Serving: Southeast Michigan
Enrollment in this Plan is
limited. You must live or work in our Geographic service area to enroll. See
page 7 for requirements.
Enrollment codes for this Plan:
KA1 Self Only KA2 Self and Family
RI 73-062
For changes in benefits
see page 8.
A Health Maintenance Organization 1
1
Page 2 3
2002
OmniCare Health Plan 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….........................................................................................
4
Plain
Language.......................................................................................................................................................................................
4
Inspector General
Advisory.................................................................................................................................................................
4-5
Section 1. Facts about this HMO
plan...................................................................................................................................................
6
How we pay
providers..........................................................................................................................................................
6
Your Rights
..........................................................................................................................................................................
6
Service Area
.........................................................................................................................................................................
7
Section 2. How we change for
2002......................................................................................................................................................
8
Program-wide changes
.........................................................................................................................................................
8
Changes to this Plan
.............................................................................................................................................................
8
Section 3. How you get care
.................................................................................................................................................................
9
Identification cards
...............................................................................................................................................................
9
Where you get covered care
.................................................................................................................................................
9
Plan providers
................................................................................................................................................................
9
Plan
facilities..................................................................................................................................................................
9
What you must do to get covered care
.................................................................................................................................
9
Primary care
...................................................................................................................................................................
9
Specialty care
.................................................................................................................................................................
9
Hospital care
................................................................................................................................................................
10
Circumstances beyond our control
.....................................................................................................................................
10
Services requiring our prior approval
.................................................................................................................................
11
Section 4. Your costs for covered
services..........................................................................................................................................
12
Copayments..................................................................................................................................................................
12
Deductible
....................................................................................................................................................................
12
Coinsurance..................................................................................................................................................................
12
Your out-of-pocket
maximum............................................................................................................................................
12
Section 5.
Benefits...............................................................................................................................................................................
13
Overview............................................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals.................................... 14
(b) Surgical and
anesthesia services provided by physicians and other health care professionals
................................ 24
(c) Services provided by a hospital or
other facility, and ambulance services
.............................................................. 28
(d)
Emergency services/accidents
.................................................................................................................................
31
(e) Mental health and substance abuse benefits
............................................................................................................
33
(f) Prescription drug benefits
........................................................................................................................................
35
(g) Special features
.......................................................................................................................................................
37
Flexible benefits option
Services for deaf and hearing impaired 2
2 Page 3 4
2002 OmniCare Health Plan 3 Table of Contents
Centers for excellence for transplants
24-hour Emergency HOT-LINE
Disease Management
Language Services
(h) Dental benefits
.........................................................................................................................................................
38
(i) Non-FEHB benefits available to Plan members
......................................................................................................
39
Section 6. General exclusions --things we don't cover
.......................................................................................................................
40
Section 7. Filing a claim for covered
services.....................................................................................................................................
41
Section 8. The disputed claims process
...............................................................................................................................................
42
Section 9. Coordinating benefits with other coverage
........................................................................................................................
44
When you have…
Other health coverage
...................................................................................................................................................
44
Original Medicare
.........................................................................................................................................................
44
Medicare managed care plan
........................................................................................................................................
46
TRICARE/Workers' Compensation/Medicaid
..................................................................................................................
46
Other Government agencies
...............................................................................................................................................
47
When others are responsible for injuries
............................................................................................................................
47
Section 10. Definitions of terms we use in this brochure
.....................................................................................................................
48
Section 11. FEHB facts
.......................................................................................................................................................................
49
Coverage
information.......................................................................................................................................................
49
No pre-existing condition
limitation.........................................................................................................................
49
Where you get information about enrolling in the FEHB
Program..........................................................................
49
Types of coverage available for you and your family
..............................................................................................
49
When benefits and premiums start
...........................................................................................................................
50
Your medical and claims records are
confidential....................................................................................................
50
When you retire
.......................................................................................................................................................
50
When you lose
benefits.....................................................................................................................................................
50
When FEHB coverage
ends......................................................................................................................................
50
Spouse equity coverage
...........................................................................................................................................
50
Temporary Continuation of Coverage
(TCC)..........................................................................................................
50
Converting to individual coverage
..........................................................................................................................
51
Getting a Certificate of Group Health Plan Coverage
.............................................................................................
51
Long term care insurance is coming later in
2002................................................................................................................................
52
Index
.....................................................................................................................................................................................
53
Summary of benefits
............................................................................................................................................................................
54
Notes
.....................................................................................................................................................................................
55
Rates.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 OmniCare Health Plan 4 Introduction/ Plain Language
Introduction
OmniCare Health Plan 1155 Brewery Park Blvd.
Detroit, Michigan 48207
This brochure describes the benefits of OmniCare
Health Plan under our contract (CS 1871) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the official statement of
benefits. No oral statement can modify or
otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available
before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 7. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
“you” means the enrollee or family member;
"we" means OmniCare Health Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure,
let us know. Visit OPM's "Rate Us" feedback area at www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may also
write to OPM at the
Office of Personnel
Management, Office of Insurance Planning and Evaluation Division, 1900
E Street, NW Washington, DC 20415-3650
Inspector General Advisory
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 800/477-6664 and explain
the situation. If we do not
resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Stop health care fraud! 4
4 Page 5 6
2002 OmniCare
Health Plan 5 Introduction/ Plain Language
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card
if the person tries to obtain services for someone who is
not an eligible family member, or is no longer enrolled in the Plan and tries to
obtain benefits. Your
agency may also take administrative action against
you. 5
5 Page 6 7
2002 OmniCare Health Plan 6 Section 1
Section 1. Facts
about this HMO plan
This Plan is a health maintenance organization
(HMO). We require you to see specific physicians, hospitals, and other providers
that contract with us. These Plan providers coordinate your health care
services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan providers, 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.
