Pages 1--32 from fed2000.PDF

WELBORN
HMO

2000
A HEALTH MAINTENANCE ORGANIZATION
For changes
in benefits
see Page 5

Serving Southwestern Indiana
Enrollment in this Plan is limited see page 6 for requirements

Enrollment code
H31 Self only
H32 Self and family

Visit the OPM website at http www opm gov insure
and
our website at http www welbornhealthplans com

Authorized for distribution by the
UNI T E D S T A T E S O F F I C E O F
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 430

Table of Contents Page 1
1 Page 2 3

Welborn HMO 2000
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations .4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6 8
Section 4 What to do if we deny your claim or request for service .9 10
Section 5 Benefits 11 20
Section 6 General exclusions Things we do not cover 21
Section 7 Limitations Rules that affect your benefits 21 23
Section 8 FEHB FACTS 23 26
Inspector General Advisory Stop Healthcare Fraud 27
Summary of benefits 31
Premiums backcover

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Welborn HMO 2000
Introduction
Welborn Health Plans 421 Chestnut Street Evansville Indiana 47713
This brochure describes the benefits you can receive from Welborn HMO under its contract CS 2394 with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of
benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are
enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective
January 1 2000 and are shown on page 5 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Welborn HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only
to make it more understandable

We have not rewritten the Benefits section of this brochure You will find new benefits language next year

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Welborn HMO 2000
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier

1 Health Maintenance Organizations HMOs This Plan is an HMO Turn to this section for a brief description of
HMOs and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our
decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also
find information about non FEHB benefits

6 General exclusions Things we do not cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

Section 1 Health Maintenance Organizations
Health Maintenance Organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and
injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

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Welborn HMO 2000
Section 2 How We Change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes care office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until
the end of your postpartum care You have similar rights if this Plan leaves the FEHB program see
Section 3 How To Get Benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record
you may add a brief statement to it If they do not provide you your records call us and we will assist
you

If you are over 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to this Your share of the non postal premium will increase by 11 for Self Only or 14.7 for Self and
Plan Family

We have a new prescription drug program We developed a formulary which consists of medications
rigorously reviewed and selected for their safety quality and effectiveness by our Pharmacy and
Therapeutics Committee Your copayment for formulary drugs is 5 for generic and 15 for brand
name drugs If you are prescribed a non formulary drug we will cover the non formulary drug but
you will be responsible for the higher copayment of 25 See page 18

As an added convenience you may fill covered maintenance drugs including birth control pills
estrogen blood pressure medications etc through our expanded pharmacy network that includes
many large retail establishments and independent pharmacies See page 18

All medically necessary inpatient and outpatient mental health services are covered This does not
apply to services for treatment of substance abuse or chemical dependency See page 17

Heart lung lung single and double kidney pancreas transplants are now covered See page 11
Foot supports are now covered

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Welborn HMO 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our
service area service area is the Indiana counties of Daviess Dubois Gibson Knox Perry Pike Posey Spencer Vanderburgh and Warrick

Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care You or a family member must notify us within 48
hours unless it was not reasonably possible to do so It is your responsibility
to ensure that we are notified timely

If you or a covered family member move outside of our service area you can enroll in another plan If
your dependents live out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in
other areas If you or a family member move you do not have to wait until Open Season to change
plans Contact your employing or retirement office

How much do I pay for You must share the cost of some services This is called either a copayment a set dollar amount or
services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services

After you pay 4,500 in copayments or coinsurance for one family member or 11,000 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments for your prescription drugs do not
count toward these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits

Do I have to You normally will not have to submit claims to us unless you receive emergency services from a
submit claims provider who does not contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you

received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides my Welborn HMO is a Managed Care Organization locally based and operated by Welborn Clinic and has
health care been licensed as a for profit privately held Health Maintenance Organization HMO since September 1 1986 As a member you are part of a locally owned health plan that offers quality access and value

