If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 7. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member; "we" means PBP Health Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the
Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare
plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm.
gov/ insure or e-mail us at fehbwebcomments@ opm. gov. 4
4 Page 5 6
2002 PBP Health Plan 5 Introduction/ Plain
Language/ Advisory
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 800/ 544-7111 and
explain
the situation. If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or are no longer
enrolled in the Plan and
tries to obtain benefits. Your agency may also take
administrative action against you 5
5 Page 6 7
2002 PBP Health
Plan 6 Section 1
Section 1. Facts about this fee-for-service
plan
This Plan is a fee-for-service (FFS) plan. You can choose your own
physicians, hospitals, and other health care providers.
We reimburse you or your provider for your covered services, usually based on
a percentage of the amount we allow. The type and extent of covered services,
and the amount we allow, may be different from other plans. Read brochures
carefully.
We also have Preferred Provider Organizations (PPO):
Our fee-for-service plan offers services through a PPO. When you use our
PPO providers, you will receive covered services at reduced cost. Contact us for
the names of PPO providers and to verify their continued participation. You can
also go to our web page, which you can reach through the FEHB website, www.
opm. gov/ insure. Do not call OPM or your agency for our provider directory.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. Provider networks may be more extensive
in some areas than others. We cannot guarantee the availability of every
specialty in all areas. If no PPO provider is available, or you do not use a
PPO provider, the standard non-PPO benefits apply.
How we pay providers
We make benefits payments to you or your
provider, on your behalf. The benefit payment is the same in both cases. When we
pay providers, our payment is based on the services they provide to you. We make
no other payments to
providers. Our payment policy does not include provider bonuses or financial
incentives. Our payment policy does not encourage your provider to give any more
or less medical care than your physical or mental condition requires.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types of
information that we must make available to you.
Some of the required information is listed below.
Compliance or licensing
requirements: None apply Years in existence: 41
Profit status: Non-profit
If you want more information about us, call 800/ 544-7111, or write to PBP
Health Plan, 1019 North Royal Street, Alexandria, Virginia 22314-1596. You may
also contact us by fax at 703/ 683-2937 or visit our website at
www.
postmasters. org/ pbp. asp. 6
6 Page 7 8
2002 PBP Health
Plan 7 Section 2
Section 2. How we change for 2002
Do
not rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5 Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We
changed the address for sending disputed claims to OPM. (Section 8) Four states
are added to the list of medically underserved areas: Georgia, Montana, North
Dakota and Texas.
Louisiana is no longer a medically underserved area. (Section 3.)
Changes to this Plan
Both Options
We clarified the brochure to
better explain that the non-PPO benefits are the standard benefits of this Plan,
that PPO benefits apply only when you use a PPO provider, and that when no PPO
provider is available, non-PPO benefits
apply. We clarified the Family planning and Infertility benefits by providing
more examples of covered and not covered
benefits. (Section 5( a)) We
clarified Surgical procedures to show that we cover a comprehensive range of
services, such as operative
procedures. (Section 5( b)) We provide up to
$2,000.00 per person per year for any combination of chiropractic services,
physical therapy,
occupational therapy, speech therapy and therapeutic
acupuncture. Previously, many of these services were subject
to individual
limits.
We now cover hepatitis B vaccinations for certain adults. (Section 5( a)) We
now cover one colonoscopy screening every two years for patients age 40 and
older. (Section 5( a))
We now cover one barium enema screening every two years for patients age 40
and older. (Section 5( a)) We now cover routine screening for chlamydial
infection. (Section 5( a))
We increased speech therapy benefits by removing
the requirement that services must be required to restore functional speech.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We clarified the brochure to show why we think you should use generic drugs
whenever possible. We moved other
language around within the Prescription
drugs section but didn't change its meaning. (Section 5( f)) We clarified the
Medicare Primary Payer Chart to explain how we coordinate benefits for former
spouses. (Section
9) We clarified other language about coordinating benefits
with Medicare. (Section 9)
Standard Option
Your share of the non-Postal premium will decrease
by 12. 0% for Self Only or 15. 6% for Self and Family. We now cover mail order
prescription drugs for up to a 90-day supply with no deductible. You pay a $15
copayment for generic drugs, a $30 copayment for formulary drug, or the
greater of a $40 copayment or 20% of the drug's cost for non-formulary drug. If
you have Medicare coverage, you pay a $7 copayment for generic drugs, a
$15
copayment for formulary drug, or the greater of a $25 copayment or 20% of the
drug's cost for non-formulary drug.
High Option
Your share of the non-Postal premium will decrease by
6. 5% for Self Only or 7. 5% for Self and Family. We now cover mail order
prescription drugs for up to a 90-day supply with no deductible. You pay a $10
copayment for generic drugs, a $25 copayment for formulary drug, or the
greater of a $40 copayment or 20% of the drug's cost for non-formulary drug. If
you have Medicare coverage, you pay a $5 copayment for generic drugs, a
$12
copayment for formulary drug, or the greater of a $25 copayment or 20% of the
drug's cost for non-formulary drug. 7
7 Page 8 9
2002 PBP Health
Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card and a
prescription drug card when you enroll. You should carry your ID card and your
prescription
drug card with you at all times. You must show your ID card
whenever you receive services from a Plan provider. You must show your
prescription drug card to obtain a prescription at a Plan pharmacy. Until
you receive your ID card, use your copy of the Health Benefits Election
Form, SF-2809, your health benefits enrollment confirmation (for
annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 800/ 544-
7111.
Where you get covered care You can get care from any "covered
provider" or "covered facility." How much we pay – and you pay – depends on the
type of covered
provider or facility you use. If you use our preferred
providers you will pay less.
Covered providers We consider the following to be covered providers
when they perform services within the scope of their license or certification:
A licensed doctor of medicine( M. D.) or a licensed doctor of osteopathy (D.
O.). Other covered providers include: a licensed doctor of podiatry
(D. P.
M.); a licensed dentist (D. D. S or D. M. D.); licensed chiropractor (D. C.);
licensed or registered physical, occupational and speech therapists
(R. P.
T., R. S. T., R. O. T. and S. P.). Other covered providers include a qualified
clinical psychologist, clinical social worker, optometrist, nurse
midwife,
Certified Registered Nurse Anesthetist (C. R. N. A.), nurse practitioner/
clinical specialist and nursing school administered clinic.
Medically underserved areas. Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that
license in states OPM determines are "medically underserved." For 2002, the
states are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri,
Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas,
Utah, and Wyoming.
Covered facilities Covered facilities include:
Free-standing
ambulatory facility An out-of-hospital facility such as medical, cancer,
dialysis, or surgical
center or clinic, and licensed outpatient facilities
accredited by the Joint Commission on Accreditation of Healthcare Organization
for treatment
of substance abuse.
Hospice A facility whose staff must include a doctor and registered nurse (R.
N.)
and may include social worker, clergymen/ counselor, volunteers,
clinical psychologists and physical or occupational therapists who are
able to provide care 24 hours a day. 8
8 Page 9 10
2002 PBP Health
Plan 9 Section 3
Hospital (1) An institution that is accredited
as a hospital under the
hospital accreditation program of the Joint
Commission on Accreditation of Healthcare Organization, or
(2) Any other institution that is operated pursuant to law, under the
supervision of a staff of doctors, with 24-hour-a-day
nursing service and
that is primarily engaged in providing for sick and injured inpatients: general
care and treatment
through medical, diagnostic and major surgical
facilities, all of which facilities must be provided on its premises or under
its control, or specialized care and treatment through medical and
diagnostic facilities (including X-ray and
laboratory) on its premises,
under its control, or through a written agreement with a hospital (as defined
above) or with
a specialized provider of those services.
Rehabilitation
facilities An institution that: (1) meets the "hospital" definition as stated;
or (2)
provides a program for the treatment of alcohol or drug abuse and
meets one of the following requirements: (a) is affiliated with a
hospital
under a contractual agreement with an established patient referral system; (b)
is licensed, certified or approved as an alcohol or
drug abuse
rehabilitation facility by the State; or is accredited as such a facility by the
Joint Commission on Accreditation of Healthcare
Organizations.
Skilled
nursing facility An institution that (1) is operated pursuant to law and
primarily
engaged in providing the following services for patients
recovering from an illness or injury: room, board and 24-hour-a-day nursing
service by professional nurses; (2) is under the fulltime supervision of a
doctor or registered nurse (R. N); (3) maintains adequate medical
records;
and (4) has the services of a doctor available under an established agreement
for 24 hours a day, if not supervised by a
doctor.
What you must do to get covered care It depends on the kind of care
you want to receive. You can go to any provider you want, but we must approve
some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling
condition and
lose access to your specialist because we drop out of the
Federal Employees Health Benefits (FEHB) Program and you enroll in another
FEHB Plan, or lose access to your PPO specialist because we terminate our
contract
with your specialist for other than cause,
you may be able to
continue seeing your specialist and receiving any PPO benefits for up to 90 days
after you receive notice of the change. Contact us
or, if we drop out of the Program, contact your new plan.
If you are in
the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to
see your
specialist and any PPO benefits continue until the end of your postpartum care,
even if it is beyond the 90 days.
Hospital care We pay for covered services from the effective date of
your enrollment. However, if you are in the hospital when your enrollment in our
Plan 9
9 Page 10 11
2002 PBP Health Plan 10 Section 3
begins, call our customer service department immediately at 800/
544-7111.
If you changed from another FEHB plan to us, your former plan will
pay for the hospital stay until:
You are discharged, not merely moved to an
alternative care center; or
The day your benefits from your former plan run
out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
How to Get Approval for…
Your hospital stay Precertification
is the process by which – prior to your inpatient hospital admission – we
evaluate the medical necessity of your proposed stay and
the number of days
required to treat your condition. Unless we are misled by the information given
to us, we won't change our decision on
medical necessity.
In most cases,
your physician or hospital will take care of precertification. Because you are
still responsible for ensuring that we are asked to
precertify your care,
you should always ask your physician or hospital whether they have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay
by $500 if no one contacts us for precertification. If the stay is not medically
necessary,
we will not pay any benefits.
How to precertify an
admission: You, your representative, your doctor, or your hospital must call
us at
1-866-218-8317 at least 48 hours before an admission.
If you have
an emergency admission due to a condition that you reasonably believe puts your
life in danger or could cause serious
damage to bodily function, you, your
representative, the doctor, or the hospital must telephone us within two
business days following
the day of the emergency admission, even if you have
been discharged from the hospital.
Provide the following information:
– Enrollee's name and Plan
identification number;
– Patient's name, birth date, and phone
number;
– Reason for hospitalization, proposed treatment, or surgery;
– Name and phone number of admitting doctor;
– Name of
hospital or facility; and
– Number of planned days of confinement. 10
10 Page 11 12
2002 PBP Health Plan 11 Section 3
We
will then tell the doctor and/ or hospital the number of approved inpatient days
and we will send written confirmation of our decision
to you, your doctor,
and the hospital.
Maternity care You do not need to precertify a
maternity admission for a routine delivery. However, if your medical condition
requires you to stay more
than 48 hours after a vaginal delivery or 96 hours
after a cesarean section, then your physician or the hospital must contact us
for precertification of
additional days. Further, if your baby stays after
you are discharged, then your physician or the hospital must contact us for
precertification of
additional days for your baby.
If your hospital
stay If your hospital stay --including for maternity care --needs to be
needs to be extended: extended, you, your representative, your doctor or
the hospital must ask
us to approve the additional days.
What happens
when you When we precertified the admission but you remained do not
follow the in the hospital beyond the number of days we approved and
precertification rules did not get the additional days precertified,
then:
– for the part of the admission that was medically necessary, we will
pay inpatient benefits, but
– for the part of the admission that was not medically necessary, we
will pay only medical services and supplies otherwise payable on
an
outpatient basis and will not pay inpatient benefits.
If no one contacted
us, we will decide whether the hospital stay was medically necessary.
– If we determine that the stay was medically necessary, we will pay the
inpatient charges, less the $500 penalty.
– If we determine that it
was not medically necessary for you to be an inpatient, we will not pay
inpatient hospital benefits. We will
only pay for any covered medical
supplies and services that are otherwise payable on an outpatient basis.
If we denied the precertification request, we will not pay inpatient hospital
benefits. We will only pay for any covered medical supplies
and services
that are otherwise payable on an outpatient basis.
Exceptions: You do
not need precertification in these cases:
You are admitted to a hospital
outside the United States.
You have another group health insurance policy
that is the primary payer for the hospital stay.
Your Medicare Part A is the primary payer for the hospital stay. Note: If you
exhaust your Medicare hospital benefits and do not want
to use your Medicare
lifetime reserve days, then we will become the primary payer and you do
need precertification. 11
11 Page 12 13
2002 PBP Health
Plan 12 Section 3
Other services Some services require a
precertification or prior authorization.
Durable medical equipment -We must
pre-approve the purchase of any covered durable medical equipment in excess of
$300. A letter of
medical necessity must be submitted to the Plan.
Network mental health and substance abuse -We must pre-approve a treatment
plan for covered network benefits. Advise your provider to
fax a written
treatment plan, for review and approval, to the attention of: PBP Mental Health
Coordinator at 703-836-8937. 12
12 Page 13 14
2002 PBP Health
Plan 13 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc. when you receive services.
Example: When you see your PPO physician under Standard Option you pay a
copayment of $10 per visit and when you go to a hospital, you pay
$250 per
admission
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
them. Copayments do not count toward any
deductible.
The calendar year deductible is $250 (PPO) or $500 (Non-PPO) per
person under Standard Option and $200 (PPO) or $400 (Non-PPO) per
person
under High Option. Under a family enrollment, the deductible is satisfied for
all family members when the combined covered
expenses applied to the
calendar year deductible for family members reach $500 (PPO) or $1000 (Non-PPO)
under Standard Option and
$400 (PPO) or $800 (Non-PPO) under High Option.
We also have separate deductibles for:
Prescription drugs -$100 for
network retail pharmacies or $150 for non-network retail pharmacies per person,
per year for both
High Option and Standard Option
Dental -$30 per person per year for High
Option. There is no Standard Option deductible for Dental Benefits.
The mental conditions/ substance abuse – $250 (PPO) or $300 (Non-PPO) per
person under Standard Option and $200 (PPO)
or $275 (Non-PPO) per person
under High Option. Under a family enrollment, the deductible is satisfied for
all family
members when the combined covered mental conditions/ substance
abuse expenses for the year reach $500
(PPO) or $600 (Non-PPO) under
Standard Option and $400 (PPO) or $550 (Non-PPO) under High Option.
Note: If you change plans during opens season, you do not have to start a new
deductible under your old plan between January 1 and the effective
date of
your new plan. If you change plans at another time during the year, you must
begin a new deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your
old
option to the deductible of your new option.
Coinsurance Coinsurance
is the percentage of our allowance that you must pay for your care. Coinsurance
doesn't begin until you meet your deductible.
Example: Under High Option you pay 10% of our allowance for office visits to
a network provider
Note: If your provider routinely waives (does not require
you to pay) your copayments, deductibles, or coinsurance, the provider is
misstating the fee 13
13 Page
14 15
2002 PBP Health Plan 14
Section 4
and may be violating the law. In this case, when we
calculate our share, we will reduce the provider's fee by the amount waived.
For example, if your physician ordinarily charges $100 for a service but
routinely waives your 30% coinsurance, the actual charge is $70. We will
pay
$49 (70% of the actual charge of $70).