How we pay providers
We contract with
individual physicians, medical groups, and hospitals to provide the benefits in
this brochure. These Plan providers accept a negotiated payment from us, and you
will only be responsible for your copayments or coinsurance. You must share the
cost
of some services. This is called either a copayment (a set dollar
amount) or coinsurance (a set percentage of charges). Please remember you must
pay this amount when you receive services. Your out-of-pocket expenses for
benefits covered under this Plan are
limited to the stated copayments
required for a few benefits.
OmniCare Health Plan is a Mixed Model
Prepayment Plan. This means you have the options of selecting your primary care
doctor from the group practice list or you may select your primary care doctor
from the list of individual practice doctors. There are
approximately 550
primary care doctors to choose from, and over 1700 specialists who are available
for referral care.
All family members do not have to use the same primary
care doctor. Each family member may have their own specific primary care doctor.
It is through the primary care doctor that all other health services,
particularly those of specialists, are obtained. It is the responsibility of
your primary care doctor to obtain any necessary authorizations from the Plan
before referring you to a specialist or making
arrangements for
hospitalization. Services of other providers are covered only when you have been
referred by your primary care doctor. The only exception is that women may see
their participating provider of obstetric and gynecology of record directly, and
members may self-refer to participating chiropractors and pediatricians,
with no need to be referred by their primary care doctor.
The Plan’s
provider directory lists primary care doctors with their locations and phone
numbers. Directories are updated on a regular basis and are available at the
time of enrollment or upon request by calling the Customer Care Call Center at
1-800-477-6664.
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.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get
information about us, our networks, providers, and facilities. OPM’s FEHB
website (www.opm.gov/insure) lists the specific types of information that we
must
make available to you. Some of the required information is listed
below.
Compliance and licensing requirements – OmniCare is in compliance
with the Patient’s Bill of rights and meets all licensing requirements
Years in existence – OmniCare has been in existence for 27 years
Profit
status – OmniCare is a non-profit organization
If you want more information
about us, call 1-800-477-6664, or write to OmniCare Health Plan, Customer Care
Call Center, 1155 Brewery Park Blvd., Suite 250, Detroit, MI 48207. You may also
contact us by fax at 313-393-7944 or visit our website at
www.ochp.com. 6
6 Page
7 8
2002 OmniCare Health Plan 7
Section 1
Service Area
To enroll in this Plan, you must
live in or work in our Service Area. This is where our providers practice. Our
service area is in the Michigan counties of Macomb, Monroe, Oakland, Washtenaw
and Wayne.
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
benefits. We will not pay for any other health care services out of our service
area unless the services have prior
plan approval.
If you or a covered
family member moves 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 moves, you do not have to wait until Open Season to change
plans. Contact your employing or retirement office.
. 7
7 Page
8 9
2002 OmniCare Health Plan 8
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not change
benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)
We
increased speech therapy benefits by removing the requirement that services must
be required to restore functional speech. (Section 5(a))
Changes to this Plan
Your share of the non-Postal premium will
increase by 13.1% for Self Only or 13.1% for Self and Family.
You have access to mail-order prescription services 8
8 Page 9 10
2002 OmniCare Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you receive services from a
Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive
your ID card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits
enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30
days after the effective date of your enrollment, or if you need replacement
cards, call us at 1-800-477-6664.
Where you get covered care You get care from “Plan providers” and
“Plan facilities.” You will only pay copayments, and you will not have to file
claims.
Plan providers Plan providers are physicians and other health
care professionals in our service area that we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update
periodically. The list is also on our website.
It depends on the type of
care you need. First, you and each family member must choose a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care. You must indicate your
choice of PCP on your enrollment form. If you do not select a PCP, we will
select one for you based on
your zip code location. If you are not satisfied
with our selection, you can call us at 1-800-477-6664, and we will help you to
select a new one.
Primary care Your primary care physician can be a family practitioner,
internist, OB/GYN, general practitioner or pediatrician. Your primary care
physician will provide most of your
health care, or give you a referral to
see a specialist.
If you want to change primary care physicians or if your
primary care physician leaves the Plan, call us. We will help you select a new
one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain number of
visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may see a
Plan chiropractor,
pediatrician or OB/GYN without a referral.
Here are
other things you should know about specialty care:
If you need to see a
specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will work with your specialist to
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 (the
physician may have to get an authorization or approval beforehand).
What you must do to get covered care 9
9
Page 10 11
2002
OmniCare Health Plan 10 Section 3
If you are seeing a specialist
when you enroll in our Plan, talk to your primary care physician. Your primary
care physician will decide what treatment you need. If he or
she decides to
refer you to a 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 to see a
specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other
than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new
plan.
If you are in the second or third trimester of pregnancy and you
lose access to your specialist based on the above circumstances, you can
continue to see your specialist until
the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care
physician or specialist will make necessary hospital arrangements and supervise
your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan
begins, call our customer service department immediately at 1-800-477-6664. If
you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care. 10
10
Page 11 12
2002
OmniCare Health Plan 11 Section 3
Your primary care physician has
authority to refer you for most services. For certain services, however, your
physician must obtain approval from us. Before giving approval,
we consider
if the service is covered, medically necessary, and follows generally accepted
medical practice.
