PacifiCare of Utah 1999 A Health Maintenance Organization
Serving: Parts of Utah along the Wasatch Front Enrollment in this Plan is limited; see page 8 for details Enrollment code:
9K1 Self Only 9K2 Self and Family
Visit the OPM website at http:// www. opm. gov/ insure and this Plans website at http:// www. phs. com
RI 73- 564
of Utah
Federal Employees Health Benefits Program
For changes to benefitssee page 22.
United States Office of Personnel Management
Authorized for distribution by the
UNITED STATES
OFFICE OF
PERSONNEL MANAGEMENT
Important Notice: Effective January 1, 1999, this Plans enrollment code changes from KU to 9K. Enrollees in this Plan will be transferred automatically to the new code unless they choose a different Plan during Open Season.
Important Notice: Effective January 1, 1999, Washington and Cache Counties will no longer be included in the Plans service and enrollment area. If you live in one of these counties, you have the option of changing Plans during Open Season.
2
PacifiCare of Utah
PacifiCare of Utah, Inc., 35 West Broadway, Salt Lake City, Utah 84101 has entered into a contract (CS 2839) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called PacifiCare - Utah, PacifiCare, or the Plan.
This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.
Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page 22 of this brochure.
Page Inspector General Advisory on Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3- 6
Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage and Certificate of Creditable Coverage)
Facts about this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6- 9
Information you have a right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; Authorizations; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Experimental/ investigational determinations Other considerations; The Plans service area
General Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9- 10
Important notice; Circumstances beyond Plan control; Arbitration of claims; Other sources of benefits
General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11- 18
Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits;
Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17- 18 Dental Care; Vision care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17- 18 Non- FEHB Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20- 21 How PacifiCare of Utah Changes January 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Summary of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Rate Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Table of Contents
3
Inspector General Advisory: Stop Health Care Fraud! General Information Confidentiality
If you are a new member
Medical and other information provided to the Plan, including claim files, is kept confidential and will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan, coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.
Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.
If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.
If you are a new member of this Plan, benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 14. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 4.
FEHB plans may not refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program. Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to
obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD. This could result in CRIMINAL PENALTIES. Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital or pharmacy, charged your plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:
Call the provider and ask for an explanation sometimes the problem is a simple error. If the provider does not resolve the matter, or if you remain concerned, call your plan at 801/ 323- 6200 and explain the
situation. If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:
THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300
The Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, N. W., Room 6400 Washington, D. C. 20415
The inappropriate use of membership identification cards, e. g., to obtain services for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.
4
General Information continued
If you are hospitalized
Your responsibility
Things to keep in mind
If you change plans or options, benefits under your prior plan or option cease on the effective date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.
It is your responsibility to be informed about your health benefits. Your employing office or retirement system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.
The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if you changed plans or plan options, see If you are a new member above. In both cases, however, the Plans new rates are effective the first day of the enrollees first full pay period that begins on or after January 1 (January 1 for all annuitants).
Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.
The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.
An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits.
You will not be informed by your employing office (or your retirement system) or your Plan when a family member loses eligibility.
You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.
An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive benefits under any other FEHB plan.
Report additions and deletions (including divorces) of covered family members to the Plan promptly.
If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.
5
General Information continued
Things to keep in mind
continued
Coverage after enrollment ends
Former spouse coverage
Temporary continuation of coverage (TCC)
Notification and election requirements
Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.
You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.
Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).
When an employees enrollment terminates because of separation from Federal service or when a family member is no longer eligible for coverage under an employee or annuitant enrollment, and the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free 31day extension of coverage. The employee or family member may also be eligible for one of the following:
When a Federal employee or annuitant divorces, the former spouse may be eligible to elect coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employees employing office (personnel office) or retirees retirement system to get more facts about electing coverage.
If you are an employee whose enrollment is terminated because you separate from service, you may be eligible to temporarily continue your health benefits coverage under the FEHB Program in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 705, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.
Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another free 31day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.
Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31day extension of coverage when they may convert to nongroup coverage.
NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.
