SPECIAL NOTICE Group Health Plan and
Prinicipal Health Care have merged with GHP being
the surviving entity See page 4 for details
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www ghp com
Authorized for distribution by the
United States Office of
Personnel Management
RI 73 104
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Group Health Plan Inc 2000
Table of Contents
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 8
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB facts 18
Inspector General Advisory Stop Healthcare Fraud 21
Summary of benefits Inside Back Cover
Premiums Back Cover
Introduction
This brochure describes the benefits you can receive from Group Health Plan HMO 111 Corporate Office Drive Ste 400 Earth City MO 63045 under its contract CS1930 with the Office of Personnel Management OPM as authorized by the Federal
Employees Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each
eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 3 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 Group Health Plan HMO as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Group 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 HMO 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
Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits Doctor's office visit copay is now 10 per visit instead of 5 per visit This
includes Primary Care Physician care specialist care preventative care including well baby
care periodic check ups and routine immunizations laboratory tests and X rays and complete
maternity care
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
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Group Health Plan Inc 2000
Section 2 How we change for 2000 continued
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 Your share of the non postal premium will decrease by 3.3 for Self Only or 35.1 for Self and Family
Benefit changes Prescription Drug copays are 7 for generics and 12 for brand name drugs instead of respectively 5 and 10
Clarifications Under Prescription Drug Benefits the maintenance mail order drug benefit description has been clarified to show how members can obtain this benefit
SPECIAL NOTICE Group Health Plan and Principal Health Care of St Louis have merged with GHP being the surviving entity Former members of Principal have been automatically transferred to GHP Former Principal
members who do not wish to be tranferred to GHP must choose a new health plan during Open Season To select another health plan Employees should contact their personnel office Retirees should follow the instructions in
the Open Season package that was mailed to them
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is the Metropolitan St Louis area Specifically St Louis City and the
Missouri counties of Crawford Franklin Gasconade Jefferson Lincoln St Charles Ste
Genevieve and Warren
The Illinois counties of Calhoun Christian Clinton Cole Franklin Jackson Jersey Johnson
Macoupin Madison Menard Monroe Montgomery Morgan Perry Randolph Saline
Sangamon St Clair Williamson and Union
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
When traveling outside of the service area due to a reciprocal agreement with HMO Group
members are covered for non emergency care The agreement is limited to areas where there is a
participating HMO and does not include specialty care The member is required to contact the
Group Health Plan Member Services Department at 314 453 0675 or 1 800 755 3901 to obtain
access to these 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 pay You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of charges Please remember you must pay this amount when
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Group Health Plan Inc 2000
Section 3 How to get benefits continued
you receive services except for prenatal and postnatal office visits inpatient hospital care home health care mental health and substance abuse care and preventive dental care
After you pay 4,700 in copayments or coinsurance for Self Only Enrollment or 11,740 for Self and Family Enrollment you do not have to make any further payments for certain services
the rest of the year This is called a catastrophic limit However copayments or coinsurance for your dental services do not count toward these limits and you must continue to make these
payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally 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 us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time
Who provides my Group Health Plan is an IPA model Health Maintenance Organization HMO Your care is health care provided by the primary care doctor you select Adults may select either an internal medicine or
family practice doctor For children you may choose a pediatrician or family practice doctor
You may choose a primary care doctor from one of the Plans participating physician groups
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 See How do I get specialty care below for services
that you can receive without a referral from your primary care doctor
The Plan's 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 Member Services Department at 1 800 755
3901 You can also find out if your doctor participates with this Plan by checking directly with
the provider or by calling us at the above 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 Plan's delivery system the continued availability and or participation of
any one doctor hospital or other provider cannot be guaranteed
Should you decide to enroll in the Plan you will be asked to select a primary care doctor for you
and each family member Plan personnel are available to help you select a doctor Members may
change their doctor selection at any time except when the member is hospitalized or undergoing
certain types of treatment Changes received before the 15th of the month will become effective
on the first of the next month This may be done by calling Member Services at 1 800 755 3901
What do I do if my primary Call us We will help you select a new one care physician leaves the
Plan
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Section 3 How to get benefits continued
What do I do if I need to go Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist into the hospital will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our member service department at 800 755 3901 If you are new to the FEHB hospital when I join this Program we will arrange for you to receive care If you are currently in the FEHB Program
Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 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 specialty care Your primary care physician will arrange your referral to a specialist Services of other providers are covered only when there has been a referral by the member's primary care doctor with the
following exceptions a woman may see her Plan gynecologist for her annual routine examination
without a referral members may have a once a year exam from a Plan provider without a
referral and members may self refer for any mental health benefits
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
Group Health Plan provides a 24 hour NurseAccess phone line staffed with registered nurses to
answer questions and provide referrals for emergency services NurseAccess is the Plan's new
name for its 24 hour Urgent Care Line These nurses answer questions and provide referrals for