We call this review and approval process prior authorization. Your physician
must obtain Plan authorization for the following services:
All surgical
procedures Temporomandibular joint treatment (TMJ)
Growth hormone therapy
(GHT) Mental Health and Substance Abuse treatment
After your physician diagnoses the problem, the diagnosis and procedure
recommended must be forwarded to the Plan Medical Director. The Medical Director
will review for
necessity of procedure. Once approved, the authorization
will be forwarded to the PCP. If a procedure is not authorized, it will not be
covered, except in the case of an
emergency.
Services requiring our prior approval 11
11
Page 12 13
2002
OmniCare Health Plan 12 Section 4
Section 4. Your costs
for covered services
You must share the cost of some services. You are
responsible for:
Copayments A copayment is a fixed amount of money
you pay to the provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of our
allowance for infertility prescription services.
Your catastrophic protection We do not have an out-of-pocket maximum.
Out-of-pocket maximum 12
12 Page 13 14
2002 OmniCare
Health Plan 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 54 for
a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain
claims forms, claims filing
advice, or more information about our benefits, contact us at 1-800-477-6664 or
at our website at www.ochp.com.
(a) Medical services and supplies provided by physicians and other health
care professionals ....................................................... 14-23
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Treatment therapies Physical
and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision
services (testing, treatment, and supplies) Foot care
Orthotic and
prosthetic devices Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals................................................. 24-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
28-30
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency
services/accidents..................................................................................................................................................
31-32 Medical emergency Ambulance
(e) Mental health and substance abuse benefits
.............................................................................................................................
33-34
(f) Prescription drug benefits
........................................................................................................................................................
35-36
(g) Special features
.............................................................................................................................................................................
37 Flexible benefits option 24-hour Emergency HOT-LINE
Services for deaf and hearing impaired Disease Management
Centers for
excellence for transplants Language Services
(h) Dental benefits
.............................................................................................................................................................................
38
(i) Non-FEHB benefits available to Plan
members............................................................................................................................
39
Summary of benefits
............................................................................................................................................................................
54 13
13 Page 14
15
2002 OmniCare Health Plan 14 Section 5(
a)
Section 5 (a). Medical services and supplies provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician’s office
$10 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
$10 per office visit for outpatient services
At home Nothing, if deemed medically necessary by Plan Medical Director
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
All charges. 14
14 Page 15 16
2002 OmniCare
Health Plan 15 Section 5( a)
Lab, X-ray and other diagnostic
tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap
tests
Pathology
X-rays
Non-routine mammograms
CAT Scans/MRI
Ultrasound
Electrocardiogram and EEG
$10 per office visit, no additional fee for services
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Colorectal Cancer Screening,
including
Fecal occult blood test
Sigmoidoscopy, screening – every five years
starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$10 per office visit
Routine pap test
Note: The office visit is covered
if pap test is received on the same day; see Diagnosis and Treatment,
above.
$10 per office visit
Preventive Care -Adult --continued on next page 15
15 Page 16 17
2002 OmniCare Health Plan 16 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
Eye exams through age 17 to determine
the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (up to age 22)
$10 per office visit 16
16 Page 17 18
2002 OmniCare
Health Plan 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
The hospital must obtain prior authorization for your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother’s maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
Single $10 office copay for entire pregnancy
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
Family planning
A broad range of voluntary family
planning services, such as:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover
oral contraceptives under the prescription drug benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges. 17
17 Page 18 19
2002 OmniCare
Health Plan 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI) intracervical
insemination (ICI)
intrauterine insemination (IUI) Injectable fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.
$10 per office visit
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization embryo transfer, gamete GIFT
and zygote ZIFT
Zygote transfer Services and supplies related to excluded ART
procedures
Cost of donor sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges. 18
18 Page 19 20
2002 OmniCare Health Plan 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/Tissue Transplants on page 27.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous
(IV)/Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment. Call 1-800-955-4578 for preauthorization. We will
ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will only
cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically necessary, we will not
cover the GHT or
related services and supplies. See Services requiring our prior approval
in Section 3.
$10 per office visit
Not covered: Unauthorized GHT or related services and supplies All
charges. 19
19 Page
20 21
2002 OmniCare Health Plan 20
Section 5( a)
Physical and occupational therapies You Pay
120 visits per condition for the services of each of the following:
qualified physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury.
Cardiac
rehabilitation following a heart transplant, bypass surgery or a
myocardial
infarction, is provided.
$10 per office visit
$10 per outpatient visit
Nothing per visit
during covered inpatient
Not covered:
long-term rehabilitative therapy
exercise programs
Speech therapy
120 visits per condition $10 per office visit
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges. 20
20 Page 21 22
2002 OmniCare Health Plan 21 Section 5( a)
Vision services (testing, treatment, and supplies) You Pay
One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit
Eye exam to determine the need for vision correction for children through age
22 (see Preventive care, children)
Annual eye refractions
Note: See
Preventive care, children
$10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthotic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges.
Orthotic and prosthetic devices
Corrective foot orthotics
Artificial limbs and eyes; stump hose
Externally worn breast prostheses
and surgical bras, including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant following
mastectomy.
Note: See 5(b) for coverage of the surgery to insert the device
$10 per office visit
Orthotic and prosthetic devices-Continued on next page 21
21 Page 22 23
2002 OmniCare Health Plan 22 Section 5( a)
Orthotic and prosthetic devices (Continued) You pay
Not covered:
orthotic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
All charges.