Separating employees Within 61 days after an employees enrollment terminates because of separation from service, his or her employing office must notify the employee of the opportunity to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.
6
General Information continued
Notification and election requirements
continued
Conversion to individual coverage
Certificate of Creditable Coverage
Facts about this plan Children You must notify your employing office or retirement system when a child becomes eligible
for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.
Former spouses You or your former spouse must notify the employing office or retirement system of the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.
The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.
Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.
When none of the above choices are available or chosen when coverage as an employee or family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.
Under Federal Law, if you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate along with any certificates you receive from other FEHB Plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a non- FEHB insurer. If you do not receive a certificate automatically, you must be given one upon request.
This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members select a personal doctor from among participating Plan primary care doctors.
Services of a specialty care doctor can only be received by referral from a primary care doctor. There are no claim forms when Plan doctors are used.
Your decision to join an HMO should be based on your preference for the plans benefits and delivery system, not because a particular provider is in the plans network. You cannot change plans because a provider leaves the HMO.
Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan places great emphasis on preventive benefits such as office visits, physicals, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.
7
Facts about this Plan continued
Who provides or arranges care to Plan members
Role of a primary care physician
Choosing your doctor
Who provides or arranges care to Plan members PacifiCare operates as a group practice plan (GPP); doctors provide care through contracted medical centers, or through affiliated provider groups. Receiving care from participating providers - For a PacifiCare member, there is never any barrier to receiving care. Costs are prepaid, and services are accessible through convenient, fully- staffed medical centers with extended hours or through participating doctors. In addition, emergency care is available 24 hours a day, 365 days a year.
How to use PacifiCare - Each PacifiCare member selects the contracted medical center or affiliated provider group which is closest to your residence. It is important to remember that the benefits and services under the PacifiCare plan are available only through participating doctors, dentists, optometrists, specialists, pharmacies, or at hospitals when under the care of a participating provider. Locations and telephone numbers of the contracted medical centers or affiliated provider groups are listed in the provider directory or can be obtained by calling the Customer Service Department at 801/ 323- 6200 or 800/ 377- 4161.
The first and most important decision each member must make is the selection of a primary care doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when there has been a referral by the members primary care doctor, with the following exception: a woman may see her Plan gynecologist for her annual routine examination without a referral..
The Plans provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 800/ 323- 6200 or 800/ 377- 4161; you can also find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.
If you enroll, you will be asked to complete a primary care doctor selection form and send it directly to the Plan, indicating the name of the primary care doctor( s) you select for you and each member of your family. Members may change their doctor selection at any time.
If you are receiving services from a doctor who leaves the Plan, the Plan will provide payment for covered services until the Plan can make reasonable and medically appropriate provisions for the assumption of such services by a participating doctor. Information you have a right to know
All carriers in the FEHB Program must provide certain information to you . If you do not receive information about this Plan, you can obtain it by calling the Carrier at 1- 800/ 377- 4161 or 801/ 323- 6200 or you may write the carrier at 35 West Broadway, Salt Lake City, Utah 84101 You may also contact the carrier by fax at 801/ 933- 3639 or at its website at http:// www. phs. com Information that must be available to you includes: Disenrollment rates for 1997 Compliance with State and Federal licensing or certification requirements and the dates met. If non- compliant, the reason for non- compliance. Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Wether the carrier meets State, Federal and accreditation requirements for fiscal solvency, confidentiality and transfer of medical records.
8
Facts about this Plan continued
Referrals for specialty care
Authorizations For new members
Hospital Care Out- of- pocket maximum
Deductible carryover
Submit claims promptly
Except in a medical emergency or when a primary care doctor has designated another doctor to see patients when he or she is unavailable, you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if specialists or consultants are required beyond those participating in the Plan, the primary care doctor will make arrangements for appropriate referrals.
When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow- up care must be provided or authorized by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If additional services or visits are suggested by the consultant, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance.
If you have chronic, complex or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health Plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.
The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your Plan doctor must obtain the Plans determination of medical necessity before you may be hospitalized, referred for speciality care or obtain follow- up care from a specialist.
