV to ital 6-20}*

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

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

Get the RI 79-27, which describes TCC, and the RI 70-5, the *Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees*, from your employing or retirement
office or from www.opm.gov/insure. *{RV to ital 6-20}*

**•Converting to** You may convert to an individual policy if:

**individual coverage** •• Your coverage under TCC or the spouse equity
law ends. If you canceled your coverage or did not pay your premium, you
cannot convert;

> •• You decided not to receive coverage under TCC or the spouse equity
> law; or
>
> •• You are not eligible for coverage under TCC or the spouse equity
> law.

If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will **not**
notify you. You must apply in writing to us within 31 days after you are
no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to
pre-existing conditions.

**Getting a Certificate of** If you leave the FEHB Program, we will give
you a Certificate of Group

**Group Health Plan Coverage** Health Plan Coverage that indicates how
long you have been enrolled with us. You can use this certificate when
getting health insurance or other health care coverage. Your new plan
must reduce or eliminate waiting periods, limitations, or exclusions for
health related conditions based on the information in the certificate,
as long as you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

**Inspector General Advisory Stop health care fraud!** Fraud increases
the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital has charged you for services you did not receive,
billed you twice for the same service, or misrepresented any
information, do the following:

-   Call the provider and ask for an explanation. There may be an error.

-   If the provider does not resolve the matter, call us at xxx/xxx-xxxx
    and explain the situation.

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

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

  -----------------------------------------------------------------------
  **Department of Defense/FEHB Demonstration Project**

  -----------------------------------------------------------------------

*{{Insert this section if you are a demonstration project participating
plan..}}*

**What is it?** The Department of Defense/FEHB Demonstration Project
allows some active and retired uniformed service members and their
dependents to enroll in the FEHB Program. The demonstration will last
for three years and began with the 1999 open season for the year 2000.
Open season enrollments will be effective January 1, 2001. DoD and OPM
have set up some special procedures to implement the Demonstration
Project, noted below. Otherwise, the provisions described in this
brochure apply.

**Who is eligible** DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:

-   You are an active or retired uniformed service member and are
    eligible for Medicare;

-   You are a dependent of an active or retired uniformed service member
    and are eligible for Medicare;

-   You are a qualified former spouse of an active or retired uniformed
    service member and you have not remarried; or

-   You are a survivor dependent of a deceased active or retired
    uniformed service member; and

-   You live in one of the geographic demonstration areas.

If you are eligible to enroll in a plan under the regular Federal
Employees Health Benefits Program, you are not eligible to enroll under
the DoD/FEHBP Demonstration Project.

**The demonstration areas** • Dover AFB, DE • Commonwealth of Puerto
Rico

• Fort Knox, KY • Greensboro/Winston Salem/High Point, NC

• Dallas, TX • Humboldt County, CA area

• New Orleans, LA • Naval Hospital, Camp Pendleton, CA

• Adair County, IA area • Coffee County, GA area

**When you can join** You may enroll under the FEHB/DoD Demonstration
Project during the 2000 open season, November 13, 2000, through December
11, 2000. Your coverage will begin January 1, 2001. DoD has set-up an
Information Processing Center (IPC) in Iowa to provide you with
information about how to enroll. IPC staff will verify your eligibility
and provide you with FEHB Program information, plan brochures,
enrollment instructions and forms. The toll-free phone number for the
IPC is 1-877/DOD-FEHB (1-877/363-3342).

You may select coverage for yourself (Self Only) or for you and your
family (Self and Family) during the 2000 and 2001 open seasons. Your
coverage will begin January 1 of the year following the open season
during which you enrolled.

> If you become eligible for the DoD/FEHB Demonstration Project outside
> of open season, contact the IPC to find out how to enroll and when
> your coverage will begin.

DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/Beneficiary Education Plan,
Frequently Asked Questions, demonstration area locations and zip code
lists at [www.tricare.osd.mil/fehbp](http://www.tricare.osd.mil/fehbp).
You can also view information about the demonstration project, including
"The 2001 Guide to Federal Employees Health Benefits Plans Participating
in the DoD/FEHB Demonstration Project," on the OPM web site at
[www.opm.gov](http://www.opm.gov/).