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs, motorized wheelchairs if medically
necessary;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 1-800-955-4578 as soon as your Plan
physician prescribes this equipment. We will arrange with a health care provider
to rent or sell
you durable medical equipment.
$10 per office visit
Not covered: Shoe inserts for plaus plantus All charges. 22
22 Page 23 24
2002 OmniCare Health Plan 23 Section 5( a)
Home health services You pay
Home health care ordered by a
Plan physician and provided by a registered nurse (R.N.), licensed practical
nurse (L.P.N.), licensed
vocational nurse (L.V.N.), or home health aide.
Services include oxygen
therapy, intravenous therapy and medications.
Nothing
Not covered: nursing care requested by, or for the convenience of,
the patient or
the patient's family; Home care primarily for personal
assistance does not include a
medical component and is not diagnostic,
therapeutic, or rehabilitative.
All charges.
Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
$15 per office visit
$300 maximum/single, $600 maximum/family
Not covered:
Services not listed above
All charges.
Alternative treatments
Not covered: naturopathic service
acupuncture hypnotherapy
biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.
Diabetes self-management
$10 per office visit 23
23 Page 24 25
2002 OmniCare
Health Plan 24 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5(c) for
charges associated with the facility (i.e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION FOR SURGICAL/INVASIVE
PROCEDURES. Please refer to the prior authorization information shown in Section
3 to be sure which services
require prior authorization and identify which
surgeries require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: Operative procedures
Treatment of fractures, including casting Normal pre-and post-operative care
by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Correction of congenital
anomalies (see reconstructive surgery) Surgical treatment of morbid obesity --a
condition in which an
individual weighs 100 pounds or 100% over his or her
normal weight according to current underwriting standards; eligible
members
must be age 18 or over Insertion of internal prosthetic devices. See 5(a) –
Orthotic and
prosthetic devices for device coverage information.
Nothing
Surgical procedures continued on next page. 24
24 Page 25 26
2002 OmniCare Health Plan 25 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization
Treatment of burns
Note: Generally, we
pay for internal prostheses (devices) according to where the procedure is done.
For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
Nothing
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member’s appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
Nothing
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Orthotic and Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the
procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Nothing.
Reconstructive surgery --continued on next page 25
25 Page 26 27
2002 OmniCare Health Plan 26 Section 5( b)
Reconstructive surgery (continued) You pay
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
Temporomandibular joint (TMJ)
treatment
Nothing
Not covered: Oral implants and transplants
Procedures
that involve the teeth or their supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
All charges. 26
26 Page 27 28
2002 OmniCare Health Plan 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/lung
Kidney
Kidney/Pancreas
Liver
Lung:
Single –Double
Pancreas
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; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical
trial at a Plan-designated center of excellence and if approved by the Plan’s
medical director in accordance with the Plan’s protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Not covered: Donor screening tests and donor search expenses,
except those
performed for the actual donor Implants of artificial
organs
Transplants not listed as covered
All charges.
Anesthesia
Professional services provided in –
Hospital
(inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Ambulatory surgical center
Office
Nothing; unless services are provided in a physician’s office, then $10 copay
per
office visit 27
27 Page
28 29
2002 OmniCare Health Plan 28
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
No calendar year deductible
Be sure to
read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by the
facility (i.e., hospital or surgical center) or ambulance service for your
surgery or care. Any costs associated with the professional charge
(i.e., physicians, etc.) are covered in Sections 5(a) or (b).
YOUR
PHYSICIAN MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 28
28 Page 29 30
2002 OmniCare Health Plan 29 Section 5( c)
Inpatient hospital (continued) You pay
Other
hospital services and supplies, such as: Operating, recovery, maternity, and
other treatment rooms
Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not
donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including
nurse anesthetist services Take-home items
Medical supplies, appliances,
medical equipment, and any covered items billed by a hospital for use at home
Nothing
Not covered: Custodial care
Non-covered facilities, such
as nursing homes, school Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges. 29
29 Page
30 31
2002 OmniCare Health Plan 30
Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
Skilled nursing facility (SNF): 30 days per
calendar year
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.
Nothing
Not covered: custodial care All charges.
Hospice care
Inpatient – 30 days unless authorized by responsible physician;
Diagnosed terminal, 6 months or less to live Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate Nothing 30
30 Page
31 32
2002 OmniCare Health Plan 31
Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year
deductible.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies
because, if not treated promptly, they might become more serious; examples
include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what they all have in
common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
doctor. In extreme emergencies, if you are unable to contact your doctor,
contact the local emergency system (e.g., the 911 telephone service area system)
or go to the nearest hospital
emergency room. Be sure to tell the emergency room personnel that you are a
Plan member so they can notify the Plan. The Plan must be notified of your
hospitalization within 48-hours by you, your family, or the hospital, 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 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.
Emergencies outside our service area:
Benefits are available for
any medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your admission, unless it was not reasonably
possible to notify the Plan within that time. If a Plan doctor believes care can
be better provided in a
Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.
To be covered
by this Plan, any follow-up care recommended by non-Plan providers must be
approved by the Plan or provided by Plan providers. 31
31 Page 32 33
2002 OmniCare Health Plan 32 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center
Emergency care as an outpatient
or inpatient at a hospital, including doctors' services
Nothing
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
Nothing
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
All charges.
Ambulance
Professional ambulance and air-ambulance service when
medically appropriate.
See 5(c) for non-emergency service.
