A Health Maintenance Organization
Serving Chicago Metropolitan area For changes
in benefits page 4 Enrollment code see
751 Self Only 752 Self and Family
Enrollment in this Plan is limited see page 5 for requirements
Visit the OPM website at www opm gov insure and
this Plan's website at www humana com
RI 73 025
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Humana Health Plan Inc 2000
Table of Contents Page
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 8 9
Section 5 Benefits 10 18
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 20 21
Section 8 FEHB facts 22 25
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits 27
Premiums 28
Introduction Humana Health Plan Inc 30 South Wacker Dr Suite 3100 Chicago Illinois 60606
This brochure describes the benefits you can receive from Humana Health Plan Inc under its contract CS 1570 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in the Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 4 Premiums are listed at the end of this brochure
Plain language The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to Humana Health Plan Inc as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Humana Health Plan Inc 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMOs This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate
your health care services The care you receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive
emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that
any one physician hospital or other provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
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Humana Health Plan Inc 2000
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB
program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we
will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Plan n Your share of the non postal premium will increase by 3.7 for Self Only or decrease by 9.2 for Self and Family
n Prescription drugs are available for up to a 30 day supply with a 3 copay for generic or 7
copay for brand name drugs listed on our formulary and a 20 copay for drugs not listed on our formulary
n Up to a 90 day supply of maintenance type prescription drugs may be obtained through our Mail
Order Drug benefit for three times the applicable drug copay
n Formulas for the treatment of phenylketonuria or other inheritable diseases are covered under the
Prescription drug benefit
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Humana Health Plan Inc 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is
area The Chicago Metropolitan area including the counties of Cook DuPage Kane Kankakee Lake McHenry and Will in Illinois and Lake and Porter counties in Indiana
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount or pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services except for emergency care
Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send all of the documents for your
claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides my Humana Health Plan Inc Chicago provides care from the staff at various Humana Health health care Centers or affiliated Physicians listed in the Plan's Provider Directory Care is provided by
doctors nurse practitioners and other skilled medical personnel If care is needed by specialists not represented on the Plan staff a Plan doctor will refer you to a specialist in the community
without cost to you
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or to go into the hospital authorized specialist will make the necessary hospital arrangements and supervise your care
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Humana Health Plan Inc 2000
Section 3 How to get benefits continued
What do I do if I'm First call our customer service department at 1 800 4HUMANA If you are new to the FEHB in the hospital when program we will arrange for you to receive care If you are currently in the FEHB program and are
switching to us your former plan will pay for the hospital stay until
I join this Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Except in a medical emergency or for annual OB GYN services or when a primary care doctor specialty care 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 doctor's 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 arranged 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 need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
with us you must receive treatment from a specialist who does Generally we will not pay for you
when I enroll to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the receive services from your current specialist until we can make arrangements for you to see
someone else
Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
the provider unless the termination is for cause If you are in the second or third trimester of
provider leaves the pregnancy you may continue to see your OB GYN until the end of your postpartum care Plan or this Plan
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
leaves the Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
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Humana Health Plan Inc 2000
Section 3 How to get benefits continued
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist medical services or recommending follow up care from a specialist Before giving approval we consider if the
service is medically necessary and if it follows generally accepted medical practice
How do you decide A drug biological product device medical treatment or procedure is determined to be if a service is experimental or investigational if reliable evidence shows it meets one of the following criteria
experimental or when applied to the circumstances of a particular patient is the subject of ongoing phase I II investigational or III clinical trials or
when applied to the circumstances of a particular patient is under study with written protocol to determine maximum tolerated dose toxicity safety efficacy or efficacy in comparison to
conventional alternatives or
is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by the USFDA or Department of Health and
Human Services
is not generally accepted by the medical community
Reliable evidence means but is not limited to published reports and articles in authoritative medical scientific literature or regulations and other official actions and publications issued by the USFDA
or the Department of Health and Human Services
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Humana Health Plan Inc 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our decision
based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or
request for service
What if I have a Call us at 1 800 4HUMANA and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening
care and my condition conditions are ones that may cause permanent loss of bodily functions or death if they is serious or life are not treated as soon as possible
threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I Your request must be complete or OPM will return it to you You must send the following send to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
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Humana Health Plan Inc 2000
Section 4 What to do if we deny your claim or request for service continued
Who can make Those who have a legal right to file a disputed claim with OPM are the request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and 3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the review request
Where should I mail Send your rquest for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contract Division IV P O Box 436 Washington DC 20044
OPM
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision the Plan's denial 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 or supplies
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record
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Humana Health Plan Inc 2000
Section 5 Benefits Medical and Surgical
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 10 office
visit copay but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 15 copay for a doctor's house call and nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 through 49 one mammogram every one or two years for women age 50 through 64 one 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 will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child
during the covered portion of the mother's hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive
treatment will be covered only if the infant is covered under a Self and Family enrollment Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints Cornea heart lung single and double lung heart lung kidney and liver transplants allogeneic
donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer Wiskott Aldrich
syndrome severe combined immuno deficiency syndrome aplastic anemia ewings sarcoma and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical and hospital
expenses of the donor are covered when the recipient is covered by this Plan 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 Dialysis
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Orthopedic devices such as braces Prosthetic devices such as artificial limbs breast prostheses and surgical bras including their
replacements and the initial pair of lenses following cataract removal Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers Implantable drugs such as Norplant injectable drugs such as Depo Provera and contraceptive
devices
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits Medical and Surgical continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical
procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth
or intra oral areas surrounding the teeth are not covered including any dental care involved in 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 member's appearance
and if the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following
a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 treatments or two months per condition if significant improvement can be
expected within two months you pay nothing Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the
member to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay nothing The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay nothing cost of donor sperm is not covered Fertility drugs are covered you pay nothing Coverage is provided for invitro fertilization
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for up to 12 weeks you pay nothing
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
Cost of donor sperm Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes Transplants not listed as covered
Hearing aids Long term rehabilitative therapy
Podiatric services Chiropractic services
Homemaker services Foot orthotics
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Section 5 Benefits Hospital Extended Care
What is covered Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized
under the care of a Plan doctor You pay nothing All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 120 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 15 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives no charge if replacement is arranged by member
Custodial care rest cures domiciliary or convalescent care
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Section 5 Benefits Emergency
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies the service area if you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member must
notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges
covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay Nothing for emergency services that are covered benefits of this Plan
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the because of injury or unforeseen illness
service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time
If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay Nothing for emergency services that are covered benefits of this Plan
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Section 5 Benefits Emergency continued
What is covered Emergency care at a doctor's 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
What is not covered 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
Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency care for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
If you are required to pay for the services submit itemized bills and your receipts to the Plan along
providers with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on pages 8
and 9
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Section 5 Benefits Mental Conditions Substance Abuse
Mental conditions What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services
Outpatient Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each care calendar year you pay nothing for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject
covered to significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate Psychological testing when not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the
medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other illness or condition and to the extent shown below the services
necessary for diagnosis and treatment
Outpatient Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay nothing for care each covered visit all charges thereafter
The substance abuse benefit may be combined with the outpatient Mental Conditions Benefit shown above provided such treatment is necessary and is approved by the Plan to permit an
additional 20 outpatient visits per calendar year
Inpatient Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program care in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing
during the benefit period all charges thereafter
What is not Treatment that is not authorized by a Plan doctor
covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Humana Health Plan Inc 2000
Section 5 Benefits Prescription drug