If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you prior to your joining this Plan is now your Plan primary care doctor, you need only call to explain that you now belong to this Plan and ask that a referral form be sent to the specialist for your next appointment.
If you are selecting a new primary care doctor, you must schedule an appointment so that the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.
If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.
Copayments are required for a few benefits. However, copayments will not be required for the remainder of the calendar year after your out- of- pocket expenses reach $1,000 per Self Only enrollment or $2,500 per Self and Family enrollment for total copayment charges required for services provided or arranged by the Plan. This copayment maximum does not include costs of prescription drugs ,eyeglasses, durable medical supplies, or dental services.
You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out- of- pocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.
If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1, any expenses that would have applied to that plans deductible will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective January 1.
When you are required to submit a claim to this Plan for covered expenses, submit your claim promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.
Other considerations
The Plans Service Area
Plan providers will follow generally accepted medical practice in prescribing any course of treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures which may be recommended by Plan providers.
Experimental and Investigative determinations
The Plan accepts the determination of PacifiCares National and Regional Medical Committees as to whether treatments, procedures and drugs are accepted as no longer experimental or investigational. The determinations are based on the safety and efficacy of new medical procedures, technologies, devices and drugs.
The service area for this Plan, where Plan providers and facilities are located is described below. You must live in the service area to enroll in this Plan. Benefits for care outside the service area are limited to emergency services, as described on page 14.
The service area for this Plan includes the following areas: Entire counties of Davis and Salt Lake The following counties are identified by Zip Codes: Box Elder, , Juab, Morgan, Sanpete, Summit, Tooele, Utah, Wasatch, , and Weber 84003- 84004, 84006, 84010- 84011, 84013- 84018,84019, 84020, 84022, 84024- 84025, 84029, 84032- 84033 84036- 84037, 84040- 84044, 84047, 84049- 84050, 84054- 84062, 84065, 84067- 84071, 84074- 84075, 84080, 84082, 84084, 84087- 84088, 84090- 84095,84097- 84098,84189- 84190, 84101- 84128,, 84131- 84145, 84147- 84148, 84150- 84153, 84157- 84158, 84165, 84170- 84171,84180,84184- 84185,84201,84244, 84199, 84301- 84302,, 84306- 84307,84309,84312,84314- 84317,84324, 84330-, 84337 84400- 84409, 84412, 84414, 84553, 84601- 84606, 84626, 84628- 84629, 84632- 84633, 84639, 84645, 84648, 84651, 84653- 84655, 84660, 84663- 84664.
If you or a covered family member move outside the enrollment area, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.
9
Facts about this Plan continued
Important Notice
Circumstances beyond Plan control
Other sources of benefits
Medicare
Although a specific service may be listed as a benefit, it will be covered for you only if, in the judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.
In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant number of Plan providers, complete or partial destruction of facilities, or other circumstances beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plain will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel.
This section applies when you or your family members are entitled to benefits from a source other than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.
If you or a covered family member is enrolled in this Plan and Medicare part A and/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.
General Limitations
10
General Limitations continued
Group health insurance and automobile insurance
CHAMPUS Medicaid Workers Compensation
DVA facilities, DoD facilities, and Indian Health Service
Other government agencies
Liability insurance and third party actions
This coordination of benefits (double coverage) provision applies when a person covered by this Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the payment of medical and hospital costs under no- fault or other automobile insurance that pays benefits without regard to fault. Information about the other coverage must be disclosed to this Plan.
When there is double coverage for covered benefits, other than emergency services from non- Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary plan.
One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full, or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners. When benefits are payable under automobile insurance, including no- fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.
If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.
If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for services required as the result of occupational disease or injury for which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers compensation (under section 8103 of title 5, U. S. C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers compensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP (or the agency)
Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from the Plan for certain services and supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.
The Plan will not provide benefits for services and supplies paid for directly or indirectly by any other local, State, or Federal Government agency.