Differences between our allowance
and the bill Our "Plan allowance" is the amount we use to calculate our
payment for covered services. Fee-for-service plans arrive at their allowances
in
different ways, so their allowances vary. For more information about how
we determine our Plan allowance, see the definition of Plan
allowance in
Section 10.
Often, the provider's bill is more than a fee-for-service plan's
allowance. Whether or not you have to pay the difference between our allowance
and
the bill will depend on the provider you use.
PPO providers
agree to limit what they will bill you. Because of that,
when you use a
preferred provider, your share of covered charges consists only of your
deductible and coinsurance or copayment. Here is
an example about coinsurance: You see a PPO physician who charges $150, but
our allowance is $100. If you have met your deductible, you
are only
responsible for your coinsurance. That is, you pay just --10% of our $100
allowance ($ 10) under High Option. Because of the
agreement, your PPO
physician will not bill you for the $50 difference between our allowance and his
bill.
Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. When you use a non-PPO provider, you will pay your
deductible and coinsurance --plus any difference between
our allowance and charges on the bill. Here is an example: You see a non-PPO
physician who charges $150 and our allowance is again
$100. Because you've
met your deductible, you are responsible for your coinsurance, so you pay 20% of
our $100 allowance ($ 20) under
High Option. Plus, because there is no
agreement between the non-PPO physician and us, he can bill you for the $50
difference between
our allowance and his bill.
The following table
illustrates the examples of how much you have to pay out-of-pocket for services
from a PPO physician vs. a non-PPO physician.
The table uses our example of
a service for which the physician charges $150 and our allowance is $100. The
table shows the amount you pay if
you have met your calendar year
deductible.
EXAMPLE PPO physician Non-PPO physician Physician's
charge $150 $150
Our allowance We set it at: 100 We set it at: 100 We pay
90% of our allowance: 90 80% of our allowance: 80
You owe: Coinsurance 10%
of our allowance: 10 20% of our allowance: 20
+Difference up to charge? No:
0 Yes: 50
TOTAL YOU PAY $10 $70 14
14
Page 15 16
2002
PBP Health Plan 15 Section 4
Your out-of-pocket maximum for
coinsurance For those services with coinsurance, other than prescription
drug services, we pay 100% of the Plan allowance for the remainder of the
calendar year after your out-of-pocket expenses for the services shown below
for the calendar year exceed $5,000 ($ 3,500 PPO) per person per
year or $5,500 ($ 4,000 PPO) per family under Standard Option and
$3,500 ($ 3,000 PPO) per person per year or $4,000 ($ 3,500 PPO) per
family
under High Option.
Out-of-pocket expenses for the purposes of this
benefit are:
Standard Option
The 30% you pay for hospital room
and board, or 10% you
pay for hospital room and board if using a PPO;
The 30% you pay for medical services or 10% if using a
PPO; The 30% you
pay for
Emergency Room Treatment or 10% if using a PPO;
The 30% you pay
for hospital services or 10% if using a
PPO; The 30% you pay for surgical
services or 10% if using a PPO; and
The 30% you pay for durable medical
equipment.
High Option
The 25% you pay for hospital room and board, or the
10%
you pay for hospital room and board if using a PPO;
The 20% you pay
for medical services or 10% if using a
PPO; The 20% you pay for
Emergency Room Treatment or 10% if using a PPO;
The 25% you pay for
hospital services or 10% if using a
PPO; The 20% you pay for surgical
services or 10% if using a PPO; and
The 20% you pay for durable medical
equipment
The following cannot be counted toward out-of-pocket expenses:
Copayments; Prescription drug expenses;
Expenses in excess of the Plan
allowances or maximum benefit limitations;
Expenses for mental conditions /
substance abuse (See Section 5( e)); Expenses for dental care; and
Any
amounts you pay because benefits have been reduced for non-compliance with this
Plan's cost containment requirements (see page
10). Deductibles
When government facilities bill us Facilities of the Department of
Veterans Affairs, the Department of Defense, and the Indian Health Service are
entitled to seek
reimbursement from us for certain services and supplies
they provide to you or a family member. They may not seek more than their
governing laws allow.
If we overpay you We will make diligent efforts to recover benefit
payments we made in error but in good faith. We may reduce subsequent benefit
payments to
offset overpayments. 15
15 Page 16 17
2002 PBP Health
Plan 16 Section 4
When you are age 65 or over and you do not
have Medicare
Under the FEHB law, we must limit our payments for those
benefits you would be entitled to if you had Medicare. And, your physician and
hospital must follow Medicare rules and cannot bill you for more than they could
bill you if
you had Medicare. The following chart has more information about
the limits.
If you… are age 65 or over, and
do not have Medicare Part A, Part
B, or both; and
have this Plan as an annuitant or as a former spouse, or
as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing
office can tell you if this applies.)
Then, for your inpatient hospital care, the law requires us to base
our payment on an amount --the "equivalent Medicare amount" --set by
Medicare's rules for what Medicare would pay, not on the actual charge;
you are responsible for your applicable deductibles, coinsurance or
copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare
amount; we will show that amount on the explanation of benefits (EOB) form that
we send you; and
the law prohibits a hospital from collecting more than the
Medicare equivalent amount.
And, for your physician care, the law
requires us to base our payment and your coinsurance on… an amount set by
Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
If
your physician… Then you are responsible for…
Participates with Medicare or accepts Medicare assignment for the claim and
is a member of our PPO network,
your deductibles, coinsurance, and
copayments;
Participates with Medicare and is not in our PPO network, your
deductibles, coinsurance, copayments, and any balance up to the Medicare
approved
amount;
Does not participate with Medicare, your deductibles,
coinsurance, copayments, and any balance up to 115% of the Medicare
approved amount
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect only up to
the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician
or hospital can collect from you. If your physician or hospital tries to collect
more than allowed by law, ask the physician or hospital to reduce the
charges. If you have paid more than allowed, ask for a refund. If you need
further assistance, call us. 16
16 Page 17 18
2002 PBP Health
Plan 17 Section 4
When you have the Original Medicare Plan
(Part A, Part B, or both)
We limit our payment to an amount that supplements the benefits that Medicare
would pay under Medicare Part A
(Hospital insurance) and Medicare Part B
(Medical insurance), regardless of whether Medicare pays. Note: We
pay our
regular benefits for emergency services to an institutional provider, such as a
hospital, that does not
participate with Medicare and is not reimbursed by
Medicare.
If you are covered by Medicare Part B and it is primary, your
out-of-pocket costs for services that both Medicare Part B and we cover depend
on whether your physician accepts Medicare assignment for the claim.
If
your physician accepts Medicare assignment, then you pay nothing
for covered
charges.
If your physician does not accept Medicare assignment, then you pay
the
difference between our payment combined with Medicare's payment and the charge.
Note: The physician who does not accept Medicare assignment may not bill you
for more than 115% of the amount Medicare bases its payment
on, called the
"limiting charge." The Medicare Summary Notice (MSN) that Medicare will send you
will have more information about the
limiting charge. If your physician
tries to collect more than allowed by law, ask the physician to reduce their
charges. If the physician does not,
report the physician to your Medicare
carrier who sent you the MSN form. Call us if you need further assistance.
When you have a Medicare Private Contract with a
physician
A physician may ask you to sign a private contract agreeing that you can be
billed directly for services Medicare ordinarily covers. Should
you sign an
agreement, Medicare will not pay any portion of the charges, and we will not
increase our payment. We will still limit our
payment to the amount we would
have paid after Medicare's payment.
Please see Section 9, Coordinating
benefits with other coverage, for more information about how we coordinate
benefits with Medicare. 17
17 Page 18 19
2002 PBP Health
Plan 18 Section 5
Section 5. Benefits – OVERVIEW
(See page 6 for how our benefits changed this year and pages 86
and 87 for a benefit summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claim forms, claims filing
advice, or more information about our benefits, contact us at 800/ 544-7111 or
at our website at www. postmasters. org/ pbp. asp
(a) Medical services and supplies provided by physicians and other health
care professionals .............................. 19-31
Diagnostic and
treatment services
Lab, X-ray, and other diagnostic tests
Preventive
care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical
and occupational therapy
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals......................... 32-38
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services....................................................... 39-43
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ Skilled nursing care
facility benefits
Hospice care
Ambulance
(d) Emergency services/
Accidents.........................................................................................................................
44-45
Medical emergency
Accidental injury
Ambulance
(e) Mental health and substance abuse benefits
.......................................................................................................
46-48
(f) Prescription drug
benefits...................................................................................................................................
49-51
(g) Special features
........................................................................................................................................................
52 Flexible benefits option
24 hours nurse line (at MAYO Clinic)
Complex surgery at MAYO Clinic
Centers of Excellence for transplants at MAYO
Clinic (h) Dental
benefits....................................................................................................................................................
53-59
(i) Non-FEHB benefits available to Plan members
......................................................................................................
60
SUMMARY OF BENEFITS……...…………………………………………….…………………………………….. 86-87
18
18 Page 19 20
2002 PBP Health Plan 19 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The calendar year deductible is: $250 (PPO) or $500 (non-PPO) per person or
$500 (PPO) or $1000 (non-PPO) per family under Standard Option and $200 (PPO) or
$400 (non-PPO)
per person or $400 (PPO) or $800 (non-PPO) per family under
the High Option. The calendar year deductible applies to almost all benefits in
this Section. We added
"( No deductible)" to show when the calendar year
deductible does not apply.
The non-PPO benefits are the standard benefits of
this Plan. PPO benefits apply only when you use a PPO provider. When no PPO
provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE:
The calendar year deductible applies to almost all benefits in this Section. We
say "( No deductible)" when it does not apply.
Diagnostic and treatment
services You pay -Standard Option You pay -High Option
Professional services of physicians
In physician's office, when billed
charges include an office
visit, labs, x-rays or surgeries rendered by the physician
during the
visit
At home
Note: These services do not include services billed by
independent
laboratory or x-ray facilities or services billed by providers other
than
physicians
PPO: $10 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and
any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Diagnostic and treatment services – Continued on next page 19
19 Page 20 21
2002 PBP Health Plan 20 Section 5( a)
Diagnostic and treatment services – continued You pay –
Standard Option You pay -High Option
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing
facility
Medical consultations
Second surgical opinion
Cardiac
rehabilitation
Initial inpatient examination of a newborn child covered
under
a family enrollment
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Note: If your PPO provider uses a non-PPO lab
or radiologist, we
will pay non-PPO benefits for any lab and X-ray charges.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount. 20
20 Page 21 22
2002 PBP Health Plan 21 Section 5( a)
Preventive care, adult You pay – Standard Option You pay -High Option
Routine screenings, limited to:
Hepatitis vaccinations, when
pre-approved by the Plan, for
high-risk individuals. Call us at 1-800-544-7111 for information
about
pre-approval
One colonoscopy every two years, age 40 and older
One barium enema every two years, age 40 and older
Total Blood
Cholesterol – once every three years
Physical exams-(including a complete
history and workup)
once every two years, age 13 through 39; and once every
year,
age 40 and above.
Chlamydial infection for sexually active females
under 25
Colorectal Cancer Screening, including
– One annual fecal occult blood
test, age 40 and older.
PPO: 10% of the Plan allowance
Non -PPO: 30% of the Plan allowance and
any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
– Sigmoidoscopy, screening – One every five years starting
at age 50
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our
allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Prostate Specific Antigen (PSA test) – One annually for men age 40
and
older
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our
allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Preventive care, adult – Continued on next page 21
21 Page 22 23
2002 PBP Health Plan 22 Section 5( a)
Preventive care, adult – continued You pay -Standard
Option You pay-High Option
Routine pap test – One annually for women age
18 and older.
Note: The office visit is covered if pap test is received on
the same
day; see Diagnosis and Treatment, above.
PPO: 10% of the Plan allowance.
Non-PPO: 30% of the Plan allowance and
any difference
between our allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Routine mammogram – covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one
every two consecutive calendar years
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Routine immunizations, limited to:
Influenza/ Pneumococcal vaccine-One
annually, age 65
and over
PPO: Nothing (No deductible)
Non-PPO: Any difference between our
allowance and
the billed amount (No deductible)
PPO: Nothing (No deductible)
Non-PPO: Any difference between our
allowance and
the billed amount (No deductible)
Not covered: Physical exams for school, sports, employment or
travel
All charges. All charges
Preventive care, children
Childhood immunizations recommended by
the American
Academy of Pediatrics
Note: Covered for dependent children
under age 22
PPO: Nothing (No deductible)
Non-PPO: Any difference between our
allowance and
the billed amount (No deductible)
PPO: Nothing (No deductible)
Non-PPO: Any difference between our
allowance and
the billed amount (No deductible)
Preventive care, children – Continued on next page 22
22 Page 23 24
2002 PBP Health Plan 23 Section 5( a)
Preventive care, children -continued You pay -Standard Option You pay
-High Option
For well-child care charges for routine examinations
(including
blood lead level screenings and routine office visits, lab, and
x-rays),
for children through age 12.
PPO: Any difference between our $125 calendar
year allowance and the
billed amount. (No
deductible).
Non-PPO: Any difference between our $125
calendar
year allowance and the billed amount. (No
deductible).
PPO: Any difference between the $150 calendar year
allowance and the
billed amount. (No deductible).
Non-PPO: Any difference between the $150 calendar
year allowance and the
billed amount. (No deductible).
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery. See
Section 3, How
you get care, for other circumstances, such as
extended stays for you or
your baby.
You may remain in the hospital up to 48 hours after a regular
delivery
and 96 hours after a cesarean delivery. We will
cover an extended stay if
medically necessary, but you,
your representative, your doctor, or your
hospital must
precertify.
We cover routine nursery care of the newborn
child during the
covered portion of the mother's maternity stay. We will
cover
other care of an infant who requires non-routine treatment if
we
cover the infant under a Self and Family enrollment.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Maternity care –Continued on next page 23
23
Page 24 25
2002
PBP Health Plan 24 Section 5( a)
Maternity care –
continued You pay -Standard Option You pay -High Option
Stand-by
doctor charges will be covered only if medically
necessary treatment is
actually rendered to the child by the
doctor.
We pay hospitalization and
surgeon services (delivery) the
same as for illness and injury. See Hospital benefits (Section
5c) and
Surgery benefits (Section 5b).
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges All Charges
Family planning
A broad range of
voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as
Norplant)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 20% of the Plan
allowance and any difference
between our allowance and the billed amount.
(No
deductible)
Injectable contraceptive drugs (Such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral
contraceptives under the prescription drug benefit.
Section 5( f).
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges All Charges
Infertility services
Diagnosis and treatment of infertility,
except as shown in Not
covered.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our
allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Infertility services – Continued on next page 24
24 Page 25 26
2002 PBP Health Plan 25 Section 5( a)
Infertility services – continued You pay -Standard
Option You pay– High Option
Not covered:
Infertility services
after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
–
artificial insemination
– in vitro fertilization
–
embryo transfer and (GIFT)
– Intravaginal insemination (IVI)
– Intracervical insemination (ICI)
– Intrauterine
insemination (IUI)
Services and supplies related to ART procedures.
Cost of donor sperm
Cost of donor egg
All charges. All Charges
Allergy care
Testing and treatment, including materials (such as
allergy serum)
Allergy injections
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants is limited to those transplants listed on page 36.