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay one of the following copays per prescription unit or
refill
3 for generic drugs listed on our formulary 7 for brand name drugs with no generic equivalent listed on our formulary
20 for generic or brand name drugs not listed on our formulary
If there is no generic equivalent you pay the 7 brand name formulary copay If generic is available and you or the doctor requests the brand name you pay the applicable generic formulary
or non formulary copay plus the difference in cost between the brand and generic drugs
What is a Our formulary is a continually updated list of drug products including strengths dispensing limits
formulary and and any prior authorization requirements that represent the current clinical judgment of the members
how are drugs of our Pharmacy and Therapeutics Committee This committee is comprised of both physicians and pharmacists The formulary contains both brand name and generic drugs all of which have FDA
added to it approval
A generic drug is a drug that is manufactured distributed and available from several pharmaceutical manufacturers and identified by the chemical name or as defined by the national
pricing standard
A brand name drug is a drug that is manufactured and distributed by only one pharmaceutical manufacturer or as defined by the national pricing standard
Proposed additions or deletions to the Formulary are welcomed at any time and will be reviewed by the Committee
Our mail order For your convenience you may receive up to a 90 day supply of a prescribed maintenance
program medication for the cost of three applicable copays per 90 day supply
Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic sicknesses or injuries
Covered Drugs for which a prescription is required by law
medications Oral contraceptive drugs
and accessories Insulin Diabetic supplies including testing agents lancet devices alcohol swabs glucose elevating agents and insulin delivery devices
Self administered injectable drugs Disposable needles and syringes to inject covered prescribed medication
Formulas for the treatment of phenylketonuria or other inheritable diseases
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits Prescription drug continued
Limited benefits Drugs to treat sexual dysfunction are limited Contact the plan for dosage limits You pay the applicable drug copayment up to the dosage limits and all charges after that
What is not covered Drugs available without a prescription or for which there is a non prescription available Vitamins fluoride dietary and nutritional substances except for the type of formulas listed above
as covered Drugs obtained at a non Plan pharmacy except for out of area emergencies
Drugs used for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medications including nicotine patches Any drug used for the purpose of weight control
Prescriptions that are to be taken by or administered to the member in whole or part while a patient in a hospital skilled nursing facility convalescent hospital inpatient facility or other
facility where drugs are ordinarily provided by the facility on an inpatient basis Medical supplies such as dressings and antiseptics
Section 5 Benefits Other
Dental care Restorative services and supplies necessary to promptly repair but not replace sound natural Accidental injury teeth The need for these services must result from an accidental injury occurring while the
benefit member is covered under the FEHB Program you pay nothing
Vision care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases What is covered of the eye this Plan provides certain vision care benefits from Plan providers
When prescribed by a Plan optometrist or physician
Eye refractions to provide a written lens prescription for eyeglasses you pay nothing The Plan provides a 75 allowance for eyeglasses or contact lenses per member every two years
You may use the allowance for either eyeglasses or contact lenses at participating optical stores
What is not Nonprescription lenses
covered Lost or broken lenses or frames Cosmetic services or materials coated oversize or tinted lenses
Laminated lenses Multifocal lenses other than bifocals FT 25
Eye exercises Contact lenses examination
Lenticular lenses
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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Humana Health Plan Inc 2000
Section 5 Benefits Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are 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 out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedures
Expanded dental benefits
DEN 998 Two exams and cleanings per year when provided by Participating General Dentists for only 15 per service
20 percent discount on all other dental services when provided by a Participating General Dentist
No additional premium required No application to complete
DEN 815 Additional premium of 86.45 per member per year Diagnostic and most preventive services provided at no charge Other services including
restorative care endodontics periodontics prosthodontics oral surgery as provided by participating dentists are offered at copayments listed in the separate plan description
When you receive services from a participating specialist you will receive a 20 discount off of their charges
CREDIT CARD PAYMENT NOWAVAILABLE See application for details
Expanded prescription Oral and injectable contraceptive drugs must be purchased through the Plan's mail service drug benefits vendor You can obtain the order form to mail to the vendor by calling 708 957 8947 for
oral contraceptives or by calling 1 800 793 2637 for injectables
Special benefits for Medicare Eligible Enrollees
If you are enrolled in this plan through FEHBP and have Medicare Part A and have purchased Medicare Part B coverage you may also enroll in the Humana Gold Plus plan for FEHBP members
Humana Gold Plus provides all Medicare Part A and Part B benefits to the Medicare beneficiary as well as additional benefits not covered by Medicare It is an arrangement between Medicare and Humana in which Medicare pays a specific amount to
Humana for each Medicare beneficiary who enrolls in Humana Gold Plus
Like your enrollment in this FEHBP plan you are required to obtain your services from this plan's doctors and providers except for emergencies and out of area urgent care The rules regarding enrollment are fully explained in the Humana Gold
Plus enrollment kit For more information please contact Humana at 1 888 393 6765
Following your enrollment in Humana Gold Plus you will be entitled to receive an enhanced benefits package that combines your FEHBP coverage with your Humana Gold Plus plan benefits If you choose to enroll in Humana Gold Plus you will be
responsible for paying the Medicare Part B premium You must make an affirmative enrollment in Humana Gold Plus Information regarding enrollment and disenrollment rules may be found in the Evidence of Coverage You will also continue
to pay the employee share of the FEHBP premium