Welborn HMO has been a recognized innovator and leader in managed health care for the past 15
years U S News World Report ranked Welborn HMO among the top HMOs nation wide for 3 years
in a row

We added approximately 250 physicians to our network in addition to our staff of quality Welborn
Clinic Primary Care Physicians and Specialists You now can choose from over 375 physicians for
your health care needs

Participating hospitals include Welborn Baptist Hospital St Mary's Medical Center Gibson General
Hospital St Mary's Warrick Harrisburg Medical Center and Wirth Regional Hospital

Members now have access to many local pharmacy locations through the Tri State region Those new
pharmacies include chains such as CVS K Mart Schnucks Shopko Buehler's Buy Low Walgreens
and many independent pharmacies Additionally members have access to over 50,000 national chain
and independent pharmacies

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Welborn HMO 2000
Section 3 How to get benefits continued
As a member you now have more choices in terms of access to physicians facilities and pharmacies We
are committed to providing high quality health care benefits with exceptional service You will need to let us
know which primary care physician you select for each member of the family If you need help in choosing
a physician please call us at 812 426 6600 You may change your choice by calling us 30 days in advance

What do I do Call us We will help you select a new one
if my primary care
physician leaves the
Plan

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will
I need to go make the necessary hospital arrangements and supervise your care
into the hospital

What do I do First call our member service department at 812 426 6600 If you are new to the FEHB Program we will
if I'm in the arrange for you to receive care If you are currently in the FEHB Program and are switching to us your
hospital when former plan will pay for the hospital stay until
I join this Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or

The 92nd day after you became a member of this Plan whichever happens first These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will arrange your referral to a specialist When you receive a referral you must
specialty care return to your primary care physician after the consultation unless he authorizes additional visits All follow up care must be provided or authorized by your primary care physician

If you need to see a specialist frequently because of a chronic complex or serious medical condition your
primary care physician will develop a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals Your primary care physician will use our criteria when
creating your treatment plan All services must be approved beforehand

You may see your participating gynecologist without a referral for your annual routine exam

What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a specialist
if I am seeing a ask if you can see your current specialist If your current specialist does not participate with us you must
specialist when I receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does
enroll not participate with our Plan

What do I do Call your primary care physician who will arrange for you to see another specialist You may receive
if my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan

What if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
serious illness your provider for up to 90 days after we notify you that we are terminating our contract with the provider
and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may
leaves the Plan or continue to see your OB GYN until the end of your postpartum care
this Plan leaves the
Program

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Welborn HMO 2000
Section 3 How to get benefits continued
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you
enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition
or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days
after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third
trimester your new plan will pay for the OB GYN care you receive from your current provider until the end
of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice

How do you decide Our Research and Technology Committee work group researches any new type of treatment that is approved
if a service is by the Food and Drug Administration For us experimental investigative means any drug device or service
experimental or that cannot be lawfully marketed without approval of the U S Food and Drug Administration and approval
investigational for marketing has not been given at the time the drug device or service is furnished

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Welborn HMO 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or will not pay your claim you may ask us to reconsider our decision
Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal
4 We may extend this time limit if you show that you were unable to make a timely request
due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make
a decision within 30 days after we receive the additional information If we do not receive the requested
information within 60 days we will make our decision based on the information we already have

When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will
OPM to review determine if we correctly applied the terms of our contract when we denied your claim or request for service
a denial

What if I have a Call us at 812 426 6600 and we will expedite our review
serious or life
threatening
condition and
you haven't
responded to my
request for
service

What if you If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so
have denied that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
my request Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are
for care and ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
my condition
is serious or life
threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial
time limits or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within 120
days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this
case OPM must receive your request within 120 days of the date we asked you for additional
information

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Welborn HMO 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send Your request must be complete or OPM will return it to you You must send the following information
to OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and