**TCC eligibility** See Section 11, FEHB Facts; it explains temporary
continuation of coverage (TCC). Under this DoD/FEHB Demonstration
Project the **only** individual eligible for TCC is one who ceases to be
eligible as a "member of family" under your self and family enrollment.
This occurs when a child turns 22, for example, or if you divorce and
your spouse does not qualify to enroll as an unremarried former spouse
under title 10, United States Code. For these individuals, TCC begins
the day after their enrollment in the DoD/FEHB Demonstration Project
ends. TCC enrollment terminates after 36 months or the end of the
Demonstration Project, whichever occurs first. You, your child, or
another person must notify the IPC when a family member loses
eligibility for coverage under the DoD/FEHB Demonstration Project.

TCC is not available if you move out of a DoD/FEHB Demonstration Project
area, you cancel your coverage, or your coverage is terminated for any
reason. TCC is not available when the demonstration project ends.

**Other features** The 31-day extension of coverage and right to convert
do not apply to the DoD/FEHB Demonstration Project.

  -----------------------------------------------------------------------
  **Index**

  -----------------------------------------------------------------------

*{Use this list as a base; remove terms you don\'t use; add as
appropriate.}*

Do not rely on this page; it is for your convenience and does not
explain your benefit coverage.

**A**ccidental injury xx

Allergy tests xx

Alternative treatment xx

Ambulance xx

Anesthesia xx

Autologous bone marrow transplant xx

**B**iopsies xx

Birthing centers xx

Blood and blood plasma xx

Breast cancer screening xx

**C**arryover xx

Casts xx

Catastrophic protection xx

Changes for 2001 xx

Chemotherapy xx

Childbirth xx

Cholesterol tests xx

Circumcision xx

Claims xx

Coinsurance xx

Colorectal cancer screening xx

Congenital anomalies xx

Contraceptive devices and drugs xx

Coordination of benefits xx

Covered charges xx

Covered providers xx

Crutches xx

**D**eductible xx

Definitions xx

Dental care xx

Diagnostic services xx

Disputed claims review x

Donor expenses (transplants) xx

Dressings xx

Durable medical equipment (DME) xx

**E**ducational classes and programs xx

Effective date of enrollment xx

Emergency xx

Experimental or investigational xx

Eyeglasses xx

**F**amily planning xx

Fecal occult blood test xx

**G**eneral Exclusions xx

**H**earing services xx

Home health services xx

Hospice care xx

Home nursing care xx

Hospital xx

**I**mmunizations xx

Infertility xx

Inhospital physician care xx

Inpatient Hospital Benefits xx

Insulin xx

**L**aboratory and pathological services xx

**M**achine diagnostic tests xx

Magnetic Resonance Imagings (MRIs) xx

Mail Order Prescription Drugs xx

Mammograms xx

Maternity Benefits xx

Medicaid xx

Medically necessary xx

Medicare xx

Members xx

Mental Conditions/Substance Abuse Benefits xx

**N**eurological testing xx

Newborn care xx

Non-FEHB Benefits xx

Nurse

Licensed Practical Nurse xx

Nurse Anesthetist xx

Nurse Midwife xx

Nurse Practitioner xx

Psychiatric Nurse xx

Registered Nurse xx

Nursery charges xx

**O**bstetrical care xx

Occupational therapy xx

Ocular injury xx

Office visits xx

Oral and maxillofacial surgery xx

Orthopedic devices xx

Ostomy and catheter supplies xx

Out-of-pocket expenses xx

Outpatient facility care xx

Oxygen xx

**P**ap test xx

Physical examination xx

Physical therapy xx

Physician xx

Point of service (POS) xx

Pre-admission testing xx

Precertification xx

Preventive care, adult xx

Preventive care, children xx

Prescription drugs xx

Preventive services xx

Prior approval xx

Prostate cancer screening xx

Prosthetic devices xx

Psychologist xx

Psychotherapy xx

**R**adiation therapy xx

Rehabilitation therapies xx

Renal dialysis xx

Room and board xx

**S**econd surgical opinion xx

Skilled nursing facility care xx

Smoking cessation xx

Speech therapy xx

Splints xx

Sterilization procedures xx

Subrogation xx

Substance abuse xx

Surgery xx

-   Anesthesia xx

```{=html}
<!-- -->
```
-   Oral xx

-   Outpatient xx

-   Reconstructive xx

    Syringes xx

    **T**emporary continuation of coverage xx

    Transplants xx

Treatment therapies xx

**V**ision services xx

**W**ell child care xx

Wheelchairs xx

Workers' compensation xx

**X**-rays xx

**NOTES:**

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*{{Summary of Benefits page. New Plans \-- see your contract specialist
for a sample.}}*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*{{Premium page \-- back cover. New Plans \-- see your contract
specialist for a sample.}}*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*