In the event any benefits are provided or paid for by the Plan under this Agreement to a Member for an injury sustained by the Member, the Plan will be entitled to all the rights of recovery that the Member may have against any person or entity as a result of the injury to the extent of the value of services paid for or provided by the Plan as a result of the injury. If the Member does not diligently seek such recovery, the Plan may. The Plans subrogation procedures and policies shall be made available to the enrollees upon request.
11 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS General Exclusions
What is covered A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office visits; you pay a $10 office visit copay and no additional copay for laboratory tests and X- ray performed during the same office visit. Within the service area, house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctors house call or for visits by nurses and health aides.
The following services are included, and are subject to the office visit copay unless stated otherwise: Preventive care, including well- baby care and periodic checkups Mammograms are covered as follows, and not subject to a copay: for women age 35 through age
39, one mammogram during these five years; for women age 40 through 49, one mammogram every one or two years; for women age 50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness. Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays. Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and
postnatal care by a Plan doctor. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays are not subject to a copay and will be extended if medically necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment. Voluntary family planning services Implanted contraceptive devices, such as Norplant IUDs Diagnosis and treatment of diseases of the eye Allergy testing and treatment, including testing and treatment materials such as allergy serum. The insertion of internal prosthetic devices, such as pacemakers and artificial joints, are not subject
to a copay. All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit,
it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your illness or condition as discuss under Authorizations on page 8. The following are excluded:
Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits)
Expenses incurred while not covered by this Plan Services furnished or billed by a provider or facility barred from the FEHB Program Services not required according to accepted standards of medical, dental, or psychiatric practice Procedures, treatments, drugs or devices that are experimental or investigational Procedures, services, drugs and supplies related to sex transformations; and Procedures, services, drugs and supplies related to abortions, except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.
Medical and Surgical Benefits
Medical and Surgical Benefits continued
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
What is covered
continued
Limited benefits
Cornea, heart, heart- lung, kidney, liver, lung (single or double), and pancreas transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for acute lymphocytic or non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Treatment for breast cancer, multiple myeloma and epithelial ovarian cancer may be provided in a non- randomized clinical trial when treatment is provided in an NCI or NIH approved clinical trial at a Plan designated center of excellence and if approved by the Plans medical director in accordance with the Plans protocols. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan, (not subject to a copay for inpatient hospital care). Women who undergo mastectomies may, at their option, have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure. The hospital stay is not subject to a copay. Dialysis Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity is not subject to a copay Home health services of nurses and health aides, including intravenous fluids and medications,
when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need. All necessary medical or care in a hospital or extended care facility from Plan doctors and other
Plan providers, at no additional cost to you. Blood and blood products are not subject to a copay
Oral and maxillofacial surgery is provided for nondental and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance and if the condition can reasonably be expected to be corrected by such surgery. Reconstructive cosmetic surgery is limited to persons who were covered under the FEHB Program at the time of the accident or surgery which necessitates such reconstruction.
Short- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected within two months; you pay a $10 copay per outpatient session. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.
Diagnosis and treatment of primary infertility is covered; you pay 50% of charges. The following types of artificial insemination are covered: intravaginal insemination (IVI); intracervical insemination (ICI) and intrauterine insemination (IUI); you pay 50% of charges; cost of donor sperm is not covered. Fertility drugs (other than Clomiphene) are not covered. Clomiphene is covered under the Prescription Drug Benefit. Other assisted reproductive technology (ART) procedures as in vitro fertilization and embryo transfer are not covered.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided at a plan facility for up to 12 weeks for Phase II and Phase III combined when specific clinical indications are met. You pay a $10 copay per visit.
Durable Medical Equipment such as contact lenses for cataract removal, corrective appliances, orthopedic braces, artificial aids, and prosthetic devices You pay 50% of charges.
13
Hospital/ Extended Care Benefits What is covered
Hospital care Extended care Hospice care
Ambulance care
Limited benefits Inpatient dental procedures
Acute inpatient detoxification
What is not covered
The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing per admission. All necessary services are covered, including:
Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care
Specialized care units, such as intensive care or cardiac care units The Plan provides a comprehensive range of benefits for up to 30 days per calendar year when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of hospitalization. You pay nothing. All necessary services are covered, including:
Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by a Plan doctor Blood and blood products Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor. You pay a $50 copay.