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy
(GHT)
Note: Growth hormone is covered under the prescription drug benefit.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Treatment therapies – Continued on next page 25
25 Page 26 27
2002 PBP Health Plan 26 Section 5( a)
Treatment therapies – continued You pay -Standard
Option You pay-High Option
Note: – We only cover GHT when we
preauthorize the treatment. To
obtain preauthorization, you may call our
customer service department at
800/ 544-7111 and have your physician submit
the complete
medical information to the Plan. If we determine GHT is not
medically
necessary we will not preauthorize the GHT or any related services
and
supplies.
Respiratory and inhalation therapies
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Not covered:
Chelation therapy, except for acute arsenic, gold, lead
or mercury
poisoning
All charges All charges
Physical and occupational therapies
Covered under Alternative
treatment
Speech therapy
Covered under Alternative treatment
Hearing services (testing, treatment, and supplies)
Hearing aids, including exams, tests and adjustments to hearing
devices
when necessitated by accidental injury or surgery
Note: Must be obtained within 120 days of the surgery or injury
PPO: Same as non-PPO
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount
PPO: Same as non-PPO
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Not covered: routine hearing testing
hearing aids,
testing and examinations and batteries for
them, except for accidental
injury or surgery
All charges. All charges 26
26 Page 27 28
2002 PBP Health
Plan 27 Section 5( a)
Vision services (testing, treatment, and
supplies) You pay -Standard Option You pay-High Option
One pair of
eyeglasses or contact lenses to correct an impairment
directly caused by
accidental ocular injury or intraocular
surgery (such as for cataracts).
PPO: Same as non-PPO
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: Same as non-PPO
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Not covered:
Eyeglasses or contact lenses and examinations for
them except as
noted as covered
Eye exercises and orthoptics (visual training)
Radial keratotomy and other refractive surgery
All charges All charges
Foot care
Routine foot care when you are under active treatment
for a
metabolic or peripheral vascular disease, such as diabetes.
PPO: 10% of
the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our
allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Not covered:
Removal or treatment of corns, calluses, free edge
of toenails, and
foot subluxations
Foot orthotics
Arch supports
Orthopedic and corrective shoes
Heel pads and heel cups
All charges All charges 27
27 Page 28 29
2002 PBP Health
Plan 28 Section 5( a)
Orthopedic and prosthetic devices You
pay -Standard Option You pay-High Option
Artificial limbs and eyes;
stump hose
Externally worn breast prostheses and surgical bras,
including necessary replacements following a
mastectomy
Internal
prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast
implants following
mastectomy. Note: See 5( b) for coverage of
the surgery to insert the
device, and 5 ( c for inpatient and
outpatient hospital charges.
PPO: Same as non-PPO
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: Same as non-PPO
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount
Not covered:
Orthopedic and corrective shoes
Arch
supports
Foot orthotics
Heel pads and heel cups
Corsets, trusses, elastic stockings, support hose, and other
supportive devices
All charges. All charges. 28
28 Page 29 30
2002 PBP Health
Plan 29 Section 5( a)
Durable medical equipment (DME) You pay
-Standard Option You pay -High Option
Durable medical equipment (DME) is
equipment and supplies that:
1. Are prescribed by your attending physician
(i. e., the physician who is
treating your illness or injury);
2. Are
medically necessary;
3. Are primarily and customarily used only for a
medical purpose;
4. Are generally useful only to a person with an illness or injury;
5.
Are designed for prolonged use; and
6. Serve a specific therapeutic purpose
in the treatment of an illness or
injury.
We cover rental or purchase, at our option, including repair and
adjustment, of durable medical equipment, such as oxygen and dialysis
equipment. Under this benefit, we also cover:
Hospital beds;
Wheelchairs;
Crutches; and
Walkers.
Note: Call
us at 800/ 544-7111 for information on how to get pre-approval.
Note: A purchase of durable medical equipment in excess of
$300 must be
supported by a letter of medical necessity and pre-approved
by the Plan to
be covered.
PPO: Same as non-PPO (No deductible)
Non-PPO: $100 copayment per device
and 30% of the
Plan allowance and any difference between our
allowance
and the billed amount (No deductible)
PPO: Same as non-PPO (No deductible)
Non-PPO: $100 copayment per device
and 20% of the
Plan allowance and any difference between our
allowance
and the billed amount (No deductible)
Not covered:
Sun or heat lamps; heating pads;
Air
conditioners, purifiers and humidifiers;
Exercise, safety, computer, communication and
convenience equipment;
Whirlpools, saunas and similar household items
All charges All charges
Durable medical equipment (DME) – Continued on next page 29
29 Page 30 31
2002 PBP Health Plan 30 Section 5( a)
Durable medical equipment (DME) – continued You pay
-Standard Option You pay -High Option
Not covered:
Stair
glides, ramps, liftchairs, elevators and other
modifications or alterations to vehicles or households;
All charges All charges
Home health services
Nursing services and home health care when:
A registered nurse (R. N.), licensed practical nurse (L. P. N.) or licensed
vocational nurse (L. V. N.) provides the services;
A home health aide, that is part of a home health care plan after discharge
from covered hospital confinement provides the services
The attending physician orders the care;
The physician identifies the
specific professional skills required by the
patient and the medical necessity for skilled services; and
The physician indicates the length of time the services are needed.
PPO: Same as non-PPO
Non-PPO: 30% of the Plan allowance and any
difference between the $10,000 per person, per
year, maximum Plan
payment and the billed
amount
PPO: Same as non-PPO
Non-PPO: 20% of the Plan allowance and any
difference
between the $10,000 per person, per year, maximum
Plan
payment and the billed amount
Not covered:
Nursing care requested by, or for the convenience
of, the
patient or the patient's family;
Services primarily for
hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral
medication;
Private duty nursing care while confined in a hospital
All charges. All charges 30
30 Page 31 32
2002 PBP Health
Plan 31 Section 5( a)
Chiropractic You pay -Standard Option
You pay -High Option
Covered under Alternative treatment
Alternative treatments
Acupuncture by a doctor of medicine,
osteopathy, or licensed
acupuncturist for anesthesia, or pain relief, or
therapeutic treatment
Physical therapy
Occupational therapy
Speech therapy
Chiropractic services
Cardiovascular, metabolic and
pulmonary conditioning when we
approve a supporting letter of medical necessity from your doctor.
PPO: 10% of the Plan allowance and any difference
between the $2,000 per
person , per year maximum Plan
payment and the billed amount
Non-PPO:
30% of the Plan allowance and any difference
between our allowance and the billed amount and any
difference between
the $2,000 per person , per year maximum
Plan payment and the billed amount
PPO: 10% of the Plan allowance and any difference between the
$2,000 per
person , per year maximum Plan payment and the
billed amount
Non-PPO:
20% of the Plan allowance and any difference
between our allowance and the billed amount and any difference
between
the $2,000 per person , per year maximum Plan
payment and the billed amount
Not covered:
Long-term rehabilitative therapy, except speech
therapy
Exercise programs Maintenance cardiac
rehabilitation
All charges All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking
cessation program per
person per lifetime, including all
related expenses such as prescription
drugs.
Note – Smoking cessation drugs and medications, including
nicotine
patches are not available under any other Plan provisions.
PPO: Same as non-PPO
Non-PPO: Any difference between the $100 per person
per lifetime Plan allowance and the billed amount
PPO: Same as non-PPO
Non-PPO: Any difference between the $100 per person
per lifetime Plan allowance and the billed amount
Diabetes self-management. PPO: 10% of the Plan allowance
Non-PPO: 30% of
the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference
between our allowance and the billed amount 31
31 Page 32 33
2002 PBP Health Plan 32 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The calendar year deductible is: $250 (PPO) or $500 (non-PPO) per person ($
500 PPO or $1000 non-PPO per family) under Standard Option and $200 (PPO) or
$400 (non-PPO)
per person ($ 400 PPO or $800 non-PPO per family) under the
High Option. The calendar year deductible applies to almost all benefits in this
Section. We added "( No deductible)"
to show when the calendar year
deductible does not apply.
The non-PPO benefits are the standard benefits of
this Plan. PPO benefits apply only when you use a PPO provider. When no PPO
provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including with Medicare.
The amounts listed
below are for the charges billed by a physician or other health care
professional for your surgical care. Look in Section 5( c) for charges
associated with the facility (i. e. hospital,
surgical center, etc.)
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE:
The calendar year deductible applies to almost all benefits in this Section. We
say "( No deductible)" when it does not apply.
Surgical procedures You pay -Standard Option You pay -High Option
A comprehensive range of services, such as:
Operative procedures Treatment of fractures,
including casting Normal
pre-and post-operative
care by the surgeon Endoscopy procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital anomalies
(see Reconstructive surgery)
Surgical treatment of morbid obesity --a
condition in which an
individual weighs 100 pounds or 100% over his or her
normal
weight according to current underwriting standards; eligible
members must be age 18 or over
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 20% of the Plan
allowance and any difference
between our allowance and the billed amount.
(No deductible)
Surgical procedures -Continued on next page 32
32 Page 33 34
2002 PBP Health Plan 33 Section 5( b)
Surgical procedures – continued You pay
-Standard Option You pay -High Option
Insertion of internal prosthetic
devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage
information
Voluntary sterilization, and Norplant (a surgically implanted
contraceptive).
Treatment of burns
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount.
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 20% of the Plan
allowance and any difference
between our allowance and the billed amount (No
deductible)
Assistant surgeons – We cover up to 20% of the Plan allowance for
the
primary surgical charge
PPO: Nothing
Non-PPO: Any difference between our
allowance and the
billed amount.
PPO: Nothing (No deductible) Non-PPO: Any difference
between our
allowance and the billed amount (No deductible)
When multiple or bilateral surgical procedures performed during the
same
operative session add time or complexity to patient care, the plan
allowance
for all procedures after the primary procedure is half of the
allowance the
procedure would have if it were a primary procedure.
Note: Multiple or bilateral surgical procedures performed through the same
incision are "incidental" to the primary surgery. That is, the procedure
would
not add time or complexity to patient care. We do not pay extra for
incidental
procedures.
PPO: 10% of the Plan allowance for the primary
procedure and any
difference between our 50% allowance
and the billed amount for subsequent
procedures.
Non-PPO: 30% of the Plan allowance for the primary
procedure and any
difference between our 50% allowance
and the billed amount for subsequent
procedures
PPO: 10% of the Plan allowance for the primary procedure and
any
difference between our 50% allowance and the billed amount
for subsequent
procedures (No deductible)
Non-PPO: 20% of allowance for the primary procedure and any
difference
between our 50% allowance and the billed amount
for subsequent procedures
(No deductible)
Not covered: Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty
All procedures associated with treatment of temporomandibular
disorders Assistant surgery services provided by a
non-physician
provider such as a Physician Assistant (P. A.), Certified
Registered Nurse
First Assistant (C. R. N. F. A.) and a Certified Surgical
Technologist (C.
S. T.)
All charges. All charges. 33
33 Page 34 35
2002 PBP Health
Plan 34 Section 5( b)
Reconstructive surgery You pay -Standard
Option You pay -High Option
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
– the
condition produced a major effect on the member's
appearance and
– the
condition can reasonably be expected to be corrected
by such surgery
Surgery to correct a condition that existed at or from
birth and is a
significant deviation from the common form or norm. Examples
of
congenital anomalies are: protruding ear deformities; cleft lip;
cleft
palate; birth marks; and webbed fingers and toes.
All stages of breast reconstruction surgery following a mastectomy,
such
as:
– surgery to produce a symmetrical appearance on
the other breast;
– treatment of any physical complications, such as
lymphedemas;
– breast prostheses; and surgical bras and
replacements (see Prosthetic devices for coverage)
Note: We pay for internal breast prostheses as hospital benefits when
the
hospital is billing for the prostheses.
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 20% of the Plan
allowance and any difference
between our allowance and the billed amount (No
deductible)
Reconstructive surgery – Continued on next page 34
34 Page 35 36
2002 PBP Health Plan 35 Section 5( b)
Reconstructive surgery – continued You pay -Standard Option
You pay -High Option
Not covered: Cosmetic surgery – any
surgical
procedure (or any portion of a procedure) performed primarily
to improve physical appearance through change in bodily form,
except
repair of accidental injury or for the correction of
congenital anomalies
Injections of silicone, collagens
and similar substances
Surgeries related to sex
transformation or sexual dysfunction or
sexual
inadequacy
All charges All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion Removal of stones from salivary ducts
Excision of tori,
leukoplakia or malignancies
Excision of cysts and incision of abscesses not
involving the teeth
Other surgical procedures that do not involve the teeth
or their supporting
structures Removal of impacted teeth
Note: When multiple or bilateral oral maxillofacial surgical procedures that
add
time or complexity to patient care are performed during the same
operative
session, the Plan pays the same benefits as indicated under
Multiple surgical
procedures for the above listed procedures.
Note: Removal of impacted teeth are not considered multiple procedures.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 20% of the Plan
allowance and any difference
between our allowance and the billed amount (No
deductible)
Not covered: Oral implants and transplants
Procedures
that involve the teeth (other than impacted teeth) or their
supporting
structures (such as the periodontal membrane, gingiva, and
alveolar bone –
See dental benefits)
All charges All charges 35
35 Page 36 37
2002 PBP Health
Plan 36 Section 5( b)
Organ/ tissue transplants You pay
-Standard Option You pay -High Option
Limited to: Cornea
Heart
Heart/ lung
Kidney Pancreas
Liver Single lung
Double lung Intestinal
transplants (small
intestine) and the small intestine with the liver or
small intestine
with multiple organs such as the liver, stomach, and
pancreas.
Bone marrow transplants and stem cell support as follows:
Allogeneic bone marrow for acute leukemia, advanced
Hodgkin's lymphoma,
advanced non-Hodgkins lymphoma,
advanced neuroblastoma (children over age
one), aplastic
anemia, chronic myelogenous leukemia, infantile malignant
osteopetrosis, severe combined immunodeficiency, thalassemia
major, and
Wiskott-Aldrich syndrome.
Autologous bone marrow transplants (autologous stem
cell and peripheral
stem support) for the following
conditions: acute lymphocytic or
nonlymphocytic leukemia;
advanced Hodgkins lymphoma and advanced
non-Hodgkins
lymphoma; advanced neuroblastoma; testicular,
mediastinal,
retroperitoneal and ovarian germ cell tumors; breast
cancer, multiple
myeloma; and epithelial ovarian cancer.
Limited Benefits – Benefits apply only if we cover the recipient and are
limited to $100,000 per transplant. We must approve all related expenses
prior to the surgery, including charges for procurement of cadaver organs.
Note: We cover related medical and hospital expenses of the donor when
we cover the recipient.
A portion of the Plan allowance for covered services and any
amount over
our $100,000 maximum per transplant.
See sections 5( a), 5( b) and 5( c) for the portion you pay.
See National
Transplant Program on next page
A portion of the Plan allowance for covered services and any
amount over
our $100,000 maximum per transplant.
See sections 5( a), 5( b) and 5( c) for the portion you pay
See National
Transplant Program on next page
Organ/ tissue transplants – Continued on next page 36
36 Page 37 38
2002 PBP Health Plan 37 Section 5( b)
Organ/ tissue transplants – continued You pay -Standard
Option You pay -High Option
National Transplant Program-
Limited to
the following preformed at the MAYO Clinic:
Bone marrow Heart
Kidney/ pancreas Liver
Heart/ lung Single lung
Double lung Note: The MAYO Clinic does not
perform intestine
transplants. Note: Benefits include
transportation and lodging provided by
MAYO Clinic. Call us at
800/ 544-7111 for more details.