Nothing
Not covered:
non-emergency service
All charges. 32
32 Page 33 34
2002 OmniCare Health Plan 33 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for similar benefits for other
illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered service, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions
after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per office visit
Mental health and substance abuse benefits -continued on next page 33
33 Page 34 35
2002 OmniCare Health Plan 34 Section 5( e)
Mental health and substance abuse benefits (continued)
You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, half-way house,
residential treatment, full-day hospitalization, facility based intensive
outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
Contact the Intake Coordinator at your selected mental health facility for
authorization of services. A listing of mental health facilities and phone
numbers are located in your
provider directory. If you do not have a
provider directory, please contact the Customer Care Call Center at
1-800-477-6664.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 34
34 Page
35 36
2002 OmniCare Health Plan 35
Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Prescriptions drugs not listed on formulary require prior authorization.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
Who can write your prescription.
A Plan physician must write the prescription.
Where you can obtain
them. You may fill the prescription at a Plan pharmacy, or by mail. You can
obtain further information about our mail order pharmacy program by calling our
Pharmacy Benefit Manager Express
Scripts, Inc. at 1-877-852-4067.
We use a formulary. OmniCare has
a list of drugs it dispenses with a prescription from a Plan doctor. This list
is called a drug formulary. OmniCare reviews drugs to include in the formulary.
The review is based on a
comparison with similar drugs and clinical advantages of the drug. Drugs not
accepted into the formulary are covered when your Plan doctor receives approval
from the Plan. It is the Plan doctor’s responsibility to obtain
the Plan
authorization. We cover non-formulary drugs prescribed by a Plan doctor.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed
for up to a 34-day supply. Sexual dysfunction drugs have dispensing
limitations and are covered at 50%. Fertility drugs are also covered at 50%
your copay. Upon verification of eligibility and the determination that the
prescription is a covered drug the member may receive mail order
pharmacy
services. The Mail Order Service Pharmacy can dispense drugs in accordance with
applicable drug dispension laws, in a quantity not to exceed a 90-day supply.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is available, and your
physician has
not specified Dispense as Written for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.
Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic equivalent to more expensive brand-name drugs. They must contain
the same active ingredients and must be equivalent in strength
and dosage to
the original brand-name product. Generics cost less than the equivalent
brand-name product. The U.S. Food and Drug Administration sets quality standards
for generic drugs to ensure that these drugs meet the
same standards of
quality and strength as brand-name drugs.
You can save money by using
generic drugs. However, you and your physician have the option to request a
name-brand if a generic option is available. Using the most cost-effective
medication saves money.
When you have to file a claim. You normally will not have to submit
claims to us unless you receive emergency services from a provider who does not
contract with us. If you file a claim, please send us all of the
documents
for your claim as soon as possible. You must submit claims by December 31 of the
year after the year you received the service. Either OPM or we can extend this
deadline if you show that circumstances
beyond your control prevented you
from filing on time. 35
35 Page
36 37
2002 OmniCare Health Plan 36
Section 5( f)
Benefit Description You pay
Covered medications
and supplies
We cover the following medications and supplies prescribed
by a Plan physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician’s prescription for their purchase, except those
listed as Not
covered. Insulin
Disposable needles and syringes for the administration
of covered medications
Contraceptive drugs and devices
Diabetic supplies, including insulin
syringes, needles, glucose test tablets and test tape, Benedict’s solution or
equivalent and acetone
test tablets
Drugs for sexual dysfunction (see Prior authorization below)
Growth hormone
Oral fertility drugs
Sexual dysfunction drugs have dispensing limitations. Contact Plan for
details.
$2 per prescription $4 per prescription for a 90-day supply
through the
mail order program
50% plus $2 copay
$2 copay
50% plus $2 copay
Note: If there is no generic equivalent available, you will be dispensed the
brand
name at the $2 copay, or $4 copay if you use mail order.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a
non-Plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
Medical
supplies such as dressings and antiseptics
Inhalers for smoking
cessation
Drugs available without a prescription or for which there
is a nonprescription equivalent available
All charges. 36
36 Page 37 38
2002 OmniCare
Health Plan 37 Section 5( g)
Section 5 (g). Special features
Feature Description
24 hour Emergency HOT-LINE For any of your health concerns, 24 hours a
day, 7 days a week, you may call 1-800-955-4578 and talk with a health
professional who will instruct you on how to obtain emergency services.
Services for deaf and hearing impaired If you are hearing impaired,
call 1-800-378-3253 (TDD Line). This service is provided at no charge to our
members.
Disease management Members have access to our disease
management program in the areas of Diabetes, Asthma, and High Risk Pregnancy.
Call 1-800-477-6664 for further information.
Centers of excellence for
transplants/ heart
surgery/ etc
University of Michigan and the Detroit Medical Center provides heart, liver,
bone marrow, kidney, and pancreas transplants. Cancer and burn unit treatment is
also
provided through the Detroit Medical Center and University of Michigan.
Language services Special language translation services are available
for all OmniCare members at no additional charge. Please call the Customer Care
Call Center at 1-800-477-6664. 37
37 Page 38 39
2002 OmniCare
Health Plan 38 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
We cover hospitalization for dental procedures only when a non-dental
physical impairment exists which makes hospitalization necessary to safeguard
the health of the patient; we do not cover the dental procedure unless it is
described below.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but
not replace) sound natural teeth. The need for these services must
result from an accidental injury.
Nothing
Dental benefits
We have no other dental benefits. 38
38 Page 39 40
2002 OmniCare Health Plan 39 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed claim about them. Fees you pay for
these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Healthy lifestyle discounts through our Omni “Perks” program:
10%
discount at 49 state-licensed day care centers
20% discount on a pre-paid
13-week membership with Weight Watchers .