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.
Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis, treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 15 for nonmedical substance abuse benefits.
Personal comfort items, such as telephone and television Custodial care, rest cures, domiciliary or convalescent care
Medical and Surgical Benefits continued
What is not covered
Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or insurance, attending school or camp, or travel Reversal of voluntary, ly- induced sterility Transplants not listed as covered Surgery primarily for cosmetic purposes Hearing aids Chiropractic services Homemaker services Orthopedic devices, such as foot orthotics Long- term rehabilitative therapy Treatment of sexual dysfunction
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
14
What is a medical emergency?
Emergencies within the service area
Plan pays... You pay...
Emergencies outside the service area
Plan pays... You pay...
What is covered What is not covered
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 the Plan may determine are medical emergencies what they all have in common is the need for quick action.
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. It is your responsibility to pay for any nonemergency services you receive in the emergency room or non- urgent care you receive in the urgent care center.
If you are hospitalized in non- Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non- Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan or provided by Plan providers.
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.
A $40 copay per hospital emergency room visit or $10 per urgent care center visit at a contracted PacifiCare provider facility or office visit, for emergency services which are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency copay is waived.
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan or provided by Plan providers.
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
A $40 copay per hospital emergency room visit or $10 per urgent care center visit which are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency care copay is waived.
Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctors services Ambulance service approved by the Plan
Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area Medical and hospital costs resulting from a normal full- term delivery of a baby outside the service
area
Emergency Benefits continued
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
15 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Mental conditions
What is covered
Outpatient care
Inpatient care
What is not covered
Substance abuse What is covered
Outpatient care
Inpatient care
What is not covered
To the extent shown below, this Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions, including the treatment of mental illness or disorders:
Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)
Up to 30 outpatient visits to Plan doctors, consultants or other psychiatric personnel each calendar year;
you pay a $10 copay for each covered visit - all charges thereafter. Up to 30 days of hospitalization each calendar year; you pay nothing for the first 30 days - all charges thereafter.
Care for psychiatric conditions which in the professional judgment of Plan doctors are not subject to significant improvement through relatively short- term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless
determined by a Plan doctor to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriate treatment of a
short- term psychiatric condition This Plan provides medical and hospital services, such as acute detoxification services, for the medical, nonpsychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition and, to the extent shown below, the services necessary for diagnosis and treatment.
Unlimited outpatient visits per calendar year to Plan providers for treatment; you pay a $10 copay for each covered visit.
Up to 30- days per calendar year for substance abuse rehabilitation (intermediate care) programs in an alcohol detoxification or rehabilitation center approved by the Plan; you pay nothing during the benefit period - all charges thereafter. No yearly limit for detoxification.
Treatment that is not authorized by a Plan doctor
Mental Conditions/ Substance Abuse Benefits Filing claims
for non- Plan providers
With your authorization, the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.
Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 20.
Emergency Benefits continued
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Prescription Drug Benefits
What is covered What is not covered
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30- days supply. Creams, liquids, inhalers and suppositories are dispensed in quantities reflected by standard package size or quantity. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary. A formulary is a list of drugs covered by the Plan and this list is updated on a regular basis. The Plans formulary is determined by reviewing pertinant medical literature, provider feedback, and changes/ improvements in medical technology. A copy of this Plans current drug formulary is available by contacting the Plan.
You pay a $5 copayment for generic formulary drugs, or a $10 copayment for name brand formulary drugs, per prescription unit or refill.
Non- formulary drugs will be covered when prescribed by a Plan doctor. You pay a $25 copayment per prescription unit or refill.
Up to a 90- day supply of maintenance medications may be obtained through mail order for the cost of one copayment. For information on the mail order drug benefit, contact Prescription Solutions at 1- 800- 562- 6223.