Nothing Nothing
Not covered: Donor screening tests and donor
search expenses,
except those performed for the actual donor
Services or supplies for or related to organ/ tissue transplants for any
diagnosis not specifically listed as covered including chemotherapy
and/
or radiation therapy when supported by allogeneic or autologous
bone marrow
or stem cell transplants, drugs or medications administered to
stimulate or
mobilize stem cells for transplant, and all other services or
supplies which
are not medically necessary or appropriate but for the
non-covered
procedure.
Allogeneic and autologus bone marrow and stem cell
transplants for
solid tumors except as noted above.
Implants of artificial
organs
Transplants not listed as covered
All charges All charges 37
37 Page 38 39
2002 PBP Health
Plan 38 Section 5( b)
Anesthesia You pay -Standard Option You
pay -High Option
Professional services provided in –
Hospital (inpatient)
PPO: 10% of the Plan allowance
Non-PPO: 30% of
the Plan allowance and any difference
between our allowance and the billed
amount.
PPO: 10% of Plan allowance (No deductible)
Non-PPO: 20% of the Plan
allowance and any difference
between our allowance and the billed amount.
(No deductible)
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount.
Note: If your PPO provider uses a non-PPO
anesthesiologist, we will pay
non-PPO benefits for any
anesthesia charges.
PPO: 10% of the Plan allowance
(No deductible)
Non-PPO: 20% of the
Plan allowance and any difference
between our allowance and billed amount. (No
deductible)
Note: If your PPO provider uses a non-PPO
anesthesiologist, we will pay
non-PPO benefits for any
anesthesia charges. 38
38
Page 39 40
2002
PBP Health Plan 39 Section 5( c)
Section 5( c). Services
provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
Unlike Sections 5( a) and 5( b), in this Section 5( c) the calendar year
deductible applies to only a few benefits. In that case, we added "( calendar
year deductible applies)". The calendar year
deductible is: $250 (PPO) or
$500 (non-PPO) per person or $500 (PPO) or $1000 (non-PPO) per family under
Standard Option and $200 (PPO) or $400 (non-PPO) per person or $400
(PPO) or
$800 (non-PPO) per family under the High Option.
The non-PPO benefits are
the standard benefits of this Plan. PPO benefits apply only when you use a PPO
provider. When no PPO provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also read
Section 9 about coordinating
benefits with other coverage, including with Medicare.
The amounts listed
below are for the charges billed by the facility (i. e. hospital or surgical
center) or ambulance service for your surgery or care. Any costs associated with
the
professional charge (i. e. physicians, etc.) are in Sections 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL
RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification
information shown in Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
NOTE: The calendar year deductible applies
ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital You pay -Standard Option You pay -High Option
Room and board, such as
ward, semiprivate, or intensive care
accommodations;
general nursing care; and
meals and special diets.
Note: We only cover a private room when you must be isolated to prevent
contagion. Otherwise, we will pay the hospital's average charge for
semiprivate
accommodations. If the hospital only has private rooms, we base
our payment
on the average semiprivate rate of the most comparable hospital
in the area.
Note: When the non-PPO hospital bills a flat rate, we prorate the
charges
to determine how to pay them, as follows: 30% room and
board and 70% other
charges.
PPO: 10% of the Plan allowance
Non-PPO: $250 per admission copayment and
30% of the Plan's
covered charges and any difference between our covered charges
and the
billed amount.
Note: If you use a PPO provider and a PPO facility, we may
still pay
non-PPO benefits if you receive treatment from a radiologist,
pathologist, or anesthesiologist that is not a PPO provider.
Note: If you are hospitalized at the MAYO Clinic for an accepted
covered
transplant or an accepted complex surgery, you pay nothing.
PPO: 10% of the Plan allowance
Non-PPO: $150 per admission copayment and
25% of the
Plan's covered charges and any difference between our
covered charges and
the billed amount.
Note: If you use a PPO provider and a PPO facility, we may still
pay
non-PPO benefits if you receive treatment from a
radiologist, pathologist,
or anesthesiologist that is not a
PPO provider.
Note: If you are
hospitalized at the MAYO Clinic for an
accepted covered transplant or an
accepted complex surgery,
you pay nothing.
Inpatient hospital -Continued on next page. 39
39 Page 40 41
2002 PBP Health Plan 40 Section 5( c)
Inpatient hospital -continued You pay -Standard Option
You pay -High Option
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints,
casts, and sterile tray services
Medical supplies and equipment, including
oxygen
Anesthetics
Take home items (including prescription drugs)
Note: Medical supplies, appliances, medical equipment,
and covered items
billed by a hospital for use at home are
covered under section 5( a)
Prosthetic devices such as artificial joints and pacemakers.
PPO: 10% of the Plan allowance
Non-PPO: $250 per admission copayment and
30% of the
Plan's covered charges and any difference between our covered
charges and the billed amount
Note: If you are hospitalized at the MAYO
Clinic for a covered
transplant or an accepted complex surgery, you pay nothing..
PPO: 10% of the Plan allowance
Non-PPO: $150 per admission copayment and
25% of the Plan's covered charges and any difference
between our covered
charges and the billed
amount.
Note: If you are hospitalized at the MAYO
Clinic for a
covered transplant or an accepted complex surgery, you
pay nothing.
Not covered:
Any part of a hospital admission that is not
medically necessary (see
definition), such as when you do not need acute hospital inpatient
(overnight) care, but could receive care in some other setting without
adversely affecting your condition or the quality of your medical care.
Note: In this event, we pay benefits for services and supplies other than
room and board at the level they would have been covered if provided
in
an alternative setting
Custodial care; see definition.
Non-covered facilities, such as nursing homes, extended care
facilities (except when Medicare A is primary) and schools
Personal comfort items, such as telephone, television, barber
services, guest meals and beds
Private nursing care
Surcharges made by hospitals
All charges. All charges. 40
40 Page 41 42
2002 PBP Health
Plan 41 Section 5( c)
Outpatient hospital or ambulatory
surgical center You pay-StandardOption You pay -High Option
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced
Pre-surgical testing
Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics
Prosthetic devices
such as artificial joints and pacemakers
NOTE: – We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment. We cover dental
procedures under the dental benefit. See section 5( h).
PPO: 10% of the Plan allowance (calendar year
deductible applies)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount (calendar year
deductible applies)
PPO: 10% of the Plan allowance (calendar year
deductible applies)
Non-PPO: 20% of the Plan allowance and any
difference between our allowance and the billed
amount (calendar year
deductible applies)
Extended care benefits/ Skilled nursing care
facility benefits
No benefit unless covered under Medicare Part A. Once Medicare has
made their primary payment, we provide secondary benefits for the
appropriate Medicare Part A deductible and coinsurance in full.
PPO: Nothing
Non-PPO: Nothing
PPO: Nothing
Non-PPO: Nothing
Not covered:
Custodial care
Services and supplies
for which Medicare Part A did not provide
benefits
All charges. All charges 41
41 Page 42 43
2002 PBP Health
Plan 42 Section 5( c)
Hospice care You pay -Standard Option
You pay -High Option
Hospice is a coordinated program of maintenance and
supportive care for
the terminally ill provided by a medically supervised team under the
direction of a doctor.
The hospice team may also include social workers,
clergymen/ counselors, volunteers, clinical psychologists, physical and
occupational therapists.
The hospice care program must begin after a
person's primary doctor
certifies terminal illness and life expectancy of six months or less.
Hospice care must be:
Ordered by the supervising doctor,
Charged by the hospice care program, and
Provided within six months from
the date the person
entered ( or re-entered after a period of remission) a
hospice care program.
Note: If you are in remission and discharged from
a hospice care
program, a readmission within three months of a prior discharge is
considered as part of the same period of care. A new period begins three
months after a prior discharge with maximum benefits available.
PPO: Same as non-PPO
Non-PPO: Any difference between the Plan allowance
and the billed amount
Note: The Plan allowance is:
$150 per day up to $3,000 per period of
inpatient care
100% of
covered charges up to $2,000
per period of outpatient care.
PPO: Same as non-PPO
Non-PPO: Any difference between the Plan allowance
and the billed amount
Note: The Plan allowance is:
$150 per day up to $3,000 per period of
inpatient care
100% of
covered charges up to $2,000
per period of outpatient care.
Bereavement benefit:
Family bereavement counseling and supportive
services if the covered
family members receive the services from a hospice care program within
three months following the death of a covered family member who
received
hospice care benefits under the Plan.
PPO: Same as non-PPO
Non-PPO: Any difference between the $200 Plan
allowance and the billed amount
PPO: Same as non-PPO
Non-PPO: Any difference between the $200 Plan
allowance and the billed amount
Not covered: Independent nursing, homemaker All charges. All charges.
42
42 Page 43
44
2002 PBP Health Plan 43 Section 5( c)
Ambulance You pay -Standard Option You pay -High Option
Local
professional ambulance service when medically
appropriate
PPO: Same as non-PPO
Non-PPO: 30% of the Plan allowance
and any
difference between our allowance and the billed
amount (calendar year
deductible applies)
PPO: Same as non-PPO
Non-PPO: 20% of the Plan allowance and any
difference between our allowance and the billed
amount (calendar year
deductible applies) 43
43 Page
44 45
2002 PBP Health Plan 44
Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
The calendar year deductible is: $250 (PPO) or $500 (non-PPO) per person ($
500 PPO or $1000 non-PPO per family) under Standard Option and $200 (PPO) or
$400 (non-PPO) per
person ($ 400 PPO or $800 non-PPO per family) under the
High Option. The calendar year deductible applies to almost all benefits in this
Section. We added "( No deductible)" to
show when the calendar year
deductible does not apply.
The non-PPO benefits are the standard benefits of
this Plan. PPO benefits apply only when you use a PPO provider. When no PPO
provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is accidental injury/ medical emergency? A medical emergency is
the sudden and unexpected onset of a condition or an injury that you believe
endangers
your life or could result in serious injury or disability, and
requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples
include deep
cuts and broken bones. Others are emergencies because they are
potentially life threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or sudden inability to breathe. There are many other acute
conditions that we
may determine are medical emergencies. What they all have
in common is the need for quick action.
What is an accidental injury? An accidental injury is a bodily injury
sustained solely through violent, external, and accidental means, such as
bruised ribs, animal bites, and poisonings.
Benefit Description You pay After the calendar year deductible…
NOTE:
The calendar year deductible applies to almost all benefits in this Section. We
say "( No deductible)" when it does not apply.
Accidental injury You pay -Standard Option You pay -High Option
If
you receive care for your accidental injury within 72 hours, we cover:
Non-surgical physician services and supplies
Related outpatient hospital
services
Note: We pay Hospital benefits if you are admitted.
PPO: Nothing (No deductible)
Non-PPO: The difference between the Plan
allowance
and the billed amount (No deductible)
PPO: Nothing (No deductible)
Non-PPO: The difference between the Plan
allowance
and the billed amount (No deductible)
Accidental injury --Continued on next page 44
44 Page 45 46
2002 PBP Health Plan 45 Section 5( d)
Accidental injury -continued You pay -Standard Option
You pay -High Option
If you receive care for your accidental injury
after 72 hours, we cover:
Non-surgical physician services
and supplies
Related outpatient hospital services
Note: We pay Hospital benefits if you are admitted. See Section
5( c) for
other hospital benefits and Section 5( b) for surgical
benefits.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
PPO: 10% of the Plan allowance
Non-PPO: 20% of the Plan allowance and any
difference between our allowance and the billed
amount
Medical emergency
Outpatient medical or surgical services and
supplies provided in a
hospital emergency room.
PPO: 10% of the Plan allowance and a $50
copayment
per access to care (No deductible)
Non-PPO: 30% of the Plan allowance and a $50 copayment
per access to care
and any difference between the sum of
our allowance plus the copayment and
the billed
amount (No deductible)
PPO: 10% of the Plan allowance and a $50 copayment
per access to care (No
deductible)
Non-PPO: 20% of the Plan allowance and a $50
copayment per access to care
and any difference
between the sum of our allowance plus the
copayment
and the billed amount (No deductible)
Ambulance
Professional ambulance service provided for accidental
injury is
covered under the accidental injury benefit.
When a patient is provided ambulance service to an outpatient
hospital
emergency room for a medical emergency (non-accidental),
we will cover as
indicated in this section.
Note: We cover air ambulance only when it is medically necessary and
the
physician provides a letter of medical necessity.
Note: See 5( c) for non-emergency service.
PPO: Same as non-PPO
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount (No deductible)
PPO: Same as non-PPO
Non-PPO: 20% of the Plan allowance and any
difference between our allowance and the billed
amount (No deductible)
45
45 Page 46 47
2002 PBP Health Plan 46 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
You may choose to get care Out-of-Network or In-Network. When you receive
In-Network care, you must get our approval for services and follow a treatment
plan we approve. If you
do, cost-sharing and limitations for In-Network
mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
The mental health and substance abuse calendar year
deductible or, for facility care, the inpatient deductible apply to almost all
benefits in this Section. We added "( No
deductible)" to show when a deductible does not apply.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE IN-NETWORK SERVICES. See the instructions after the benefits
descriptions below.
In-Network mental health and substance abuse benefits are shown below, then
Out-of-Network benefits begin on page 48.
I M
P O
R T
A N
T
Benefit Description You pay After the mental health and substance
abuse calendar year deductible
NOTE: The mental health and substance
abuse calendar year deductible applies to almost all benefits in this Section.
We say "( No deductible)" when it does not apply.
In-Network benefits
All diagnostic and treatment services
contained in a treatment plan that we approve. The treatment plan may include
services,
drugs, and supplies described elsewhere in this brochure.
Note: In-Network benefits are payable only when we determine the care is
clinically appropriate to treat your
condition and only when you receive the care as part of a treatment plan that
we approve. To request approval, advise
your provider to fax a written
treatment plan to the attention of: PBP Mental Health Coordinator at
703-836-8937.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management is paid as medical. See Section 5 (a)
Note:
Prescription drugs are paid under the Prescription drug benefit. See Section 5
(f)
10% of our allowance , after a mental condition/ substance abuse calendar
year
deductible of $250 under Standard Option or $200 under High Option.
In-Network benefits --Continued on next page. 46
46 Page 47 48
2002 PBP Health Plan 47 Section 5( e)
In-Network benefits – continued You pay
Diagnostic tests – psychiatric
Diagnostic tests – medical are paid
as medical. See Section
5( a)
10% of our allowance, after a mental condition/ substance abuse calendar year
deductible of $250 under Standard Option or $200 under High Option.
Inpatient services provided by a hospital or other facility
Inpatient
services in approved alternative care settings
10% of the Plan allowance.
Outpatient services provided by a hospital or other facility
Outpatient
services in approved alternative care settings
10% of the Plan allowance,
after a mental condition/ substance abuse
calendar year deductible of $250 under Standard Option or $200 under High
Option
Not covered: Services we have not approved.
Note: OPM will
base its review of disputes about treatment plans on the treatment plan's
clinical appropriateness. OPM
will generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.
All charges
Preauthorization To be eligible to receive these enhanced mental
health and substance abuse benefits you must follow your treatment plan and all
of the following
network authorization processes:
Advise your provider
to fax a written treatment plan, for review and approval, to the attention: PBP
Mental Health Coordinator at 703-836-8937,
to initiate consideration of your
case. To identify network providers, call 1-866-218-8317. We will not provide
enhanced benefits for care received
prior to our approval of a treatment
plan.