emergencies only All other referrals are to come from the member's Primary Care Physician
What do I do if I am As a new GHP member your Primary Care Physician will need to notify GHP's medical seeing a specialist when management department of any ongoing specialty care you may need If your current specialist
I enrole does not participate with us you must receive treatment from a specialist who does Generally
we will not pay for you 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 Plan receive services from your current specialist until we can make arrangements for you to see
someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the Plan contract with the provider unless the termination is for cause If you are in the second or third or this Plan leaves the trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
Program care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a medical services specialist or recommending follow up care Before giving approval we consider if the service
is medically necessary and if it follows generally accepted medical practice
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Section 3 How to get benefits continued
How do you decide if a The Plan's experimental investigational determination process is based on authoritative service is experimental information obtained from medical literature medical consensus bodies health care standards
or investigational database searches evidence from national medical organizations State and Federal government agencies and research organizations The review and approval process for medical policies and
clinical practice guidelines includes clinical input from doctors with specialty expertise in the subject
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
Be in writing Refer to specific brochure wording explaining why you believe our decision is wrong and
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
Maintain our denial in writing Pay the claim
Arrange for a health care provider to give you the service or 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 to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal 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 serious Call us at 1 800 755 3901 and we will expedite our review or life threatening condition
and you haven't responded to my request for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can
my condition is serious or call OPM's health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
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
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 send to OPM Your request must be complete or OPM will return it to you You must send the following information
A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
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Section 4 What to do if we deny your claim or request for service continued
Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
Copies of all letters you sent us about the claim Copies of all letters we sent you about the claim and
Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request
Anyone enrolled in the Plan The estate of a person once enrolled in the Plan and
Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with
the review request
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs disputed claim to OPM Contract Division IV P O Box 436 Washington D C 20044
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base a lawsuit its 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from Privacy Act you 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
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit
copay but no additional copay for laboratory tests and X rays House calls will be provided within
the Service Area if in the judgment of the Plan doctor such care is necessary and appropriate
You pay nothing for a doctors house call nothing for home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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 over 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 Prenatal and postnatal office visit copayments are
waived once pregnancy has been confirmed 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 testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung single or double 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 nonlymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors when the transplant is
authorized by the Plan and received at a Center of Excellence hospital 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 Inpatient
stays will be extended if medically necessary
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Othopedic devices such as braces initial placement only prescription or custom made orthotics
Prosthetic devices such as artifical limbs and external lenses following cataract removal
initial placement or set only Coverage of breast prostheses is limited to initial placement
and 1 replacement every 2 years Surgical bras and replacements are covered at two per
calendar year
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Cardiac rehabilitation
IUD's diaphragms and contraceptive implants
Limited benefits Diagnosis and treatment of infertility is covered you pay a 10 office visit copay Artificial insemination specifically intrauterine insemination IUI is covered The cost of donor sperm is
not covered Other assisted reproductive technology ART procedures such as in vitro fertilization
and embryo transfer are not covered Infertility services are not covered for members who
previously were voluntarily sterilized Fertility drugs are not covered
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 visits per condition if significant improvement can be
expected You pay nothing
Durable Medical Equipment is authorized based on medical necessity but the authorization is not valid for more than a three 3 month period Reauthorization is required at the end of the
authorization period and is based on continued medical necessity of the durable medical equipment The durable medical equipment must be ordered by a Plan provider and obtained from a
Plan DME contracted provider You pay nothing Repairs and replacements of purchased equipment are not covered
Chiropractic services for acute episode spinal manipulations are covered for 10 copayment when obtained through a plan provider and referred by a primary care physician
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 surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Long term rehabilitative therapy
Weight loss programs
Blood and blood derivatives no charge if replacement is arranged by member
Orthopedic shoes and other foot support devices including over the counter or non prescription orthotics
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Chiropractic services other than spinal manipulations
Transplants not listed as covered
Repairs and replacement of purchased durable medical equipment
Nutritional supplements including tube feeding
Testicular implants
Replacement of prosthetic devices
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are Hospital care 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 This Plan provides a comprehensive range of benefits with no dollar limit for up to 45 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 inpatient and home care when authorized by a Plan doctor and performed by a Plan provider housekeeping services are not covered