Benefits on this page are not part of the FEHB contract
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Humana Health Plan Inc 2000
Section 6 General exclusions Things we don't cover
What is not covered The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to
prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric
practice Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
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Humana Health Plan Inc 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 18
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage coverage You must tell us if you or a family member has double coverage You must also send
us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary
care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for injuries that another person caused you must reimburse us for whatever services we paid for 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
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
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Humana Health Plan Inc 2000
Section 7 Limitations Rules that affect your benefits continued
Workers We do not cover services that compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must provide
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 the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other government We do not cover services and supplies that a local State or Federal Government agency directly agencies or indirectly pays for
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Humana Health Plan Inc 2000
Section 8 FEHB facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also
find out about care management which includes medical practice guidelines disease
your HMO management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 1 800 4HUMANA or write to Humana Health Plan Inc 30 South Wacker Dr Suite 3100 Chicago Illinois 60606 You may also contact us
by fax at 502 580 7896 or visit our website at www humana com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
an informed decision about
enrolling in the When you may change your enrollment FEHB Program How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment
We 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
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire 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 which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are available unmarried dependent children under age 22 including any foster or step children your employing
or retirement office authorizes coverage for Under certain circumstances you may also get
for my family and me 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 you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
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Humana Health Plan Inc 2000
Section 8 FEHB facts continued
Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract this plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating
claims Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage 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 more information about your coverage choices
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Humana Health Plan Inc 2000
Section 8 FEHB facts continued
What is TCC Temporary Continuation of Coverage TCC If you leave federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I If you leave Federal service your employing office will notify you of your right to enroll under
enroll in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I convert to You may convert to an individual policy if individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available 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
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Humana Health Plan Inc 2000
Section 8 FEHB facts continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
health insurance or other health care coverage You must arrange for the other coverage within
Group Health 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations Plan Coverage or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well
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Humana Health Plan Inc 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or
misrepresented any information do the following
Call the provider and ask for an explanation There may be an error If the provider does not resolve the matter call us at 1 800 4HUMANA and explain the
situation If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE 202 418 3300
U S Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400 Washington D C 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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Humana Health Plan Inc 2000
Summary of Benefits for Humana Health Plan Inc Chicago 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes care 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 12
Extended Care All necessary services for up to 120 days per year You pay nothing 12
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient
care per year You pay nothing 15
Substance Abuse Up to 30 days per year in a substance abuse treatment program You pay nothing 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care including specialist's care preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay for office visits 15 per house call by a doctor 10 11
Home Health Care All necessary visits by nurses and health aides You pay nothing 10
Mental Conditions Up to 20 outpatient visits per year You pay nothing 15
Substance Abuse Up to 20 outpatient visits per year You pay nothing 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay nothing 13 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 3 copay for generic formulary drugs a 7 copay for brand name formulary drugs
or a 20 copay for generic or brand name non formulary drugs 16 17
Dental care Accidental injury benefit You pay nothing 17
Vision care Refractions covered as needed a 75 allowance for eyeglasses or contact lenses every two years 17
Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits 5
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Authorized for Distribution by the
United States Office of Personnel Management
2000 Rate Information for
Humana Health Plan Inc Chicago
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency
that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates
will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in
The Guide to Federal Employees Health Benefits Plans for United States Postal
Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain
special postal employment classes or associate members of any postal employee
organization Such persons not subject to postal rates must refer to the applicable
Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share Share Share Share Share Share Share Share
Self Only 751 75.02 25.01 162.55 54.18 88.78 11.25 88.78 11.25
Self and Family 752 175.97 63.93 381.27 138.51 207.74 32.16 201.02 38.88
28 28