Out-of-pocket limit For those services with coinsurance, we pay
100% of the Plan allowance for the remainder of the calendar year after
out-of-pocket expenses for the
mental health and substance abuse coinsurance
for that calendar year exceed $3,500 per person per year or $4,000 per family
under Standard Option
and $3,000 per person per year or $3,500 per
family under High Option. 47
47 Page 48 49
2002 PBP Health
Plan 48 Section 5( e)
Out-of-Network benefits You pay
For mental conditions, we cover inpatient doctor visits provided during
a covered admission. A $300 annual deductible and 50% of the Standard Option
Plan allowance or
a $275 annual deductible and 20% of the High Option Plan
allowance, and
any difference between our allowance and the billed charges.
For mental conditions, we cover inpatient room and board and other hospital
charges for up to 100 days per covered
person each calendar year.
Note:
For individual cases, we may agree to cover hospital day treatment (partial
hospitalization) the same as inpatient
care. We consider two admissions
separated by less than 30 days to be one admission.
A $500 per admission copayment, 40% of the Standard Option Plan
allowance
or 30% of the High Option Plan allowance, and any difference
between our
allowance and the billed charges.
For mental conditions, we allow up to $100 per visit for 25 outpatient visits
per person per year.
Note: Visits used to meet the deductible amount are not
counted as part of the 25 visits.
A $300 annual deductible and 50% of the
Standard Option Plan allowance or
a $275 annual deductible and 50% of the
High Option Plan allowance and
any difference between our allowance and the
billed charges
For substance abuse, we cover hospital inpatient care and services,
outpatient services and supplies, and rehabilitation.
This benefit is
limited to a maximum.
A $500 annual deductible, 30% of the Plan allowance,
and charges in excess
of our allowance and the $3,500 per person per year
maximum benefit.
Not covered:
Treatment related to marital discord
Personal
comfort items such as telephone and television, guest meals and beds, barber and
beauty services
Custodial care (see page72)
Treatment for learning disabilities
Services rendered or billed by schools, residential treatment centers
or halfway houses or members of their staffs
All charges
Precertification The medical necessity of your admission to a hospital
or other covered facility must be precertified for you to receive these
Out-of-Network benefits. Emergency
admissions should be reported
immediately, but no more than two business days following the day of admission
even if you have been discharged. Otherwise, the
benefits payable will be
reduced by $500. See Section 3 for details.
See these sections of the brochure for more valuable information about these
benefits:
Section 5( e), Mental health and substance abuse benefits
provides the full information about the catastrophic protection for these
benefits.
Section 7, Filing a claim for covered services for information about
submitting out-of-network claims. 48
48 Page 49 50
2002 PBP Health
Plan 49 Section 5( f)
Section 5 (f). Prescription drug
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
The annual drug deductible is $100 per person for network retail
pharmacies or $150 per person for non-network retail pharmacies for both
Standard Option and High Option. The
annual drug deductible applies to
almost all benefits in this section. We added "( No deductible)" to show when
the annual drug deductible does not apply.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or a licensed
dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a network
pharmacy, a non-network pharmacy, or by mail. We pay a higher level of benefits
when you use a network pharmacy or our mail
order program for maintenance
medication. To locate a network pharmacy in your area call NPA/ BeneCard at
1-800-467-2006 or visit our website at http:// www. postmasters. org/ pbp. asp
We use a formulary. The formulary identifies preferred name brand
drugs. Our formulary applies to drugs received from a network retail pharmacy or
our mail order program. Your copayment is less for
drugs listed on our
formulary than for those drugs not listed.
We have an open formulary. If
your physician believes a name brand product is necessary or there is no generic
available, your physician may prescribe a name brand drug from a formulary list.
This list
of name brand drugs is a preferred list of drugs that we selected to meet
patient needs at a lower cost. To order a prescription drug brochure, call
1-800-467-2006
These are the dispensing limitations. We will cover up to a 30-day
supply of covered drugs or supplies from network retail pharmacies or from
non-network retail pharmacies. Call NPA/ Benecard at
1-800-467-2006 or visit
our website at http:// www. postmasters. org/ pbp. asp to locate a network
retail pharmacy in your area. If you file a prescription at a non-network retail
pharmacy, our benefit is based
on the cost of the drug at a network retail
pharmacy. Network pharmacies will not dispense a refill until enough time has
passed for the prior prescription to be mostly used. You must present your
prescription drug identification card when using a network retail pharmacy
to receive network benefits. If you fail to present the card for any reason,
non-network benefits will apply.
You may purchase up to a 90-day supply of maintenance drugs through the Mail
Order Drug Program. The Mail Order Drug Program will not dispense drugs that
require constant refrigeration, are too heavy
to mail, or that must be
administered in a clinical setting.
When a doctor prescribes different doses
of the same medication on the same prescription, we consider each dose a new
prescription, therefore a copayment would be required. 49
49 Page 50 51
2002 PBP Health Plan 50 Section 5( f)
The Mail Order Drug Program will dispense a generic equivalent drug if
it is available, unless your
doctor specifically requires a name brand. If
you receive a name brand drug when a Federally-approved generic drug is
available, and your doctor has not specified Dispense as Written for the
name brand drug, you have to pay the difference in the cost between the name
brand drug and the generic.
Why use generic drugs? Generic drugs are the therapeutic equivalent of
more expensive brand
name drugs. Generic drugs are less expensive than the
brand name drugs they replace. You may reduce your out-of-pocket costs by
choosing to use generic drugs.
When you file a claim There is no claim to file when a network retail
pharmacy or the mail order program fills prescriptions. We will send you
information on the mail order drug program and how to
file a claim for
non-network retail pharmacies. You must complete the initial mail order form,
enclose your prescription and copayment, and mail your order. Allow two weeks
for delivery.
Benefit Description You Pay
After the annual drug deductible…
NOTE: The annual drug deductible applies to almost all benefits in this
Section. We say "( No deductible)" when it does not apply.
Covered medications and supplies You pay -Standard Option You pay -High
Option
Each new enrollee will receive a description of our prescription
drug
program, a prescription drug identification card, a mail order
form/ patient profile and a preaddressed reply envelope.
You may purchase the following medications and supplies prescribed
by a
physician from either a pharmacy or by mail:
Drugs and medicines (including
those administered during a non-covered
admission or in a non-covered
facility) that by Federal
law of the United States require a physician's
prescription for their
purchase, except those listed as Not covered.
Insulin Needles and syringes for the
administration of covered
medications
Contraceptive drugs and devices
Network Retail: The greater of 20% or $15 generic, $30
formulary brand
name, or $40 non-formulary brand name
Network Retail Medicare: The greater of 20% or $15 generic,
$30 formulary
brand name, or $40 non-formulary brand name
Non-Network Retail: 30% of the Plan allowance for a
network pharmacy and
any difference between our
allowance and the billed amount.
Non-Network Retail Medicare: 30% of the Plan allowance for a
network
pharmacy and any difference between our
allowance and the billed amount.
Network Retail: The greater of 20% or $10 generic, $25
formulary brand
name, or $40 non-formulary brand
name
Network Retail Medicare: The
greater of 20% or $10
generic, $25 formulary brand name, or $40 non-formulary
brand name
Non-Network Retail: 20% of the Plan allowance for a
network pharmacy and any difference between our
allowance and the billed
amount.
Non-Network Retail Medicare: 20% of the Plan
allowance for a network
pharmacy and any difference
between our allowance and the billed amount.
Covered medications and supplies – Continued on next page 50
50 Page 51 52
2002 PBP Health Plan 51 Section 5( f)
Covered medications and supplies – continued You pay
-Standard Option You pay -High Option
Each new enrollee will receive a
description of our prescription drug
program, a prescription drug
identification card, a mail order
form/ patient profile and a preaddressed
reply envelope.
You may purchase the following medications and supplies prescribed
by a
physician from either a pharmacy or by mail:
Drugs and medicines (including
those administered during a non-covered
admission or in a non-covered
facility) that by Federal
law of the United States require a physician's
prescription for their
purchase, except those listed as Not covered.
Insulin Needles and syringes for the
administration of covered
medications
Contraceptive drugs and devices
Network Mail Order: $15 generic, $30 formulary brand
name, or the greater
of 20% or $40 non-formulary brand name
(No deductible)
Network Mail
Order Medicare: $7 generic, $15 formulary
brand name, or the greater of 20% or $25 non-formulary
brand name. (No
deductible)
Note: If there is no generic equivalent available, you will
still have to pay the brand name copayment.
Network Mail Order: $10 generic, $25 formulary brand
name, or the greater
of 20% or $40 non-formulary brand
name (No deductible)
Network Mail
Order Medicare: $5 generic, $12
formulary brand name, or the greater of 20% or $25 non-formulary
brand
name (No deductible)
Note: If there is no generic equivalent available, you will
still have to
pay the brand name copayment
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines
Drugs to aid in smoking cessation other than those
covered under the
smoking cessation benefit.
Medical supplies such as dressings and antiseptics
All Charges All Charges 51
51 Page 52 53
2002 PBP Health
Plan 52 Section 5( g)
Section 5 (g). Special features
Special features Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly
alternative benefit.
Alternative benefits are subject to our ongoing
review.
By approving an alternative benefit, we cannot guarantee you will
get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular
contract benefits.
Our
decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 1-866-218-8317 and talk with a registered nurse who
will discuss treatment options and answer your health
questions.
Complex surgery The MAYO Clinic operates three facilities (Minnesota,
Florida and Arizona) that specialize in providing efficient and economical
complex surgical care such as hip/ knee replacements,
coronary bypass, heart
valve replacement, or mastectomy. If the MAYO Clinic accepts your case, you pay
nothing for the hospital
and surgical care they render. Call us at 800/
544-7111 for details about seeking care at the MAYO Clinic.
Centers of excellence for transplants See National Transplant Program
under Organ/ Tissue transplant in Section 5( b). The MAYO Clinic operates three
facilities (Minnesota, Florida and Arizona) that specialize in providing
efficient and economical transplants for most organ transplants. If you
receive a transplant, listed as covered under the Transplant
Program, at the
MAYO Clinic, you pay nothing for the hospital and surgical care they render.
Call us at 800/ 544-7111 for details
about seeking care at the MAYO Clinic.
52
52 Page 53 54
2002 PBP Health Plan 53 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
There is a $30 per person annual dental deductible under High Option. There
is no dental deductible under Standard Option.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including
with Medicare.
Note: We cover hospitalization for dental procedures only
when the patient has a non-dental physical impairment which makes
hospitalization necessary to safeguard the
patient's health.
I M
P O
R T
A N
T
Accidental injury benefit You pay -Standard Option You pay -High Option
We cover restorative services and supplies necessary to promptly
repair (but not replace) sound natural teeth. The need for these services
must result from an accidental injury.
Note: Injury to the teeth from chewing or biting is not considered
an
accidental injury for purposes of this provision.
Any amount over the High Option Schedule of
allowances.
Any amount
over the High Option Schedule of
allowances.
Dental benefits
We provide dental benefits for services listed in
the following Schedule of dental allowances:
Under Standard Option, we cover charges up to the applicable allowance shown
in the Schedule of dental allowances. There is no calendar year maximum.
Under High Option, after the $30 yearly dental deductible, we cover charges
up to a percentage of the applicable allowance shown in the Schedule of dental
allowances. This percentage depends upon the number
of calendar years the
member has been continuously enrolled under the High Option of this Plan, as
follows: first calendar year, 50% of scheduled allowance; second calendar
year, 75% of scheduled allowance,
thereafter, 100% of
scheduled allowance.
Under High Option the maximum benefit payable for any
calendar year is $800 per person, $2,000 per family. Only scheduled allowances
shown in the Schedule of dental allowances may be applied toward the
dental
deductible or the maximum payable.
The following Schedule of dental
allowances, is a complete list of covered dental services available.
Note: We pay actual charges up to the scheduled allowances. 53
53 Page 54 55
2002 PBP Health Plan 54 Section 5( h)
Dental benefits We pay (scheduled allowance)
Service Standard
Option High Option You pay
Basic services
Diagnostic
Periodic oral evaluation (routine exams limited to two per year) $6.50 $6.50
* All charges in excess of
the scheduled amounts
listed to the left
Limited oral evaluation –
problem focused $6.50 $6.50 * Comprehensive oral evaluation $9.00 $9.00 *
Detailed and extensive oral evaluation-problem focused, by report N/ A $11.00
*
Intraoral, complete series including bite wings (limited to one every
three years) $15.00 $23.00 *
Intraoral periapical first film $1.00 $3.50 *
Intraoral, periapical each additional film $1. 00 $1. 00 *
Intraoral, occlusal film $7.50 $7.50 * Extraoral, first film N/ A $7. 00 *
Extraoral, each additional film N/ A $7. 00 * Bitewing, single film $3.00
$3.50 *
Bitewings, two films $4.00 $6.50 * Bitewings, four films ( bitewings
limited to
two series per year) $6.50 $9.50 * Panoramic film (considered a
complete
series) $15.00 $19.00 * Pulp vitality N/ A $7. 00 *
Diagnostic
casts N/ A $15.50 *
Preventive * Prophylaxis, adult (age 14 or over)
(prophylaxes or cleanings are limited to two per year) $10.50 $14.50 *
Prophylaxis, child (under age 14) (prophylaxes or cleanings are limited to
two
per year)
$10.50 $10.50 *
Topical application of fluoride, including prophylaxis $16.00 $17.00 *
Topical application of fluoride, prophylaxis not included (application of
fluoride, limited
to one per year and to children under age 14)
$5.50
$6.50 *
Space maintainer, fixed, unilateral N/ A $77.50 * Space maintainer, fixed,
bilateral N/ A $77.50 *
Space maintainer, removable, unilateral N/ A $113.50
* Space maintainer, removable, bilateral N/ A $113.50 *
Recementation of
space maintainer (space maintainer are passive appliance, schedule
limit
includes all adjustments)
N/ A $10.00 * 54
54
Page 55 56
2002
PBP Health Plan 55 Section 5( h)
Restorative Note:
Multiple restorations on one surface
will be considered as a single
restoration.