COVERED MEDICATIONS AND ACCESSORIES INCLUDE; Drugs for which a prescription is required by law. Oral and injectable contraceptives drugs;
contraceptive diaphragms and IUDs Insulin with a copay charge applied to each vial Diabetic supplies, including insulin syringes, needles, glucose test strips, (50 strips per prescription
unit) and lancets Intravenous fluids and medication for home use, implantable drugs and some injectable drugs, such
as Depo Provera, are covered under Medical Benefits Clomiphene for infertility Depo Provera, an injectable, is covered under the Medical and surgical
Benefit, at a $10 office visit copay. Disposable needles and syringes needed for injecting covered prescribed medication Drugs to treat sexual dysfunction when medically necessary, limited to six pills per month. You
pay 50% of the cost of the medication copay per prescription unit or refill. Drugs available without a prescription or for which there is a nonprescription equivalent Drugs obtained at a non- Plan pharmacy, except for out- of- the area emergencies Vitamins and nutritional substances which can be purchased without a prescription Medical supplies, such as dressings and antiseptics Contraceptive devices (except diaphragms) Drugs for cosmetic purposes Drugs to enhance athletic performance Smoking cessation drugs and medication, including nicotine patches Implanted time- release medications, other than Norplant Infertility drugs with the exception of Clomiphene Skin patches for motion sickness (Transderm- Scop) Anorexiants/ antiobesity agents Progesterone suppositories and capsules Vaccinations for foreign travel
17 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Other Benefits
Dental care What is covered
The following dental services are covered when provided by participating Primary Care Plan dentists:
Preventive & diagnostic You Pay
Initial examination, including full series x- rays .............................................................................. Nothing Recall examinations, including bite wing x- rays............................................................................. Nothing Single films ...................................................................................................................................... Nothing Prophylaxis and fluoride treatment
(child) ........................................................................................................................................ Nothing Prophylaxis (adult).................................................................................................................... Nothing Preventive education ................................................................................................................. Nothing
Emergency treatment
Palliative (at PacifiCare Dental Centers) During office hours................................................................$ 14 After hours or as provided by the PacifiCare dentist on call..................................................................$ 53
Restorative
Routine fillings - Amalgam or Composite for permanent or primary teeth. For each filling:
1 surface Amalgam ..........................................................................................................................$ 13 Anterior composite...........................................................................................................................$ 19 2 surfaces Amalgam.........................................................................................................................$ 19 2 Anterior composite........................................................................................................................$ 33 3 surfaces Amalgam.........................................................................................................................$ 25 Anterior composite...........................................................................................................................$ 51 4 surfaces Amalgam.........................................................................................................................$ 39 Stainless steel crown........................................................................................................................$ 58
Periodontics
Deep scaling, root planing and curettage per quadrant.. ........................................................................$ 77 Periodontal consultation..........................................................................................................................$ 41 Gingevectomy per quadrant ..................................................................................................................$ 120 Muco- osseous surgery per quadrant .....................................................................................................$ 270 Gingivectomy per tooth (to three teeth)..................................................................................................$ 20
Oral surgery
Extractions (routine) 1st tooth.................................................................................................................$ 32 each additional tooth ...............................................................................................................................$ 26 extractions ..............................................................................................................................................$ 55 Impacted teeth - soft tissue .....................................................................................................................$ 59 Impacted teeth - partial bony ..................................................................................................................$ 88 Impacted teeth - full bony .....................................................................................................................$ 122
Endodontics
Pulp cap...................................................................................................................................................$ 18 Vital pulpotomy.......................................................................................................................................$ 27 Root Canal, Single canal.......................................................................................................................$ 108 Two canals.............................................................................................................................................$ 131 Three canals ..........................................................................................................................................$ 161
Crowns & bridges
Crown build up with pins........................................................................................................................$ 30 Preformed post and build up ...................................................................................................................$ 51 Porcelain fused to metal crown per unit ...............................................................................................$ 266 Cast crown.............................................................................................................................................$ 336
Other Benefits continued
Dental care
continued
Plan Maximum
Accidental injury benefit
What is not covered
Vision care What is covered
What is not covered
Removable dentures
Complete denture (upper or lower).......................................................................................................$ 375 Partial denture - cast frame ...................................................................................................................$ 419 Teeth & clasp, extra per unit ...................................................................................................................$ 36 Stayplates ..............................................................................................................................................$ 150 Repairs, full or partial dentures, simple or involved teeth, each ............................................................$ 34 Relines, per denture...............................................................................................................................$ 126
reventive orthodontics
Space maintainer - unilateral...................................................................................................................$ 47 Lingual holding arch ...............................................................................................................................$ 50 Habit- breaking appliance ........................................................................................................................$ 90
No annual or lifetime maximum limit. Plan pays up to $50 for emergency services required when member is over 100 miles from home and a Plan dentist is not available. You pay all charges thereafter.
Restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth are covered. The need for these services must result from an accidental injury; you pay nothing.
Other dental services not shown as covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, annual eye refractions (which include the written lens prescription) may be obtained from Plan providers. You pay a $10 copay per visit.
Eye exercises Corrective lenses or frames
18
19
Non- FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB, but are made available to all enrollees and family members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium; any charges for these services do not count toward any FEHB deductibles, or out- of- pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.
PacifiCare is pleased to provide our members with value- added benefits during 1999
Optical benefit
Prescription eyeglasses - For a $55.00 charge, subscribers and their covered dependents can each receive one pair of eyeglasses which includes untinted, single vision, bifocal lenses, during each 12 month period.
Optional Enhanced Dental Coverage - PacifiCare offers you a dental option to enhance your basic Federal dental coverage. By paying an annual premium, which can be billed to you by the Plan, your basic dental coverage would be expanded for the following dental services: Restorative, Periodontics, Oral surgery, Endodontics, Crown & Bridges, Dentures, and Orthodontics.
The monthly cost to you would be: Self only $10.13 Family $26.10 Additional copay may be necessary if services of a Dental Specialist are necessary.
To enroll in this dental option: check your PacifiCare informational packet for detailed benefit information on the enhanced dental package, or call the plan at 1- 800- 365- 1334.
Note: Enrollment in the Enhanced Dental is limited to open season. This dental package is optional. You are not required to enroll in the Enhanced Dental to join the regular PacifiCare FEHB.
Benefits on this page are not part of the FEHB contract
20
How to Obtain Benefits Questions
Plan reconsideration
OPM Review
If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Customer Service Department at 801/ 323- 6200 or 800/ 377- 4161, or you may write to the Plan at 35 West Broadway, Salt Lake City, Utah 84101. You may also contact the carrier by fax 801/ 933- 3639 or at its web site at http:// www. phs. com
If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and within six months of the date of the denial, to reconsider its denial before you request a review by OPM. OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.
Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.
If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plans actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plans letter affirming its initial denial.
You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.
This right is available only to you or the executor of a deceased claimants estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review.
Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.
Your request must include the following information or it will be returned by OPM: A copy of your letter to the Plan requesting reconsideration; A copy of the Plans reconsideration decision (if the Plan failed to respond, provide instead (a) the
date of your request to the Plan or (b) the dates the Plan requested and you provided additional information to the Plan); Copies of documents that support your claim, such as doctors letters, operative reports, bills,
medical records, and explanation of benefit (EOB) forms; and Your daytime phone number.
Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy Act.
Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division IV, P. O. Box 436, Washington, DC 20044.
Disputed claims review
21
How to Obtain Benefits continued
OPM Review
continued
You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plans decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.
Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plans benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Plans denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.
Privacy Act statement If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.
22
How PacifiCare Utah Changes 1999 Program- wide Changes
Changes to this Plan
Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights. Women may see their Plan gynecologist for their annual routine examination without a referral
from their primary care doctor. (See page 7) If you have a chronic complex or serious medical condition that causes you to frequently see a
specialist, your primary care doctor will develop a treatment plan with you and your health Plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals.( See page 8 for further details) A medical emergency is defined as the sudden and unexpected onset of a condition or injury that
you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care( see page 14). The diagnosis , evaluation and medical management of certain mental conditions will be covered
under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any cost for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits. Office visits for the medical aspects of treatment do not count toward the 30 outpatient Mental Conditions visit limit.