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by the Plan or a Plan doctor
Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a Inpatient dental need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
procedures 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 14 for Non Medical 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
Private duty nursing except when prescribed by a Plan physican
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Section 5 Benefits continued
Emergency Benefits
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 the If you are in an emergency situation please call your primary care doctor or the Plan's Urgent service area Care phone line at 314 453 9090 or 1 800 580 9733 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 You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure
that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it is 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 and
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 your Plan primary care physician
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan This charge is waived upon admission to the hospital
Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area 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 your Plan primary care physician
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan This charge is waived upon admission to the hospital
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Section 5 Benefits 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 doctor's services
Ambulance service approved by the Plan
What is not covered Elective care or non emergency 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 for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers 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 the 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 7 and 8
Mental Conditions Substance Abuse Benefits
Mental conditions To the extent shown below the Plan provides the following services necessary for the What is covered 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 care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay nothing per visit for each covered visit all charges thereafter Group
outpatient visits may be substituted on a two for one basis for individual outpatient mental health care visits
Inpatient care Up to 30 days of hospitalization each calendar year You pay nothing for covered days all charges thereafter One inpatient benefit day may be exchanged for two outpatient day visits
One individual outpatient day treatment may be exchanged for two group therapy visits
What is not covered Care for psychiatric conditions that in the professional judgement 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
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Group Health Plan Inc 2000
Section 5 Benefits continued
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the What is covered 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 These substance abuse benefits may be combined with the
outpatient Mental condition benefit shown above provided such treatment is necessary as a
Mental condition service and is approved by the Plan to permit an additional 20 outpatient visits
with the applicable Mental conditions copayments
Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year You pay nothing for each covered visit all charges thereafter Group outpatient visits may be substituted on a two
for one basis for individual visits
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation program in an alcohol detoxification or rehabilitation center approved by the Plan You pay nothing for covered days all
charges thereafter One inpatient benefit day may be exchanged for two outpatient day visits One individual outpatient day treatment may be exchanged for two group therapy visits
What is not covered Treatment that is not authorized by a Plan doctor
All charges for a substance abuse rehabilitation program if the member does not complete the program
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply You pay a 7 copay for generic and a
12 copay for name brand
Prescription drugs listed in the Plan's drug formulary and prescribed by a Plan doctor are covered by this Plan GHP's drug formulary is a listing of prescription drugs determined by committee If
a member prefers a name brand or non formulary drug when a generic is available the member will be charged the difference in cost between the brand name and the generic in addition to the
copayment In certain circumstances a medication needed by the member may not be on the drug formulary Exceptions to the formulary can be requested by the member's GHP physician
Nonformulary drugs will be covered when prescribed by a Plan physician Exceptions to the formulary are made on a case by case basis by the Plan Pharmacist and Medical Director
Maintenance medications may be obtained through the Plan's mail order program A 90 day supply of a maintenance medication is available for two copayments For information on how to
access our mail order program contact our Member Services Department at 1 800 755 3901
Covered medications and accessories include
Drugs for which a prescription is required by law
Full range of FDA approved drugs prescriptions and devices for birth control
Insulin with a copay charge applied to each vial
Disposable needles and syringes needed for injecting insulin and covered prescribed medication
Blood glucose test strips for insulin dependent members
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Group Health Plan Inc 2000
Section 5 Benefits continued
Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
Limited benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay 12 copayment up to the dosage limits and all charges above that
What is not covered Drugs available without a prescription or for which a non prescription equivalent is available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Fertility drugs
Diabetic supplies except for needles and syringes and blood glucose test strips
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Drugs for weight loss
Refills for prescriptions resulting from loss or theft
Prescription drugs for travel
Special packaging required for drugs dispensed in nursing homes
Other Benefits
Dental Care The following preventive and diagnostic dental services are provided by participating Plan What is covered dentists You pay nothing Services are limited to one visit per 6 months per member
Oral examination and X rays as necessary Dental prophylaxis cleaning
Topical application of fluoride
Accidential injury Restorative services and supplies necessary to promptly repair within 3 days but not replace benefit sound natural teeth The need for these services must result from an accidental injury You pay
nothing
What is not covered Other dental services not shown as covered
Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of disease What is covered of the eye annual eye refractions to provide a lens prescription for eyeglasses may be obtained
from Plan providers you pay a 10 copay per visit
What is not covered Eye exercises
Corrective eyeglasses and frames or contact lenses including the fitting of contact lenses