Standard Option High Option You pay
Amalgam, one surface, primary $11.50 $13.50 * Amalgam, two surfaces, primary
$16.50 $19.50 *
Amalgam, three surfaces, primary $22.00 $25.00 * Amalgam,
one surface, permanent $11.50 $14.50 *
Amalgam, two surfaces, permanent
$18.00 $22.00 * Amalgam, three surfaces, permanent $22.00 $29.50 *
Silicate
cement $16.50 $18.00 * Resin, one surface $11.50 $17.00 *
Resin, two
surfaces $18.00 $24.00 * Resin, three surfaces $22.00 $29.50 *
Pin
retention, per tooth in addition to restoration N/ A $10.50 *
Endodontics Pulp cap, direct N/ A $9.50 *
Pulp cap, indirect N/ A
$9.50 * Therapeutic pulpotomy N/ A $17.50 *
Root canal, one N/ A $108.00 *
Root canal, two N/ A $131.00 *
Root canal, three or more N/ A $178.50 *
Apexification/ recalcification-initial visit N/ A $7. 00 *
Apicoectomy/
periradicular surgery-anterior N/ A $113.00 *
Periodontics
Gingivectomy or gingivosplasty, per quadrant N/ A $86.00 *
Gingivectomy or gingivosplasty, per tooth N/ A $22.00 * Gingival curettage,
surgical, per quadrant, by
report N/ A $12.00 * Gingival flap procedure
including root
planning, per quadrant N/ A $33.50 * Clinical crown
lengthening-hard tissue N/ A $90.00 *
Osseous surgery (including flap entry
and closure) per quadrant N/ A $194.00 *
Bone replacement graft-first site
in quadrant N/ A $84.00 * Free soft tissue procedure (including donor
site
surgery) N/ A $142.00 * Provisional splinting, intracoronal N/ A $33.50 *
Provisional splinting, extracoronal N/ A $35.50 * Periodontal scaling and
root planing, per
quadrant N/ A $15.00 * Periondontal maintenance procedure
(following active therapy) N/ A $19.50 *
Prosthodontics (removable)
repairs Repair broken complete denture base N/ A $26.00 *
Replace missing or broken teeth, complete denture (each tooth) N/ A $5.00 *
Repair resin denture base N/ A $25.00 * Repair cast framework N/ A $34.00 *
Repair or replace broken clasp N/ A $20.00 * Prosthodontics (removable) –
Continued on next page 55
55 Page 56 57
2002 PBP Health
Plan 56 Section 5( h)
Prosthodontics (removable) repairs
-continued Standard Option High Option You Pay
Replace broken teeth, per
tooth N/ A $5.00 * Add tooth to existing partial denture N/ A $11.00 *
Add
clasp to existing partial denture N/ A $24.00 *
Oral surgery (includes
local anesthesia and routine
postoperative care) Extraction, single teeth $12.50 $17.00 *
Extraction, each additional tooth $7.50 $14.50 * Root removal, exposed roots
N/ A $18.00 *
Surgical removal of erupted tooth requiring elevation of
mucoperiostael flap and removal
of bone and/ or section of tooth
$19.00
$24.00 *
Surgical removal of residual tooth roots (cutting procedure N/ A $28.50 *
Surgical exposure of impacted or unerupted tooth to aid eruption N/ A $46.50
*
Alveoloplasty in conjunction with extractions per quadrant N/ A $30.50 *
Alveoloplasty not in conjunction with extractions per quadrant N/ A $49.50 *
Removal of odontogenic cyst or tumor, lesion diameter up 1.25 cm N/ A $42.00
*
Removal of odontogenic cyst or tumor, lesion diameter over 1.25 cm N/ A
$94.50 *
Incision and drainage of abscess, intraoral soft tissue N/ A $24.50
*
Incision and drainage of abscess, extraoral soft tissue N/ A $24.50 *
Excision of hyperplastic tissue, per arch N/ A $67.00 * Excision of
pericoronal gingiva N/ A $28.50 *
Adjunctive general services General anesthesia N/ A $45.00 *
Analgesia N/ A $9.00 * Intravenous sedation N/ A $43.00 *
Consultation
(diagnostic service provided by dentist or physician other than practitioner
providing treatment)
N/ A $18.00 *
Office visit for observation (during regularly scheduled hours) N/ A $6.50 *
Office visit, after regularly scheduled hours N/ A $8. 00 * Occlusion
analysis, mounted case N/ A $17.50 *
Occlusal adjustment, limited N/ A
$25.00 * Occlusal adjustment, complete N/ A $110.00 *
Major services
Restorative Gold foil, one surface N/ A $24.50 *
Gold foil, two surfaces N/ A $53.50 * Gold foil, three surfaces N/ A $74.50 *
Restorative – Continued on next page 56
56
Page 57 58
2002
PBP Health Plan 57 Section 5( h)
Restorative – continued
Standard Option High Option You Pay
Inlay, metallic, one surface N/ A
$40.00 * Inlay, metallic, two surfaces N/ A $92.50 *
Inlay, metallic, three
or more surfaces N/ A $117.50 * Inlay, porcelain/ ceramic, one surface N/ A
$24.50 *
Inlay, porcelain/ ceramic, two surfaces N/ A $45.00 * Inlay,
porcelain/ ceramic, three or more
surfaces N/ A $69.00 * Crown, resin
(laboratory) N/ A $73.50 *
Crown, resin with high noble metal N/ A $198.50 *
Crown, resin with predominantly base metal N/ A $167.00 *
Crown, resin with
noble metal N/ A $182.50 * Crown, porcelain/ ceramic substrate N/ A $184.00 *
Crown, porcelain fused to high noble metal N/ A $215.50 * Crown, porcelain
fused to predominantly base
metal N/ A $184.00 * Crown, porcelain fused to
noble metal N/ A $199.50 *
Crown, full cast high noble metal N/ A $203.50 *
Crown, full cast predominantly base metal N/ A $172.00 *
Crown, full cast
noble metal N/ A $188.00 * Crown, cast metallic N/ A $198.50 *
Recement
inlay N/ A $11.50 * Recement crown N/ A $11.50 *
Prefabricated stainless
steel crown primary or permanent tooth N/ A $40.00 *
Prefabricated resin
crown N/ A $40.00 * Sedative filling N/ A $8. 00 *
Core buildup including
any pins N/ A $2.00 * Cast post and core in addition to crown N/ A $56.50 *
Prefabricated post and core in addition to crown N/ A $32.00 *
Temporary
crown (fractured tooth) N/ A $40.00 *
Prosthodontics (removable)
Complete upper or lower denture N/ A $242.50 *
Immediate upper or lower denture N/ A $275.00 * Maxillary partial
denture-resin (including any
conventional clasps, rest and teeth) N/ A
$237.50 * Mandibular partial denture-resin base
(including any conventional
clasps, rest and teeth) N/ A $237.50 *
Maxillary partial denture-cast metal
framework with resindenture bases (including
any conventional clasps and
teeth)
N/ A $271.00 *
Mandibular partial denture-cast metal framework with resin denture bases
(including any conventional clasps, rest and teeth)
N/ A $271.00 *
Removable unilateral partial denture-one piece cast metal (including clasps
and teeth) N/ A $157.50 *
Prosthodontics (removable) – Continued on next
page 57
57 Page
58 59
2002 PBP Health Plan 58
Section 5( h)
Prosthodontics (removable) – continued
Standard Option High Option You pay
Adjust complete upper or
lower denture N/ A $17.00 * Adjust partial upper or lower denture N/ A $17.00 *
Rebase complete denture N/ A $94.50 * Rebase partial denture N/ A $71.00 *
Reline complete denture ( chairside) N/ A $56.50 * Reline partial denture
(chairside) N/ A $43.00 *
Reline complete denture (laboratory) N/ A $76.00 *
Reline partial denture (laboratory N/ A $65.00 *
Interim complete denture N/
A $115.50 * Interim partial denture N/ A $65.00 *
Tissue conditioning per
denture unit N/ A $20.00 * Overdenture, complete, by report N/ A $350.00 *
Overdenture, partial, by report N/ A $280.00 * Precision attachment, by
report N/ A $98.00 *
Prosthodontics (fixed) * Pontic, cast high noble metal N/ A $204.00 *
Pontic, cast predominantly base metal N/ A $172.00 * Pontic, cast noble
metal N/ A $188.00 *
Pontic, porcelain fused to high noble metal N/ A
$215.50 *
Pontic, porcelain fused to predominantly base metal N/ A $184.00 *
Pontic, porcelain fused to noble metal N/ A $199.50 * Pontic, resin with high
noble metal N/ A $222.00 *
Pontic, resin with predominantly base metal N/ A
$175.00 * Pontic, resin with noble metal N/ A $197.00 *
Inlay, metallic two
surfaces N/ A $92.50 * Inlay, metallic three or more surfaces N/ A $117.50 *
Retainer-Cast metal for resin bonded fixed prosthetics N/ A $34.00 *
Crown, resin with high noble metal N/ A $215.50 * Crown, resin with
predominantly base metal N/ A $184.00 *
Crown, resin with noble metal N/ A
$199.50 * Crown, porcelain fused to high noble metal N/ A $234.00 *
Crown,
porcelain fused to predominantly to base metal N/ A $185.00 *
Crown,
porcelain fused to noble metal N/ A $205.00 * Crown, cast high noble metal N/
A $198.50 *
Crown, full cast high noble metal N/ A $209.00 * Crown, full
cast predominantly base metal N/ A $187.00 *
Crown, full cast noble metal N/
A $185.00 * Recement fixed partial denture N/ A $21.00 *
Stress breaker N/ A
$56.50 * Precision attachment N/ A $92.50 *
Cast post and core in addition
to fixed partial denture retainer N/ A $66.00 *
Prosthodontics (fixed) –
Continued on next page 58
58 Page 59 60
2002 PBP Health
Plan 59 Section 5( h)
Prosthodontics (fixed) -continued
Standard Option High Option You pay
Cast post as part of fixed
partial denture retainer N/ A $51.00 *
Prefabricated post and core in
addition to fixed partial denture retainer N/ A $37.00 *
Not covered:
Services and supplies furnished by other than a
licensed dentist, except for a
prophylaxis (cleaning) which may be performed by a licensed dental
hygienist
working under the supervision of a dentist or an accredited school
of
dentistry
Dental services and supplies for which other
benefits are payable
Replacement of bridges, dentures or appliances within five years of
coverage
of previous placement by this Plan
Fluorides for home
use
Dental implants
Any dental service or supply for
cosmetic purposes
Training in preventive care, oral hygiene or dietary practices
Orthodontic treatment
N/ A N/ A All charges 59
59 Page 60 61
2002 PBP Health
Plan 60 Section 5 (I)
Section 5 (i). Non-FEHB benefits
available to Plan members
The benefits on this page are not part of the
FEHB contract or premium, and you cannot file an FEHB disputed claim about
them. Fees you pay for these services do not count toward FEHB deductibles
or out-of-pocket
maximums.
Long term care (LTC)
What would happen to your finances today if
you required immediate long-term nursing home care? You may need benefits beyond
those available through your FEHB Program or through Medicare's "skilled"
nursing home benefits.
Long term care (LTC) coverage is the answer. The League has secured the
services of Long Term Preferred Care, Inc., the nation's premier long term care
expert, to help you determine your needs. To find out more, call their toll-free
line
(800)-742-1110 or visit their web site at www. ltpc. com. Be
sure to tell them you are a LEAGUE member.
Supplemental Dental
All members of the League may enroll in the
League Dental Program. The League does not require enrollment in the FEHB Plan
for enrollment in the League Dental Program. The League Dental Program provides
up to $1, 000 of
benefits per year. With the League Dental Program, you do not have to change
from your current dentist. This program pays benefits directly to you, or to
your dentist. Members may enroll in one of the three levels of coverage:
individual,
self and spouse, or family. Enrollees pay premiums quarterly.
Coverage becomes effective the first of the month following receipt of your
completed application and quarterly premium. For more information about
benefits,
limitations and premiums, and to request an application, write to:
League Insurance Services, 4800 Montgomery Lane, M25, Bethesda, MD 20814. To get
information by telephone, call toll free 1-800-522-1857.
Guaranteed Issue Life Insurance
Guaranteed issue group term life
insurance is available to all PBP Health Plan enrollees. Two major private
insurance companies, US Life and American General, are offering
ALL PBP Health Plan enrollees guaranteed issue extra life
insurance.
No
health questions. No medical exams. Extra benefits for accidental death.
Personal premiums are based on your age. For example, $15, 000 of life insurance
PLUS $15, 000 of accidental death coverage for just $7. 50 biweekly. For
details,
call US Life Customer Service at 1-800-346-7692.
Eyewear program
Outlook Vision Services Program offers you and
your entire family all the saving advantages available only to Outlook Vision
Services members from over 6000 Professional Vision Care Providers in all
50 States and Puerto Rico. The
network includes national and regional vision care centers such as JC Penney
Optical, Montgomery Ward, Royal Optical, Sears, Pearl Vision, For Eyes Only,
Sterling Optical, Eye Masters. It also includes independent optometrists
and
opticians.
Best of all, as a member, you can save up to 50% off the
retail price of prescription glasses and sunglasses, contact lenses,
nonprescription sunglasses, and accessories. For more information, contact
Outlook Vision Services at:
Guardian Eagle Corporation, P. O. Box 84415,
Sioux Falls, SD 57118 or 1-800-342-7188
Non-FEHBP Benefits are not part of the FEHB contract 60
60 Page 61 62
2002 PBP Health Plan 61 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless we determine it is
medically necessary to prevent, diagnose, or treat your illness, disease,
injury, or condition.
We do not cover the following:
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term, or when the
pregnancy is the result of an act of rape or incest
Services, drugs, or supplies related to sex transformations; or sexual
dysfunction; or sexual inadequacy;
Services, drugs, or supplies you receive
from a provider or facility barred from the FEHB Program.
Charges that would
not be made if covered individual had no health insurance coverage;
Services
furnished without charge ( except as described on page 71; services rendered
while in active military service; or services required for an illness or injury
sustained on or after the effective date of enrollment (1) as a
result of an act of war within the United States, its territories or
possessions or (2) during combat;
Services furnished by immediate relatives
or household members, such as a spouse, parent, child, brother, or sister, by
blood, marriage or adoption;
Services furnished or billed by noncovered facility, except that medically
necessary prescription drugs are covered;
Services not specifically listed
as covered;
Services provided in connection with a noncovered service;
Any portion of a provider's fee or charge ordinarily due from the enrollee
but that has been waived. If a provider routinely waives (does not require the
enrollee to pay) a deductible, copay or coinsurance, we will
calculate the actual provider fee or charge by reducing the fee or charge by
the amount waived;
Charges neither you nor we have a legal obligation to
pay, such as excess charges for annuitant age 65 or older who is not covered by
Medicare Parts A and/ or B ( see page 16), doctor charges exceeding the amount
specified
by the Department of Health and Human Services when benefits are payable
under Medicare (limiting charge see page 17), or State premium taxes however
applied;
Routine preventive care, immunizations and all related expenses except as
provided on pages 21, 22 and 23;
Treatment for weight control or reduction
(except morbid obesity);
Social, recreational and educational services or
training not specifically listed as covered
Therapy, other than speech
therapy, for developmental delays, learning disabilities, stuttering, tongue
thrusting or deviate swallowing;
Treatment of temporomandibular joint disorder;
Services rendered by
Christian Scientist providers (including sanitariums); 61
61 Page 62 63
2002 PBP Health Plan 62 Section 6
Services rendered by massage therapists, rolfers, myotherapists, and
trager clinics;
Services rendered by hypnotherapists, neuromuscular
therapists and naturopaths;
Hospital benefits for admissions required for
surgical procedures excluded by us
Interest, completion of claim forms, or
similar administrative charges made by providers;
Travel, transportation,
convalescent care or rest cures; or
Services and supplies for cosmetic
purposes such as Rogaine or wigs. 62
62 Page 63 64
2002 PBP Health
Plan 63 Section 7
Section 7. Filing a claim for covered
services
How to claim benefits To obtain claim forms or other claims
filing advice or answers about our benefits, contact us at 800/ 544-7111, or at
our website at
www. postmasters. org/ pbp. asp
In most cases, providers
and facilities file claims for you. Your physician must file on the form
HCFA-1500, Health Insurance Claim Form. Your
facility will file on the UB-92
form. For claims questions and assistance, call us at 800/ 544-7111
When you must file a claim --such as for overseas claims or when another
group health plan is primary --submit it on the HCFA-1500 or a claim
form
that includes the information shown below. See Section 5( f), Prescription
drug benefits for information about special claim filing
instructions.