Free 2-week trial membership
with Fitness USA .
15% discount on purchases at GNC (one visit per
month).
Special membership offer to join Franklin Fitness & Racquet
Club, includes 10% discount on child day care
Kmart merchandise discount
when you fill a new prescription at Kmart pharmacy (coupon required)
20%
discount on additional frames, lenses, and contacts at over 175 optical centers
Number of locations subject to change, please call 1-800-477-6664 for
location verification. 39
39 Page 40 41
2002 OmniCare
Health Plan 40 Section 6
Section 6. General exclusions
--things we don't cover
The exclusions in this section apply to all
benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury,
or condition
and we agree, as discussed under What Services Require Our Prior Approval
on page 11.
We do not cover the following:
Care by non-Plan
providers except for authorized referrals or emergencies (see Emergency
Benefits);
Services, drugs, or supplies you receive while you are not
enrolled in this Plan;
Services, drugs, or supplies that are not medically
necessary;
Services, drugs, or supplies not required according to accepted
standards of medical, dental, or psychiatric practice;
Experimental or
investigational procedures, treatments, drugs or devices;
Services, drugs,
or supplies related to abortions, except when the life of the mother would be
endangered if the fetus were carried to term or when the pregnancy is the result
of an act of rape or;
Services, drugs, or supplies related to sex transformations;
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program; or
Expenses you incurred while you were not enrolled in this Plan.
40
40 Page 41 42
2002 OmniCare Health Plan 41 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or obtain
your prescription drugs at Plan pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment, or coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital and drug In most cases, providers and facilities
file claims for you. Physicians must file on the benefits form HCFA-1500,
Health Insurance Claim Form. Facilities will file on the UB-92 form.
For
claims questions and assistance, call us at 1-800-477-6664.
When you must
file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a
claim form that includes the information shown below. Bills and receipts should
be
itemized and show:
Covered member’s name and ID number;
Name and
address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
OmniCare Health Plan Claims Department
1155 Brewery Park Blvd., Suite
250 Detroit, MI 48207
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service, unless timely
filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 41
41 Page
42 43
2002 OmniCare Health Plan 42
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: 1155 Brewery Park Blvd., Suite
250, Detroit, MI 48207; and
(c) Include a statement about why you believe
our initial decision was wrong, based on specific benefit provisions in this
brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request—go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 42
42 Page 43 44
2002 OmniCare Health Plan 43 Section 8
The Disputed Claims process (Continued)
Send
OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific
written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM’s decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs, or supplies or from the year in
which you were denied precertification or prior approval. This is the only
deadline that may not
be extended.
OPM may disclose the information it
collects during the review process to support their disputed claim decision.
This information will become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was before OPM when
OPM decided to
uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/prior approval, then call us at 1-800-477-6664 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/606-0737
between 8 a.m. and 5 p.m. eastern time. 43
43
Page 44 45
2002
OmniCare Health Plan 44 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health care expenses
without regard to
fault. This is called “double coverage.”
When you have
double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if
you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare + Choice is the term used to describe
the various health plan choices available
to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay
your share. Some things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be
authorized by your Plan PCP, or prior authorized as
required.
We will waive some copayments, and coinsurance as follows: Office
visits
(Primary payer chart begins on next page.)
The Original Medicare Plan (Part A or Part B) 44
44 Page 45 46
2002 OmniCare Health Plan 45 Section 9
The following chart illustrates whether the Original Medicare Plan
or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered family member
has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then
the primary payer is… A. When either you --or your covered spouse --are age 65
or over and …
Original Medicare This Plan
1) Are anactiveemployeewith
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability), !
2) Are an annuitant, !
!
3) Are a reemployed annuitant with the Federal government when…
a)
The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you..) !
4) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court
judge who retired under Section 7447 of title 26, U.S.C. (or if your
covered spouse is this type of judge), !
5) Are enrolled in Part B only,
regardless of your employment status, ! (for Part B services) ! (for other
services)
6) Are a former Federal employee receiving Workers’ Compensation
and the Office of Workers’ Compensation Programs has determined that
you are
unable to return to duty,
!
(except for claims related to Workers’
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD, !
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD, !
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision, !
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or !
b) Are an active employee, or !
c) Are a former spouse of an annuitant,
or !
d) Are a former spouse of an active employee !
Claims process --You normally will not have to submit claims to us
unless you receive emergency services from a provider who does not contract with
us. Please note, if your Plan physician does not participate with Medicare, you
will have to file a claim with
Medicare 45
45
Page 46 47
2002 OmniCare Health Plan 46 Section 9
Claims process
when you have the Original Medicare Plan --You probably will never have to
file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original
Medicare is the primary payer, Medicare processes your claim first.
In most
cases, your claims will be coordinated automatically and we will pay the balance
of covered charges. You will not need to do anything. To find out if you
need to do something about filing your claims, call us at 1-800-477-6664.
We do not waive any costs when you have Medicare
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+Choice plan --a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or hospitals that
are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care
plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www.medicare.gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in another plan’s Medicare managed care plan and also
remain enrolled in our FEHB plan.
We will still provide benefits when your
Medicare managed care plan is primary, but we will not waive any of our
copayments or coinsurance. If you enroll in a Medicare
managed care plan,
tell us. We will need to know whether you are in the Original Medicare Plan or
in a Medicare managed care plan so we can correctly coordinate
benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare
managed care plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare managed care plan premium.)