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Group Health Plan Inc 2000
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 procedure
MEDICARE PREPAID PLAN ENROLLMENT This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare without payment of an
FEHB premium As indicated on page 17 certain annuitants and former spouses who are covered by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB Contact your retirement
system for information on changing your FEHB enrollment Contact us at 314 506 1525 for information on the Medicare prepaid plan and the cost of that enrollment
ADDITIONAL DENTAL BENEFITS In addition to the preventative dental benefits included in the FEHB package Group Health Plan is offering the
following at no additional cost A 30 discount on any major or minor restorative care provided by general dentists listed in our directory
Benefits on this page are not part of the FEHB contract
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Group Health Plan Inc 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition We do
not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare 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 re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your 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 16
Other group insurance When anyone has coverage with us and with another group health plan it is called double 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
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Group Health Plan Inc 2000
Section 7 Limitations Rules that affect your benefits continued
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
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency 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
If you have a If you have a malpractice claim because of services you did or did not receive from a plan malpractice claim provider it must go to binding arbitration Contact us about how to begin our binding arbitration
process
Section 8 FEHB Facts
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the 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 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 800 755 3901 or write to 111 Corporate Office Drive Ste 400 Earth City MO 63045 You may also contact us by fax at 314 506 1712 or visit our website at www ghp com
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal about enrolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to
FEHB program make an informed decision about
When you may change your enrollment How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment
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Group Health Plan Inc 2000
Section 8 FEHB Facts continued
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 effective 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
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been 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 coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse and available for my family and your unmarried dependent children under age 22 including any foster or step children your
me employing or retirement office authorizes coverage for Under certain circumstances you may also get 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
Are my medical and claims We will keep your medical and claims information confidential Only the following will have records confidential access to it
OPM this Plan and subcontractors when they administer this contract This plan and appropraite third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payment 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 conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
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Group Health Plan Inc 2000
Section 8 FEHB Facts continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this Your enrollment ends unless you cancel your enrollment or
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 spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits 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
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 enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under 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
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Group Health Plan Inc 2000
Section 8 FEHB Facts
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
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
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when
Health Plan Coverage getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error If the provider does not resolve the matter call us at 800 775 3901 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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Group Health Plan Inc 2000
Notes
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Group Health Plan Inc 2000
Summary of Benefits for Group Health Plan Inc 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 care 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 .11
Extended care All necessary services up to 45 days per year You pay nothing .11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days per conditions calendar year One benefit day may be exchanged for two outpatient day visits
and one individual outpatient day treatment may be exchanged for two group therapy visits You pay nothing .13
Substance Up to 30 days per calendar year in an approved substance abuse program abuse One benefit day may be exchanged for two outpatient day visits and one
individual outpatient day treatment may be exchanged for two group therapy visits You pay nothing .14
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or care injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit nothing per
house call by a doctor .8
Home All necessary visits by nurses and health aides You pay nothing .9 health care
Mental Up to 20 outpatient visits per calendar year You pay nothing .13 conditions
Substance Up to 20 outpatient visits per calendar year You pay nothing .14 abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room or
urgent care center visit and any charges for services that are not covered by this Plan .12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 7 copay for generic and 12 copay for name brand per prescription unit or
refill .14,15
Dental care Preventive dental care Treatment of accidental dental injuries You pay nothing .15
Vision care Annual eye refraction including lens prescriptions examination You pay a 10 copay per visit .15
Out of pocket maximum Copayments are required for a few benefits However after your out of pocket expenses reach a maximum of 4,700 per Self Only enrollment or 11,740 per
Self and Family enrollment per calendar year covered benefits will be provided at 100 This copayment maximum does not include costs of prescription drugs
and dental services .5
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Authorized for distribution by the
United States Office of Personnel Management
2000 Rate Information for
Group Health Plan Inc
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 Gov't Your Gov't Your USPS Your USPS Your Enrollment
Code Share Share Share Share Share Share Share Share
Self Only MM1 76.46 25.49 165.67 55.22 90.78 11.47 90.48 11.47
Self and Family MM2 166.69 55.56 361.16 120.38 197.25 25.00 197.25 25.00
24 24