Bills and receipts should be itemized and show:
Name of patient and
relationship to enrollee;
Plan identification number of the enrollee;
Name and address of person or firm providing the service or supply;
Provider tax identification number (needed for assigned claims and PPO
providers);
Dates that services or supplies were furnished;
Diagnosis;
Type of
each service or supply; and
The charge for each service or supply.
Note:
Canceled checks, cash register receipts, or balance due statements are not
acceptable substitutes for itemized bills.
In addition:
You must send a copy of the explanation of benefits (EOB)
from any primary payer (such as the Medicare Summary Notice (MSN)) with
your
claim.
Bills for home nursing care must show that the nurse is a registered
or licensed practical nurse and should include nursing notes.
Claims for rental or purchase of durable medical equipment in excess of $300;
private duty nursing; and physical, occupational, and speech
therapy require
a written statement from the physician specifying the medical necessity for the
service or supply and the length of time
needed. 63
63 Page 64 65
2002 PBP Health Plan 64 Section 7
Claims for prescription drugs and supplies that are not ordered through
the Mail Service Prescription Drug Program must include receipts
with the
prescription number, name of drug or supply, prescribing physician's name, date,
and charge.
You must include an English translation and currency conversion to U. S.
dollars with claims for overseas (foreign) services.
For dental claims,
complete the member's section of the claim form and give it to the dentist to
complete the remainder.
Submit Medical Claims To: PBP Health Benefit Plan
PO Box 1040 Columbia, MD 21044
Submit Dental Claims To: Attn: PBP Dental
Unit
Vista Plan Administrators, Inc. 2556 Arthur Kill Road
Staten
Island, NY 10309
Submit Mental and Substance Abuse Claims To:
PBP Health Plan PO Box 1040
Columbia, MD 21044
Submit non-network Pharmacy Claims To:
BeneCard 168 Franklin Corner Road
Building 2, Suite 201 Lawrenceville, NJ 08648
Records Keep a separate record of the medical expenses of each covered
family member as deductibles and maximum allowances apply separately to each
person. Save copies of all medical bills, including those you accumulate to
satisfy a deductible. In most instances they will serve as evidence of your
claim. We will not provide duplicate or year-end statements.
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. Once we pay benefits,
there is a three-year limitation on the reissuance of uncashed checks.
Overseas claims For covered services you receive in hospitals outside
the United States and Puerto Rico and performed by physicians outside the United
States, send a
completed claim form and the itemized bills to:
PBP
Health Plan 1019 N. Royal Street
Alexandria, VA 22314-1596.
Send any
written inquiries concerning the processing of overseas claims to this address.
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. 64
64 Page
65 66
2002 PBP Health Plan 65
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for preauthorization/ prior approval:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision;
(b) Send your request to us at: PBP Health Plan
1019 N. Royal
Street
Alexandria, Virginia 22314-1596
(c) Include a statement about why
you believe our initial decision was wrong, based on specific benefit provisions
in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim; (or if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we
will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us --if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II, 1900 E Street, Washington, D. C. 20415-3620. 65
65 Page 66 67
2002 PBP Health Plan 66 Section 8
The disputed claims process (continued)
Send OPM the
following information:
A statement about why you believe our decision was
wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you
received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior approval. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, Federal law governs your lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 800/ 544-7111 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818
between 8 a. m. and 5 p. m.
eastern time. 66
66
Page 67 68
2002
PBP Health Plan 67 Section 9
Section 9. Coordinating benefits
with other coverage
When you have other health coverage You must tell us
if you are covered or a family member is covered under another group health plan
or have automobile insurance that pays health
care expenses without regard
to fault. This is called "double coverage."
When you have double coverage,
one plan normally pays its benefits in full as the primary payer and the other
plan pays a reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is primary according to the National Association of
Insurance
Commissioners' guidelines.
When we are the primary payer, we
will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people
do not have to pay for Part A. If you
or your spouse worked at least 10
years in Medicare covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who
was a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if you are 65 or older, you may be able to buy it. Contact
1-800-
MEDICARE for more information.
Part B (Medical Insurance).
Most people pay monthly for Part B. Generally,
Part B premiums are withheld
from your monthly Social Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan choices
available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of
Medicare+ Choice plan you have.
The Original Medicare Plan
(Part A or Part B) The Original Medicare Plan (Original Medicare) is
Medicare+ Choice plan that is available everywhere in the United States. It is
the way everyone
used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor,
specialist, or hospital that accepts Medicare. The Original Medicare Plan
pays its share and you pay your share. Some things are not covered under
Original Medicare, like prescription drugs.
When you are enrolled the
Original Medicare along with this Plan, you still need to follow the rules in
this brochure for us to cover your care. This
provision applies when
Medicare benefits are exhausted. 67
67 Page 68 69
2002 PBP Health
Plan 68 Section 9
Claims process when you have the Original
Medicare Plan --You may never have to file a claim form when you have both
our Plan and the
Original Medicare Plan.
When we are the primary payer,
we process the claim first.
When Original Medicare is the primary payer,
Medicare processes your
claim first. In some cases, your claims will be
coordinated automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something about
filing your claims, call us at 800/ 544-7111 or visit our website at
www.
postmasters. org/ pbp. asp.
We waive some costs when you have the
Original Medicare Plan --When Original Medicare is the primary payer, we
will waive some out-of-pocket
costs, as follows:
Medical services and supplies provided by physicians and other health
care professionals. If you are enrolled in Medicare Part B, we will waive
the calendar year deductible and coinsurance.
Surgical and anesthesia services provided by physicians and other
health
care professionals. If you are enrolled in Medicare Part B, we waive the
calendar year deductible and the coinsurance.
Services provided by a hospital or other facility, and ambulance
services. If you are enrolled in Medicare Part A, we waive the per admission
copayment and the coinsurance. If you are enrolled in
Medicare Part B, we waive the calendar year deductible and the coinsurance
for covered ambulance services.
Emergency services/ Accidents. If you are enrolled in Medicare Part B,
we
waive the coinsurance and copayment for covered emergency room charges. If you
are enrolled in Medicare Part B, we waive the calendar
year deductible and the coinsurance for covered ambulance services.
Mental health and substance abuse. If you are enrolled in Medicare Part
A, we waive the per admission copayment and the mental health and substance
abuse coinsurance. If you are enrolled in Medicare Part B,
we waive the mental health and substance abuse deductible and coinsurance.
In cases where we cover a service that is not covered by Medicare, we are the
primary payer. In these cases, we do not waive any out-of-pocket costs. 68
68 Page 69 70
2002 PBP Health Plan 69 Section 9
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
Then the primary payer
is… A. When either you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Areanactive employeewiththeFederal
government(includingwhenyou or afamilymemberare eligibleforMedicaresolely
becauseofadisability),
2) Are an annuitant,
3) Are a reemployed
annuitant with the Federal government when
a) The position is excluded from
FEHB, or
b) The position is not excluded from FEHB
(Ask your employing
office which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or
if your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other
services)
6) Are a former Federal employee receiving
Workers' Compensation and the Office of Workers' Compensation Programs has
determined that you are unable to return to duty,
(except for claims
relatedtoWorkers' Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee
c) Are a former spouse of an annuitant
d) Are a former spouse of an
active employee 69
69 Page
70 71
2002 PBP Health Plan 70
Section 9
Medicare managed care plan If you are eligible for
Medicare, you may choose to enroll in and get your Medicare benefits from
another type of Medicare+ Choice plan… a
Medicare managed care plan. These
are health care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you
can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans provide all the
benefits that Original
Medicare covers. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan, contact
Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary, even out of the managed care
plan's network and/ or service
area, but we will not waive any of our copayments, coinsurance, or deductibles.
If you enroll in a Medicare
managed care plan, tell us. We will need to know
whether you are in the Original Medicare Plan or in a Medicare managed care plan
so we can
correctly coordinate benefits with Medicare.
Suspended FEHB
coverage to enroll in a Medicare managed care plan: If you are an annuitant
or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM does not contribute to
your Medicare
managed care plan premium.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-enroll
in
the FEHB Program, generally you may do so only at the next Open Season
unless you involuntarily lose coverage or move out of the Medicare
managed
care plan's service area.
Private Contract with your physician A
physician may ask you to sign a private contract agreeing that you can be billed
directly for services ordinarily covered by Original Medicare.
Should you
sign an agreement, Medicare will not pay any portion of the charges, and we will
not increase our payment. We will still limit our
payment to the amount we
would have paid after Original Medicare's payment.
If you do not enroll in Medicare Part A or Part B If you do not have
both Parts of Medicare, you can still be covered under the FEHB Program. We will
not require you to enroll in Medicare Part B
and, if you can't get
premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office
of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they must provide; or 70
70 Page 71 72
2002 PBP Health
Plan 71 Section 9
OWCP or a similar agency pays for through a
third party injury
settlement or other similar proceeding that is based on a
claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care.
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 for injuries When you receive money to
compensate you for 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. 71
71 Page
72 73
2002 PBP Health Plan 72
Section 10
Section 10. Definitions of terms we use in this
brochure
Assignment An authorization by you or your spouse for us to
issue payment or benefits directly to the provider. We reserve the right to pay
the member directly
for all covered services.
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 13.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. You may also be responsible for additional amounts. See
page 13.
Covered services Services we provide benefits for, as
described in this brochure.
Congenital anomaly A condition existing
at or from birth which is a significant deviation from the common form or norm.
For purposes of this Plan, congenital
anomalies include protruding ear
deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes and
other conditions that we may
determine to be congenital anomalies. In no
event will the term congenital anomaly include conditions relating to teeth or
intraoral structures
supporting the teeth.
Cosmetic surgery Any operative procedure or any portion of a procedure
performed primarily to improve physical appearance and/ or treat a mental
condition
through change in bodily form.
Custodial care Treatment or services, regardless of who recommends
them or where they are provided, that could be rendered safely and reasonably by
a person not
medically skilled, or that are designed mainly to help the
patient with daily living activities. These activities include but are not
limited to:
(1) personal care such as help in: walking; getting in and out
of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;
(2) homemaking, such as preparing meals or special diets; (3) moving the
patient;
(4) acting as companion or sitter; (5) supervising medication that
can usually be self administered; or
(6) treatment or services that any
person may be able to perform with minimal instruction, including but not
limited to recording
temperature, pulse, and respiration, or administration
and monitoring of feeding systems.
We determine which services are custodial care.
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 13.
Durable medical equipment Equipment that: (1) is prescribed by your
attending doctor;
(2) is medically necessary; 72
72 Page 73 74
2002 PBP Health Plan 73 Section 10
(3) is primarily and customarily used only for a medical purpose; (4) is
generally useful only to a person with illness or injury;
(5) is designed
for prolonged use; and (6) serve a specific therapeutic purpose in treatment of
an illness or injury.
Experimental or investigational services A drug, device or biological
product is experimental or investigational if the drug, device, or biological
product cannot be lawfully marketed
without approval of the U. S. Food and
Drug Administration (FDA) and approval for marketing has not been given at the
time it is furnished.
Approval means all forms of acceptance by the FDA
A medical treatment or
procedure, or a drug , device, or biological product is experimental or
investigational if 1) reliable evidence shows that it is the
subject of
ongoing phase I, II, or III clinical trials or under study to determine its
maximum tolerated dose, its toxicity, its safety, its efficacy,
or its
efficacy as compared with the standard means of treatment or diagnosis; or 2)
reliable evidence shows that the consensus of opinion
among experts
regarding the drug, device, or biological product or medical treatment or
procedure is that further studies or clinical trials are necessary
to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or
its efficacy as compared with the standard means of treatment
or diagnosis.
Reliable evidence means only published reports and articles in the
authoritative medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol( s) of another
facility studying substantially the same drug, device, or medical treatment or
procedure; or the written informed consent used by the treating facility or
by another facility studying substantially the same drug, device, or medical
treatment or procedure.
Note: We use a formal procedure to determine if
a service is experimental or investigational. We review claims with no procedure
codes or
experimental procedure codes. Physicians and medical specialists
review complex claims and recommend whether we should consider the procedure
to be experimental or investigational. We make the final decision.
A
service or supply may be experimental or investigational if a: Product is not
FDA approved,
Service or treatment is still in some stage of trials, Service
or treatment is not normally used to treat your condition, or
Provider
requires that you sign a special release prior to receiving the care.
Enrollees who have a question about a specific service or supply may call us
at 800/ 544-7111
Group health coverage Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a particular
organization or group
that provides payment for hospital, medical, or other
health care services or supplies, or that pays a specific amount for each day or
period of
hospitalization if the specified amount exceeds $200 per day,
including extension of any of these benefits through COBRA.
Home health care agency An agency or organization that provides a
program of home health care that meets all the following requirements: (1) it is
certified by the patient's
doctor as an appropriate provider of home health
services; (2) it has a full- 73
73 Page 74 75
2002 PBP Health
Plan 74 Section 10
time administrator; (3) it maintains written
records of services provided to the patient; and (4) its staff includes at least
one registered nurse( R. N.).
Incurred date The date services and
supplies are received. The applicable benefits are those in effect on this date.
The incurred date for major dental care
expenses that involve preparatory
services is the date the inlay, crown, bridge or denture is seated, placed or
installed in the patient's mouth.
Medical necessity Services, drugs, supplies or equipment provided by a
hospital or covered provider of the health care services that we determine;
(1) are appropriate to diagnose or treat the patient's condition, illness or
injury;
(2) are consistent with standards of good medical practice in the
United States;
(3) are not primarily for the personal comfort or convenience
of the patient, the family, or the provider;
(4) are not a part of or
associated with the scholastic education or vocational training of the patient;
and
(5) in the case of inpatient care, cannot be provided safely on an
outpatient basis.
The fact that a covered provider has prescribed, recommended, or approved a
service, supply, drug or equipment does not, in itself, make it
medically or
dentally necessary.
Mental conditions/ substance abuse Conditions and diseases listed in
the most recent edition of the International Classification of Diseases (ICD) as
psychoses, neurotic
disorders, or personality disorders; other nonpsychotic
mental disorders listed in the ICD, to be determined by us or disorders listed
in the ICD
requiring treatment for abuse of or dependence upon substances
such as alcohol, narcotics, or hallucinogens.
Plan allowance Our 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:
We refer to national databases such as those provided by St Anthony
Publishing to determine the prevailing health care charges in a given
geographic area. We use the 70 th percentile of those charges as the Plan
allowance for a given covered service in a geographic area. In some cases
such as Dental benefits, the Plan Allowance is printed in this brochure.
Charges subject to the Plan Allowance include, but are not limited to,
charges for all surgery, anesthesia, medical care and mental health care.
We also use special industry or federal guidelines or consult with medical
specialists to establish an allowance based on unusual cases or complex
care. When we negotiate a discounted fee on an individual claim, that fee is
the Plan Allowance. The fees that are negotiated with network providers
as
part of their network contract are considered the Plan Allowances. If you use a
network provider, your cost is limited to the cost sharing
provisions listed
in this brochure's benefit charts. If you use a non-network provider, you are
also responsible for charges in excess of the Plan
allowance. 74
74 Page 75 76
2002 PBP Health Plan 75 Section 10
For more information, see Differences between our allowance and the
bill in Section 4.
Remission A remission is the halt or actual
reduction in the progression of illness resulting in discharge from a hospice
care program with no further
expenses incurred. A readmission within three
months of a prior discharge is considered as part of the same period of care. A
new
period begins three months after a prior discharge with maximum benefits
available.