For information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB Program, generally you may do
so only at the next open season unless you involuntarily
lose coverage or
move out of the Medicare managed care plan's service area.
If you do not
have one or both Parts of Medicare, you can still be covered under the FEHB
Program. We will not require you to enroll in Medicare Part B and, if you can't
get premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers’
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
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.
If you do not enroll in Medicare Part A or Part B 46
46 Page 47 48
2002 OmniCare Health Plan 47 Section 9
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid
When you have this Plan and Medicaid, we pay first.
When other
Government agencies We do not cover services and supplies when a local,
State, are responsible for your care or Federal Government agency
directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries for injuries or illness caused
by another person, you must reimburse us for any expenses we paid.
However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 47
47 Page
48 49
2002 OmniCare Health Plan 48
Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same
year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we
provide benefits for, as described in this brochure.
The Plan bases its
determination of whether or not a treatment, service, or supply is experimental
or investigational in nature, if there is no consensus in the medical
community as to the safety or effectiveness of the technology or the
treatment as applied to the patient’s medical problem; or there is insufficient
evidence to determine its
appropriateness in a given situation; or the
technology is undergoing clinical trials or is largely confined to research
protocols; or the physician or facility rendering the treatment
classifies
the treatment as experimental or investigational for purposes of obtaining an
informed consent.
Group health coverage Legal entity or company who has contracted with
the Plan to provide health care services to its employees and eligible
dependents
Medical necessity The Plan evaluates health care services
to determine if they are: medically appropriate and necessary to meet basic
health needs; consistent with the diagnosis or condition and
rendered in a
cost-effective manner; and consistent with national medical practice guidelines
regarding type, frequency and duration of treatment.
Us/ We Us and we refer to OmniCare Health Plan
You You
refers to the enrollee and each covered family member.
Experimental or investigational services 48
48 Page 49 50
2002 OmniCare Health Plan 49 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www.opm.gov/insure. Also, your
employing or retirement office can answer your about enrolling in the
questions, and give you a Guide to Federal Employees Health Benefits
Plans, brochures
FEHB Program for other plans, and other
materials you need to make an informed decision about:
When you may change
your enrollment;
How you can cover your family members;
What happens
when you transfer to another Federal agency, go on leave without pay, enter
military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don’t determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22, including any
foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a disabled
child 22
years of age or older who is incapable of self-support.
If you
have a Self Only enrollment, you may change to a Self and Family enrollment if
you marry, give birth, or add a child to your family. You may change your
enrollment 31
days before to 60 days after that event. The Self and Family
enrollment begins on the first day of the pay period in which the child is born
or becomes an eligible family
member. When you change to Self and Family
because you marry, the change is effective on the first day of the pay period
that begins after your employing office receives your
enrollment form;
benefits will not be available to your spouse until you marry.
Your
employing or retirement office will not notify you when a family member
is no longer eligible to receive health benefits, nor will we. Please tell us
immediately when
you add or remove family members from your coverage for any
reason, including divorce, or when your child under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another FEHB
plan. 49
49 Page
50 51
2002 OmniCare Health Plan 50
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you joined this Plan premiums start during
Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants’ coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell you the
effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following records are confidential
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse
equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse’s enrollment.
But, you may be eligible
for your own FEHB coverage under the spouse equity law. If you are recently
divorced or are anticipating a divorce, contact your ex-spouse’s employing or
retirement office to
get RI 70-5, the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees, or other information about your
coverage choices.
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 Temporary Continuation of Coverage (TCC). For
example, you can receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage
and Former Spouse Enrollees, from
your employing or retirement office or from www.opm.gov/insure. It explains what
you have to do to enroll. 50
50 Page 51 52
2002 OmniCare Health Plan 51 Section 11
Converting to
You may convert to a non-FEHB 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 of your right
to convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us
within 31 days
after you are no longer eligible for coverage.
Your
benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a
waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a Group Health Plan Coverage
Federal law that offers limited Federal protections for health coverage
availability and
continuity to people who lose employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates
how long you have been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting
periods, limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the FEHB web site
(www.opm.gov/insure/archive/health);
refer to the “TCC and HIPAA” frequently asked question. These highlight
HIPAA rules, such as the requirement that Federal employees must
exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and information about Federal and State agencies you can
contact for more information. 51
51 Page 52 53
2002 OmniCare Health Plan 52 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office
of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in October 2002. As part of its educational effort,
OPM asks you to consider these questions:
It’s insurance to help pay for
long term care services you may need if you can’t take care of yourself because
of an extended illness or injury, or an age-related disease
such as
Alzheimer’s. LTC insurance can provide broad, flexible benefits for nursing home
care, care in an
assisted living facility, care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care provided by
family members, reducing the
burden you place on them.
Welcome to
the club! 76% of Americans believe they will never need long term care, but the
facts are that
about half them will. And it’s not just the old folks. About
40% of people needing long term care are under age 65. They may need chronic
care due to a serious
accident, a stroke, or developing multiple sclerosis,
etc. We hope you will never need long term care, but everyone should have a plan
just in
case. Many people now consider long term care insurance to be
vital to their financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that’s
before inflation! Long term care can easily exhaust your savings.
Long term care insurance can
protect your savings.
Not FEHB. Look
at the "Not covered" blocks in sections 5(a) and 5(c) of your FEHB
brochure. Health plans don’t cover custodial care or a stay in an assisted
living facility or a continuing need for a home health aide to help you get
in and out of bed and with other activities of daily living. Limited stays in
skilled nursing
facilities can be covered in some circumstances. Medicare
only covers skilled nursing home care (the highest level of nursing care)
after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for
those who meet their state’s poverty guidelines, but has restrictions on covered
services and where they can be received. Long term
care insurance can
provide choices of care and preserve your independence.