Medical providers legal counsel and other interested parties who are acting as the enrolled person's
representative They must send a copy of the person's specific written consent with the review
request

Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs Contract
mail my disputed Division III P O Box 436 Washington D C 20044
claim to OPM

What if OPM
upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your
Plan's denial only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies

What laws
apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review on
a lawsuit the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefit in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services
supplies or drugs covered by us until you have completed the OPM review procedure described above Your records

and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
Privacy Act determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of

Information Act and the Privacy Act OPM may disclose this information to support the disputed claim
decision If you file a lawsuit this information will become part of the court record

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Welborn HMO 2000
Section 5 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 10 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 judgment of the Plan doctor such care is necessary and appropriate you pay a 10
copay for a doctor's 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 well baby care and periodic check ups
Sigmoidoscopy screening for colorectal cancer every five years for those age 50 and above
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years

for women age 50 through 64 one monogram every year and for women age 65 and above every
two years In addition to routine screening mammograms are covered when prescribed by the
doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters copay is waived
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 Copays are waived for maternity care The mother at her option

may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
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 under the Plan has
ended Ordinary nursery care of the newborn child during the covered portion of the mother's
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 you pay 5 per injection

The insertion of internal prosthetic devices such as pacemakers and artificial joints including the cost of the device implantable drugs
Cornea heart heart lung lung single and double kidney pancreas and liver 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 nonlymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and
testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered
when approved by the Medical Director 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

Breast prostheses and surgical bras including replacement you pay 20 of charges
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics you pay 20 of charges
Prosthetic devices such as artificial limbs and lenses following cataract removal you pay 20 of charges Implantable drugs such as Norplant

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Welborn HMO 2000
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Section 5 Medical and Surgical Benefits continued
What is covered Diabetic supplies including Glucoscan test supplies and lancets Lancets and strips are covered as
continued medical supplies at 100 and you pick them up at the pharmacy Other diabetic supplies such as glucometers are covered as durable medical equipment and you pay 20 of charges

Durable medical equipment such as wheelchairs and hospital beds you pay 20 of charges Repair replacement or maintenance is not covered

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
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as a 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 treatment of temporomandibular joint
TMJ dysfunction syndrome

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 member's appearance and when the
condition can reasonably be expected to be corrected by surgery

A patient and her attending physician may decide whether to have breast reconstruction surgery
following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance

Short term rehabilitative therapy physical speech occupational and cardiac is provided on an
inpatient or outpatient basis for up to 60 treatment days per condition if significant improvement can be
expected within two months you pay 10 per visit 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 as well as artificial donor insemination ADI and intrauterine
insemination IUI and certain Plan approved fertility drugs are covered you pay 50 of charges cost
of donor sperm is not covered Other assisted reproductive technology ART procedures that enable a
woman with otherwise untreatable infertility to become pregnant through artificial conception
procedures such as in vitro fertilization and embryo transfer are not covered

Removal of selected benign lesions lipomas sebaceous cysts seborrheic keratoses and skin tags
performed in a doctor's office or outpatient facility is covered You pay 50 of charges

Acupuncture with a referral from your primary care doctor is covered for post operative pain from
dental surgery low back pain tennis elbow arthritis migraines nausea and vomiting from
chemotherapy and anesthesia and menstrual cramps You pay 20 per visit

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 or voluntary surgically induced sterility

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Welborn HMO 2000
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Section 5 Medical and Surgical Benefits continued
What is not Surgery primarily for cosmetic purposes
covered Homemaker services
continued Hearing aids Transplants not listed as covered

Long term rehabilitative therapy
Orthopedic shoes
Refractions including lens prescriptions and corrective eyeglasses or contact lenses including the fitting of contact lenses except as necessary for the first pair of corrective lenses following

cataract surgery
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and blurring astigmatism

Chiropractic care
Lift chairs
Custodial care

Section 5 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 for up to 100 days per condition 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
Services include inpatient and outpatient care and family counseling these services are provided under
the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life
expectancy of approximately six months or less

Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay
service 50 copay per ground transport and a 250 per air or water transport

Limited Benefits
Inpatient Hospitalization for certain dental procedures is covered when a Plan doctor determines there
dental is a need for hospitalization but not the cost of the professional dental services Conditions for which
procedures hospitalization would be covered included hemophilia and heart disease the need for anesthesia by itself is not such a condition

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Welborn HMO 2000
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Section 5 Hospital Extended Care Benefits continued
Acute Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis and
inpatient medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that
detoxification outpatient management is not medically appropriate See page 17 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Welborn HMO 2000
Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
medical endangers your life or could result in serious injury or disability and requires immediate medical or
emergency 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 If you are in an emergency situation please call your primary care doctor In extreme emergencies if
within the you are unable to contact your doctor contact the local emergency system e g the 911 telephone
service area 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 a non Plan facility 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

Plan pays 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

You pay Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

Emergencies 50 per hospital emergency room or 25 per urgent care center visit for emergency services that are
outside the covered benefits of the Plan If the emergency results in admission to a hospital the emergency care
service area copay is waived

Benefits are available for any medically necessary health service that is immediately required because
of injury or unforeseen illness If you need to be hospitalized the Plan must be notified within 48 hours
or on the first working day following your admission unless it was not reasonably possible to notify the
Plan within that time

If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full

Plan pays 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

You pay Reasonable charges for emergency care service to the extent the services would have been covered if
received form Plan providers

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Welborn HMO 2000
Section 5 Emergency Benefits continued
What is 50 per emergency room or 25 per urgent care center visit for emergency services that are covered
covered benefits of the Plan or provided by Plan providers Emergency care a doctor's office or an urgent care center

Emergency care as an outpatient or impatient at a hospital including doctors services
Ambulance service approved by the Plan
Prescription drugs obtained outside of the Service Area because of unforeseen illness or injury

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 care
for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
providers 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 Plan's decision you may request
reconsideration in accordance with the disputed claims procedure described on page 9

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Welborn HMO 2000
Section 5 Mental Conditions Substance Abuse Benefits
Mental Conditions
What is To the extent shown below the Plan provides the following services necessary for the diagnosis and
covered 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

Outpatient All medically necessary visits You pay 10 per visit
care

Inpatient Comprehensive range of medical services with no dollar or day limit You pay nothing
care

What is Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
not covered significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court ordered or as a condition of parole or probation unless

determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance Abuse
What is This Plan provides medical and hospital services such as acute detoxification services for the medical
covered 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 Up to 40 outpatient visits You pay a 20 copay per visit for individual therapy and 10 per visit for
care group therapy for the first 20 visits You pay 50 of charges for visits 21 40 all charges thereafter

Inpatient Up to 30 days per calendar year in a substance rehabilitation program in an alcohol or drug
care rehabilitation center approved by the Plan You pay nothing for those 30 days all charges thereafter

What is not Treatment that is not authorized by a Plan doctor
covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Welborn HMO 2000
Section 5 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 In lieu of name brand drugs generic
drugs will be dispensed when substitution is permissible When generic substitution is permissible i e
a generic drug is available and the prescribing doctor does not require the use of a brand name drug
but you request the name brand drug you pay the price difference between the generic and name brand
drug as well as the name brand drug copay per prescription unit or refill You pay a 5 copay per
generic prescription unit or refill on the formulary and a 15 copay per name brand prescription unit or
refill on the formulary and a 25 copay for a non formulary prescription unit or refill The copay will
not exceed the cost of the drug

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Non formulary drugs will be covered when prescribed by a Plan doctor