Sound natural tooth A natural tooth that is whole or properly
restored, without impairing periodontal or other conditions and not in need of
the treatment rendered or
proposed for any reason other than accidental
injury.
Surgery A " surgical procedure" means cutting, suturing, treating
burns, correcting a fracture, reducing a dislocation, manipulating a joint under
anesthesia,
electrocauterizing, tapping (paracentesis), applying plaster
casts, administering pneumothorax, endoscopy or injecting sclerosing solution.
Us/ We Us and we refer to PBP Health Plan
You You refers to
the enrollee and each covered family member. 75
75
Page 76 77
2002
PBP Health Plan 76 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you
a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also
continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period in
which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective on
the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age
22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB
plan, that person may not be enrolled in or covered as a family member by
another
FEHB plan. 76
76 Page 77 78
2002 PBP Health
Plan 77 Section 11
When benefits and premiums start The benefits
in this brochure are effective on January 1. If you joined this Plan during Open
Season, your coverage begins on the first day of your first pay period that
starts
on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell you the
effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal
service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation of
Coverage and Former Spouse Enrollees, or
other information about your coverage choices.
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, if you
lose your
Federal job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct. 77
77 Page
78 79
2002 PBP Health Plan 78
Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure. It explains
what you have to do to enroll.
Converting to individual coverage
You may convert to a non-FEHB individual policy if:
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 arenoteligiblefor coverageunderTCCor thespouseequitylaw.
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 Group Health Plan Coverage
TheHealthInsurancePortability andAccountabilityActof 1966(HIPPA)isa
Federallawthatoffers limitedFederalprotectionsfor healthcoverageavailabilityand
continuity topeoplewholose employergroupcoverage.If youleavetheFEHB
Program,we willgiveyoua CertificateofGroupHealth PlanCoveragethatindicates
howlongyou havebeenenrolledwith us.Youcanuse thiscertificatewhengetting
healthinsuranceor otherhealthcarecoverage. Yournew planmustreduceor
eliminatewaiting periods,limitations,orexclusions forhealthrelatedconditions
basedontheinformation inthecertificate,as longasyouenroll within63daysof
losingcoverage underthisPlan.If you have been enrolled with us for less than
12 months, but were previously enrolled in other FEHB plans, you may
also
request a certificate from those plans.
For more information get OPM
pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer
to the "TCC and HIPPA" frequently asked questions. These highlight HIPPA rules,
such as
the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health coverage
under
HIPPA, and have information about Federal and State agencies you can
contact for more information. 78
78 Page 79 80
2002 PBP Health
Plan 79 Long Term Care Insurance
Long Term Care Insurance is Coming
Later in 2002
Many FEHB enrollees think that their health plan and/ or
Medicare will cover their long-term care needs. Unfortunately, they are
WRONG!
How are YOU planning to pay for the future custodial or
chronic care you may need? You should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
It's insurance
to help pay for long term care services you may need if you can't take care of
yourself because of an extended illness or injury, or an age-related
disease
such as Alzheimer's. LTC insurance can provide broad, flexible benefits for
nursing home care,
care in an assisted living facility, care in your home,
adult day care, hospice care, and more. It can supplement care provided by
family members,
reducing the burden you place on them.
Welcome to the
club! 76% of Americans believe they will never need long term care, but the
facts
are that about half them will. And it's not just the old folks. About
40% of people needing long term care are under age 65. They may need chronic
care
due to a serious accident, a stroke, or developing multiple sclerosis,
etc. We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital
to their financial and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year.
And
that's before inflation! Long term care can easily exhaust your savings. Long
term care insurance
can protect your savings.
Not FEHB. Look at the
"Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure.
Health plans don't cover custodial care or a stay in an
assisted living
facility or a continuing need for a home health aide to help you get in and out
of bed and with other activities of daily living. Limited stays in
skilled
nursing facilities can be covered in some circumstances. Medicare only covers
skilled nursing home care (the highest level of nursing
care) after a
hospitalization for those who are blind, age 65 or older or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who meet
the their state's poverty guidelines, but has restrictions on covered services
and where they can be
received. Long term care insurance can provide
choices of care and preserve your independence. {RV: 7-26}
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in
mid-2002. In the meantime, you can learn more about the program on our web site
at www. opm. gov/ insure/ ltc.
What is long term care (LTC) insurance?
I'm healthy. I won't need long
term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage?
How can I find out more about the program NOW? 79
79 Page 80 81
2002 PBP Health Plan 80 DoD/ FEHB Demonstration
Project
Department of Defense/ FEHB Demonstration Project
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,
2002. 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 2001 open season, November 12, 2001, through December 10,
2001. Your coverage will begin
January 1, 2002. 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 open season. Your coverage will begin
January 1 2002. 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. You can also view information about the demonstration
project, including "The 2002 Guide to Federal Employees Health Benefits
Plans Participating in the DoD/ FEHB Demonstration Project," on the OPM web site
at
www. opm. gov. 80
80 Page 81 82
2002 PBP Health
Plan 81 DoD/ FEHB Demonstration Project
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. 81
81 Page 82 83
2002 PBP Health Plan 82 Index
Index
Do not rely on this page; it is for your convenience
and may not show all the pages where the terms appear.
Abortion 61
Accidental injury 26, 35, 44, 45,
53, 75 Allergy care 25
Alternative
treatment 26, 31 Allogeneic (donor) bone marrow
transplant 36, 37 Ambulance
39, 43, 45, 68
Assignment 16, 17, 72 Assisted reproductive technology
25
Biopsy 32
Blood and blood plasma 20, 21, 23, 40, 41
Bone marrow
transplant 25, 36, 37 Calendar year deductible 13, 14,
19, 32, 39,
41, 43, 44, 46, 47, 68 Chemotherapy 25, 37
Chiropractic 31 Coinsurance 13,
14, 15, 16, 41, 47,
61, 68, 70, 72, 74, Colorectal cancer screening 21
Congenital anomalies 32, 34, 35, 72
Contact lenses 27, 60 Contraceptive
drugs 24, 50, 51
Convalescent care 62 Coordination of benefits 17, 19,
32, 39, 44, 46, 49, 53, 67, 69, 77
Cosmetic surgery 35, 72 Covered
charges 14, 17, 39, 40,
42, 68 Covered facility 8, 48, 50, 51, 61
Covered providers 8, 74 Custodial care 40, 41, 48, 72, 79
Days
certified 10, 11 Deductible 13-16, 19, 22-24, 29,
32-35, 38, 39, 41,
43-51, 53, 60, 61, 64, 68, 70, 72
Definitions 72 Dental care 15, 74
Diabetes 27, 31 Diagnostic services 9, 19, 20, 40,
41, 46, 47, 54, 56
Disputed claims review 52, 60, 65,
66, 77 Donor expenses (transplants) 36,
37 Durable medical equipment 12, 15,
29, 30, 63, 72 Educational
classes and programs 31
Effective date of enrollment 8, 9, 13, 61, 72,
77
Embryo transfer 25
Emergency care 10, 15, 17, 18, 44, 45, 48, 68
Experimental or
investigational 61, 73
Explanation of benefits 16, 63, 65, 66
Eyeglasses
27 Family planning 24
Fecal occult blood test 21 Flexible benefits
option 52
Foot care 27 Freestanding ambulatory
facilities 8, 38, 41
Gamete intrafallopian transfer 25
General Exclusions 61 Hearing
services 26
Home health services 30, 73, 79 Home nursing care 30, 63
Home visits 25, 30, 60, 63, 79 Hospice care 42, 75, 79
Hospital
admission 10, 40 Immunizations 22, 61
Incidental procedures 33
Independent laboratory 20
Infertility 24, 25 Inhospital physician care 19-38
Inpatient Hospital Benefits 10, 11, 16, 39, 40
Insulin 50, 51 In vitro
fertilization 25
Laboratory and pathological services 19, 20, 23, 40,
41
Machine diagnostic tests 47 Mail Order Drugs 49-51
Mammograms
20 Maternity Benefits 11, 23, 24
Medicaid 71, 79 Medical emergency 44, 45
Medically necessary 10, 11, 19, 23, 24, 26, 29, 32, 37, 39,
40, 45, 49,
53, 61, 72 Medically underserved areas 8
Medicare 11, 16, 17, 19, 32, 39-41,
44, 46, 49-51, 53, 60, 61,
63, 67-70, 79, 80 Mental Conditions/ Substance
Abuse Benefits 8, 12, 13, 15, 46-48, 63, 68, 74
Newborn care 20,
23 Non-FEHB Benefits 60
Nurse 8, 9, 30, 33, 52, 63, 74 Nursery charges 23
Nursing School Administered Clinic 8, 9, 30
Occupational therapy
8, 26, 31, 42, 63
Ocular injury 27 Office visits 13, 23
Oral and maxillofacial surgery 35
Orthopedic devices 27, 28, 33
Out-of-pocket expenses 13, 15, 17, 47, 60, 68
Outpatient services 47, 48 Overseas claims 63, 64
Pap test 21, 22
Physical examination 21, 22, 26,
31, 42, 63 Physical therapy 31
Physician 5, 9-11, 13, 14, 17, 18, 20, 26, 29, 30, 32, 33, 39,
44, 45,
49-51, 56, 63-66, 68, 70, 73, 78
Precertification 10-12, 39, 48, 66
Preferred Provider Organization
(PPO) 6, 7, 9, 13-16, 19-45, 63,
Prescription drugs 13, 31, 40, 46, 61, 64, 67, 70
Preventive care, adult
21, 22 Preventive care, children 22, 23
Prior approval 65, 66 Prostate
specific antigen 21
Prosthetic devices 28, 33, 34, 40, 41
Radiation
therapy 25, 37 Room and board 15, 39, 40, 48
Second surgical
opinion 20 Skilled nursing facility care 9, 20, 38
Smoking cessation 31, 51
Speech therapy 8, 26, 31, 61, 63
Sterilization procedures 24, 25, 33
Subrogation 71 Surgery 10, 24-26, 28, 32-37, 39,
40, 52, 55, 56, 72, 74
Anesthesia 31, 32 38, 56,
68, 74, 75 Assistant surgeon 33
Multiple
procedures 35 Oral 35
Outpatient 32-38 Reconstructive 32, 34, 35
Temporary continuation of coverage 77, 87, 81
Transplants 25, 26,
35-37, 52 Treatment therapies 25, 26
Vision services 27, 60
Well-child care 23
Wheelchairs 29 Workers' compensation 69, 70,
77 X-rays 19, 20, 23, 40, 41 82
82
Page 83 84
2002
PBP Health Plan 83 Notes
Notes 83
83 Page 84 85
2002 PBP Health Plan 84 Notes
Notes 84
84 Page
85 86
2002 PBP Health Plan 85
Notes
Notes 85
85 Page 86 87
2002 PBP Health
Plan 86 Summary
Summary of benefits for the PBP Health Plan -Standard
Option -2002
Do not rely on this chart alone. All benefits are
subject to the definitions, limitations, and exclusions in this
brochure. On
this page we summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the $250 ($ 500 non-PPO)
calendar year deductible. And, after
we pay, you generally pay any
difference between our allowance and the billed amount if you use a non-PPO
physician or other health care professional.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
PPO: 10%*
Non-PPO: 30%* 19
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient..........................................................................................
PPO: 10%, non-PPO: 30%
PPO: 10%*, non-PPO: 30%*
39
41
Emergency benefits:
Accidental
injury.............................................................................
Medical
emergency.........................................................................
PPO: $0, non-PPO: charges over our allowance
PPO: $50 then 10%, non-PPO:
$50 then 30%
44
45
Mental health and substance abuse treatment
..................................... PPO: Same as medical Non-PPO: Reduced
benefits 46
Prescription drugs
Network retail
..........................................................................
20% of network allowance or $15 generic, $30 formulary, or
$40 brand name 50
Non-network retail
................................................................... 30% of
network allowance and amounts over our allowance 50
Mail order
...............................................................................
Mail order with Medicare
........................................................
$15 generic, $30 formulary, or 20% of the network allowance or
$40 for
non-formulary.
$7 generic, $15 formulary, or 20% of the network allowance or
$25
for non-formulary.
51
51
Dental
Care........................................................................................
Charges over our fee schedule 53
Special features: MAYO Clinic's center of
excellence transplants, flexible benefits option, 24-hour nurse line 52
Protection against catastrophic costs (your out-of-pocket
maximum).........................................................
Nothing
after $3,500 ($ 5,000 non-PPO) per person or $4,000
($ 5,500 non-PPO) per family per year
Some costs do not count toward this
protection
15 86
86 Page
87 88
2002 PBP Health Plan 87
Summary
Summary of benefits for the PBP Health Plan -High Option -2002
Do not rely on this chart alone. All benefits are subject to the
definitions, limitations, and exclusions in this
brochure. On this page we
summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the $200 ($ 400 non-PPO)
calendar year deductible. And, after
we pay, you generally pay any
difference between our allowance and the billed amount if you use a non-PPO
physician or other health care professional.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
PPO: 10%*
Non-PPO: 20%* 20
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient..........................................................................................
PPO: 10%, non-PPO 25%
PPO: 10%*, non-PPO: 20%*
39
41
Emergency benefits:
Accidental
injury.............................................................................
Medical
emergency.........................................................................
PPO: $0, PPO: charges over our allowance
PPO: $50 then 10%, non-PPO: $50
then 20%
44
45
Mental health and substance abuse treatment
.....................................
PPO: Same as medical
Non-PPO:
Reduced benefits 46
Prescription drugs
Network retail
.........................................................................
20% of network allowance or $10 generic, $25 formulary, or
$40 brand
name 50
Non-network retail
...................................................................
20% of
network allowance and amounts over our allowance
20% of network allowance or
$10 generic, $25 formulary, or $40
brand name
50
Mail order
...............................................................................
Mail order with Medicare
........................................................
$10 generic, $25 formulary, or 20% of the network allowance or
$40 for
non-formulary.
$5 generic, $12 formulary, or 20% of the network allowance or
$25
for non-formulary.
51
51
Dental
Care........................................................................................
Charges over our fee schedule 53
Special features: MAYO Clinic's center of excellence transplants, flexible
benefits option, and 24-hour nurse line 52
against catastrophic costs (your out-of-pocket
maximum).........................................................
Nothing
after $3,000 ($ 3,500 non-Protection PPO) per person or $3,500
($ 4,000 non-PPO) per family per year
Some costs do not count toward this protection
15 87
87 Page 88
2002
PBP Health Plan 88 Rates
2002 Rate Information for PBP Health
Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in
a special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career U. S. Postal Service employees. Most
employees should refer to the FEHB Guide for United States Postal Service
Employees, RI-70-2. Different postal rates apply and
special FEHB guides are
published for Postal Service Nurses (see RI 70-2B); and for Postal Service
Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
High Option
Self Only 361 $ 97.86 $163.42 $ 212.03 $354.08 $115.52
$145.76
High Option
Self and Family 362 $ 223.41 $ 340.32 $ 484.06 $ 737.36 $
263.75 $ 299.98
Standard Option
Self Only 364 $ 97.86 $ 50.95 $ 212.03 $ 110.39 $
115.52 $ 33.29
Standard Option
Self and Family 365 $ 223.41 $ 98.50 $ 484.06 $ 213.41
$263.75 $ 58.16 88