Employees will
get more information from their agencies during the LTC open enrollment period
in the late summer/early fall of 2002.
Retirees will receive information at
home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can
learn more about the program on our web site at www.opm.gov/insure/archive/ltc.
Many FEHB enrollees think that their health plan and/or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I'm healthy. I won't need long term care. Or, will I?
Is long term
care expensive?
But won't my FEHB plan, Medicare or Medicaid cover
my
long term care?
When will I get more information on how to apply for this new
insurance coverage?
How can I find out more about the program NOW? 52
52 Page 53 54
2002 OmniCare Health Plan 53 Index
Index Do not rely on this page; it is for your convenience and
may not show all pages where the terms appear.
Allergy tests 18
Alternative treatment 23
Allogenetic (donor) bone marrow transplant 27
Ambulance 30, 32
Anesthesia 27 Autologous bone marrow transplant 27
Biopsies 24 Blood and blood plasma 29
Casts 24 Changes for
2002 8
Chemotherapy 19 Chiropractic 23
Claims 42 Coinsurance 12
Colorectal cancer screening 15 Congenital anomalies 24
Contraceptive
devices and drugs 17, 36 Coordination of benefits 44
Covered charges 9
Covered providers 9
Crutches 22 Deductible 12
Definitions 48
Dental care 38
Diagnostic services 14 Disputed claims review 42
Donor
expenses (transplants) 27 Dressings 29
Durable medical equipment (DME) 22
Educational classes and programs 23
Effective date of enrollment 9
Emergency 31
Experimental or investigational 48 Eyeglasses 20
Family
planning 17 Fecal occult blood test 15
General Exclusions 40
Hearing services 20 Home health services 23
Hospice care 30 Home
nursing care 23
Hospital 28 Immunizations 16
Infertility 18
Inhospital physician care 14
Inpatient Hospital Benefits 28 Insulin 36
Laboratory and pathological services 15
Machine diagnostic
tests 15 Magnetic Resonance Imagings
(MRIs) 15 Mail Order Prescription Drugs
36
Mammograms 15 Maternity Benefits 17
Medicaid 47 Medically necessary
48
Medicare 44 Mental Conditions/Substance
Abuse Benefits 33 Newborn
care 17
Non-FEHB Benefits 39 Nurse
Licensed Practical Nurse 23 Nurse
Anesthetist 29
Registered Nurse 23 Obstetrical care 17
Occupational therapy 20 Office visits 14
Oral and maxillofacial surgery
26 Orthotic devices 21
Out-of-pocket expenses 6 Outpatient facility care 14
Oxygen 29
Pap test 15 Physical examination 14
Physical therapy 20 Physician
9
Prior authorization 11 Preventive care, adult 15
Preventive care,
children 16 Prescription drugs 35
Prior approval 11 Prostate cancer
screening 15
Prosthetic devices 21 Psychologist 33
Radiation
therapy 19 Renal Dialysis 44
Room and board 28 Second surgical
opinion 14
Skilled nursing facility care 30 Smoking cessation 23
Speech
therapy 20 Splints 29
Sterilization procedures 17 Subrogation 47
Substance abuse 33 Surgery 24
Anesthesia 27 Oral 26
Outpatient 29
Reconstructive 25
Syringes 36 Temporary continuation of coverage
50 Transplants 27
Vision services 21 Well child care 16
Wheelchairs 22 Workers’ compensation 46
X-rays 15 53
53 Page 54 55
2002 OmniCare Health Plan 54 Summary
Summary of benefits for the OmniCare Health Plan -2002
Do not
rely on this chart alone. All benefits are provided in full unless indicated
and are subject to the definitions,
limitations, and exclusions in this
brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover on
your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
Office visit copay: $10 primary care; $10 specialist 14
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
Nothing 28
29
Emergency benefits:
In-area
.............................................................................................
Out-of-area......................................................................................
Nothing; unless care is received at a doctor’s office, then $10 copay
Nothing
32
32
Mental health and substance abuse treatment
..................................... Regular cost sharing. 33
Prescription
drugs.................................................................................
$2 copay brand, $2 copay generic
$4 copay mail-order
36
Dental
Care........................................................................................
Nothing for accidental injury 38
Vision
Care........................................................................................
$10 per office visit, exam only 21
Special features: Special benefits
option; 24-hour Emergency Hot-Line; Services for deaf and hearing impaired;
Disease Management; Centers for Excellence for transplants; Language Services 37
54
54 Page 55 56
2002 OmniCare Health Plan 55 Notes
Notes
55
55 Page 56
57
2002 OmniCare Health Plan 56
2002
Rate Information for OmniCare Health Plan
Non-Postal rates apply to most
non-Postal enrollees. If you are in a special enrollment category, refer to the
FEHB Guide for that category or contact the agency that maintains your health
benefits enrollment.
Postal rates apply to career Postal Service
employees. Most employees should refer to the FEHB Guide for United States
Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB
guides are
published for Postal Service Nurses, RI 70-2B; and for Postal
Service Inspectors and Office of Inspector General (OIG) employees (see RI
70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Southeast Michigan
Self Only KA1 $76.99 $25.66 $166.81 $55.60 $91.10
$11.55
Self and Family KA2 $193.25 $64.41 $418.70 $139.56 $228.67 $28.99 56
56 Page 57
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