As an added convenience you may refill first prescription must be filled at the local retail pharmacy
covered maintenance prescription drugs prescribed to treat chronic conditions like arthritis high blood
pressure heart conditions and diabetes through our PCS Mail Service Program Birth control pills and
estrogen may also be filled A 60 day supply has an 8 copay for formulary generic drugs 24 copay
for formulary brand name drugs and a 40 non formulary drug copay 90 day supplies have a 12
copay for formulary generic drugs 36 copay for formulary brand name drugs and a 60 copay for
non formulary drugs

A formulary is a list of medications rigorously reviewed and selected for their safety quality and
effectiveness by our Pharmacy and Therapeutics Committee By encouraging the use of medications
that are safe and effective we continue our efforts to help you lead healthy lives and manage health
care costs The formulary is reviewed and revised periodically The Food and Drug Administration
FDA have approved all drugs on the formulary By law brand and generic drugs must meet the same
standards for safety and effectiveness

To request a formulary list or ask questions about our prescription program or mail order program
please call our Member Services Department at 812 426 6600 or 800 521 0265 or visit our website
at www welbornhealthplans com

Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs up to a 90 day supply per refill of maintenance and oral contraceptive drugs may be obtained with a copay applied to each 30 day supply

Diaphragms with a prescription
Insulin with a copay charge applied to each vial
Disposable needles and syringes for injecting prescribed medications

Diabetic supplies except insulin and insulin syringes contraceptive devices other than diaphragms
intravenous fluids and medications for home use implantable drugs such as Norplant and injectable
drugs such as Depo Provera are covered under the Medical and Surgical Benefits

Limited Fertility drugs limited to certain Plan approved drugs you pay 50 of charges
benefits Sexual dysfunction drugs have dispensing limitations and require documentation of medical

necessity from the prescribing doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Welborn HMO 2000
Section 5 Prescription Drug Benefits continued
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available
covered 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
Smoking cessation drugs and medications including nicotine patches
Implanted time release medications other than Norplant

Section 5 Other Benefits
Dental Care
Accidental Injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are
benefit covered The need for these services must result from an accidental injury You pay nothing

What is not Dental services not shown as covered
covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Welborn HMO 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under
the contract ith 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

Medicare prepaid plan enrollment This Plan offers Medicare recipients the
opportunity to enroll in the Plan through Medicare As indicated on page 21
certain annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan
when one is available in their area They may later reenroll in the FEHB Program
Most Federal annuitants have Medicare Part A Those without Medicare Part A
may join this Medicare prepaid plan but will probably have to pay for hospital
coverage in addition to the Part B premium Before you join the plan ask whether
the plans covers hospital benefits and if so what you will have to pay Contact
your retirement system for information on changing to a Medicare prepaid plan
Contact us at 812 426 6600 for information on the Medicare prepaid plan and the
cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO
sponsored by this Plan without dropping your enrollment in this Plan's FEHB
plan call 812 426 6600 for information on the benefits available under the
Medicare HMO

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT

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Welborn HMO 2000
Section 6 General exclusions Things we do not 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

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices 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
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare A or B Medicare will determine who is
responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan 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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your Social Security Administration SSA office or
request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan offered by this
Plan call 812 426 9398

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits first We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the first
plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not
file a claim with your other plan you must still inform us that you have double coverage

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Welborn HMO 2000
Section 7 Limitations Rules that affect your benefits continued
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the first
plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not
file a claim with your other plan you still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we my have to delay your services or be unable to provide
beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries 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

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 are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

Worker's We do not cover services that
Compensation We need because of a workplace related disease or injury that the Office of Workers Compensation

Programs OWCP or a similar Federal or State agency determine they must provide

OWCP or a similar agency pays for a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits as long as you use our providers

Medicaid We pay first if both Medicaid and this Plan cover you

Other We do not cover services and supplies that a local State or Federal Government
Government agency directly or indirectly pays for
Agencies

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Welborn HMO 2000
Section 7 Limitations Rules that affect your benefits continued
If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it
malpractice must go to binding arbitration Contact us about how to begin our binding arbitration process
claim

Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
information about information about your health plan its networks providers and facilities You can also find out about
your HMO care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov insure

lists the specific types of information that we must make available to you
If you want specific information about us call 812 426 6600 or write to 421 Chestnut Street Evansville
Indiana 47713 You may also contact us by fax at 812 426 9874 or visit our website at
www welbornhealthplans com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the FEHB informed decision about
Program 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
The next Open Season for enrollment

We do not determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
I retire 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 which is

described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage for a
family and me disabled child 22 years of age or older who is incapable of self support

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Welborn HMO 2000
Section 8 FEHB Facts continued
What types of If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give
coverage are birth or add a child to your family You may change your enrollment 31 days before to 60 days after you
available for my give birth or add the child to your family The benefits and premiums for your Self and Family
family and me enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
continued family member

Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan

Are my medical We will keep your medical and claims information confidential Only the following will have access to
and claims records it
confidential 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

Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809
cards or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits

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Welborn HMO 2000
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage 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 more information about your coverage choices

Information for new members continued
What is TCC Temporary Continuation of Coverage 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 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

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

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Welborn HMO 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You
TCC must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within
60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling
in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notifies
your employing or retirement office within the 60 day deadline

How can I convert 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

Information for new members continued
How can I convert to If you leave Federal service your employing office will notify you if individual coverage is available
individual coverage You must apply in writing to us within 31 days after you receive this notice However if you are a
continued 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

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate If you have been enrolled with us
for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate
from them as well

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Welborn HMO 2000
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 812 426 6600 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 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

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Welborn HMO 2000
NOTES

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Welborn HMO 2000
NOTES

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Welborn HMO 2000
NOTES

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Welborn HMO 2000
Summary of Benefits for Welborn HMO 2000
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 CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient care Comprehensive range of medical and surgical services without dollar or day limit Hospital Includes in hospital doctor care room and board general nursing care private room
and private duty nursing care if medically necessary diagnostic tests drugs and
medical supplies use of operating room intensive care and complete maternity care
You pay nothing 13

Extended care All necessary services up to 100 days per calendar year You pay nothing 13
Mental conditions Diagnosis and treatment of acute psychiatric conditions You pay nothing 17
Substance abuse Up to 30 days inpatient care per year You pay nothing 17

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays complete maternity care You pay
a 10 copay per office visit copays are waived for maternity care and immunizations 10
copay per house call by a doctor .11

Home health care All necessary visits by nurses and health aides You pay nothing .12

Substance abuse Up to 40 outpatient visits per year You pay a 20 copay per visit for individual therapy 10 per visit for group therapy for the first 20 visits then 50 of charges for the
remaining 20 visits .17

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay each visit for emergency care services and
any charges for services that are not covered benefits of this plan 15

Prescription Drugs Drugs prescribed by a Plan doctor or referral doctor and obtained at a Plan pharmacy You pay a 5 copay for a generic prescription unit or refill on the formulary
a 15 copay for a name brand prescription unit or refill on the formulary or a 25 copay
for a prescription unit or refill not on the formulary .18

Dental care Accidental injury benefit you pay nothing 19
Vision care No current benefit

Out of pocket Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of maximum 4,500 per Self Only or 11,000 per
Self and Family enrollment per calendar year covered benefits will be provided
at 100 This copay maximum does not include prescription drugs 6

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Welborn HMO 2000
2000 Rate Information for
Welborn HMO

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 In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but not a member of a special postal employment class refer to the category definitions in The
Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to
determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment
classes or associate members of any postal employee organization Such persons not subject to postal rates must
refer to the applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Code Gov't Your Gov't Your USPS Your USPS Your Share Share Share
Enrollment Share Share Share Share Share

Self Only H31 69.80 23.26 151.22 50.41 82.59 10.47 82.59 10.47
Self and Family H32 175.97 64.59 381.27 139.94 207.74 32.82 201.02 39.54

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