The Plan has increased outpatient copays from $5 to a $10 copay per visit for medical office visits, cardiac rehabilitation, mental health, substance abuse, and vision eye examinations.
The Plans prescription drug benefit has changed from a formulary/ non- formulary benefit; to a generic formulary/ name brand formulary/ and non- formulary benefit.( see page 16).
The Plan now only requires one copayment for a 90 day supply of mail order prescription drugs. The Plan has increased the amount You Pay for all dental services, with the exception of
preventive and diagnostic. Effective January 1, 1999, this Plans enrollment code changes from KU to 9K Enrollees in this
Plan will be transferred automatically to the new code unless they choose a different Plan during Open Season.
Effective January 1, 1999, Washington and Cache Counties will no longer be included in the Plans service and enrollment area. If you live in one of these counties, you have the option of changing Plans during Open Season. Do not rely on this page; it is not an official statement of benefits.
Summary of Benefits for PacifiCare of Utah 1999
23
Inpatient care
Hospital Extended care Mental conditions
Substance Abuse
Comprehensive range of medical and surgical services with no dollar or day limit. Includes in- hospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room intensive care and complete maternity care.
You pay nothing..................................................................................................................... 13 All necessary services, up to 150 consecutive days per disability per calendar year.
You pay nothing..................................................................................................................... 13 Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year. You pay nothing .............................................................................................. 15
Each member is entitled to a 30- day per calendar year substance abuse programs.
You pay nothing no limit for detoxification .......................................................................... 15
Outpatient care
Home Health care
Mental conditions
Substance Abuse
Comprehensive range of services such as diagnosis and treatment of illness or injury, including specialists care; preventive care, including well- baby care, periodic check- ups and routine immunizations; laboratory tests and X- rays; complete maternity care. You pay $10 per office visit.......................................................................................... 11
All necessary visits by nurses and home health aides. You pay nothing .............................. 12 Up to 30 outpatient visits per year. You pay $10 copay per visit ......................................... 15 Unlimited outpatient visits per year. You pay $10 copay per visit ....................................... 15 Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.
Benefits Plan pay/ provides Page Emergency care Prescription drugs Dental care Vision care Out- of- pocket
Resonsable charges for services and supplies required because of a medical emergency. You pay $40 copay to the hospital for each emergency room visit and a $10 copay for Urgent Care Centers and any charges for services that are not covered benefits of this Plan. ......... 14
Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay a $5 copay for generic formulary drugs or a $10 copay for formulary name brand drugs, or a $25 copay for non formulary drugs per prescription unit or refill .......................................................... 16
Accidental injury benefit; you pay nothing. preventive dental care, and diagnostic services; you pay nothing. Restorative services, periodontics, oral surgery, crowns and bridges, dentures, preventive orthodontics and emergencies are covered; you pay a fixed copay per procedure (see copay schedule) ............................................................................................. 17
One refraction annually. You pay a $10 copay per visit..................................................... 17 Copayments are required for a few benefits; however, after your out- of- pocket expenses reach a maximum of $1,000 per Self Only or $2,500 per Self and Family enrollment per calendar year, covered benefits will be provided at 100%. This copay maximum does not include prescription drugs, dental services, eyeglasses, or durable medical supplies............... 8
24
1999 Rate Information for PacifiCare of Utah
Non- Postal rates apply to most non- Postal enrollees. If you are in a special enrollment category, refer to an FEHB Guide or contact the agency that maintains your health benefits enrollment.
Postal rates apply to most career U. S. Postal Service employees, but do not apply to non- career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.
Postal Premium Biweekly Non- Postal Premium
Biweekly Monthly Your Share USPS
Share Your
Share Govt
Share Your
Share Govt
Share Code Type of
Enrollment 9K1 $64.80 $21.60 $140.40 $46.80 $76.68 $9.72 9K2 $153.17 $51.05 $331.86 $110.62 $181.25 $22.97 Self Only
Self and Family