2001
A Health Maintenance Organization
Serving: St. Louis, Central, Southeast and Southwest Missouri areas and
St. Clair and Madison counties in Illinois
Enrollment in this plan is
limited; see page 7 for requirements
Enrollment code: 9G1 Self Only
9G2 Self and Family
RI-73-516
For changes
in benefits
see page 8.
This plan has accreditation
from the NCQA. See the 2001 Guide
for more information on NCQA. 1
1 Page 2 3
2001 BlueCHOICE
Table of Contents 2
Table of Contents
Introduction…………………………………………………………………................................................................
4
Plain
Language………………………………………………………………...............................................................
4
Section 1. Facts about this HMO plan
..........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Who provides my health
care?.....................................................................................................................
5
Patients' Bill of Rights
.................................................................................................................................
5
Service
Area.................................................................................................................................................
7
Section 2. How we change for
2001………………………………………..................................................................
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.............................................................................................................
11
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........ 25
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 30
(d) Emergency services/
accidents.........................................................................................................
33
(e) Mental health and substance abuse
benefits....................................................................................
37
(f) Prescription drug
benefits................................................................................................................
40
(g) Special features
...............................................................................................................................
43
(h) Dental benefits
................................................................................................................................
44
(i) Non-FEHB benefits available to Plan
members..............................................................................
45 2
2 Page 3 4
2001 BlueCHOICE Table of Contents 3
Section
6. General exclusions --things we don't
cover..............................................................................................
46
Section 7. Filing a claim for covered services
............................................................................................................
47
Section 8. The disputed claims
process.......................................................................................................................
49
Section 9. Coordinating benefits with other coverage
................................................................................................
51
When you have…
Other health coverage
........................................................................................................................
51
Original
Medicare..............................................................................................................................
51
Medicare managed care plan
.............................................................................................................
54
TRICARE/ Workers' Compensation/
Medicaid..........................................................................................
54
Other Government
agencies......................................................................................................................
55
When others are responsible for
injuries....................................................................................................
55
Section 10. Definitions of terms we use in this
brochure............................................................................................
56
Section 11. FEHB
facts...............................................................................................................................................
58
Coverage information
...............................................................................................................................
58
No pre-existing condition
limitation...................................................................................................
58
Where you get information about enrolling in the FEHB
Program.................................................... 58
Types of
coverage available for you and your
family.........................................................................
58
When benefits and premiums
start......................................................................................................
59
Your medical and claims records are
confidential..............................................................................
59
When you retire
.................................................................................................................................
59
When you lose benefits
............................................................................................................................
59
When FEHB coverage
ends................................................................................................................
59
Spouse equity coverage
.....................................................................................................................
59
Temporary Continuation of Coverage
(TCC)....................................................................................
59
Converting to individual
coverage.....................................................................................................
60
Getting a Certificate of Group Health Plan Coverage
....................................................................... 60
Inspector General Advisory
.....................................................................................................................
60
Department of Defense/ FEHB Demonstration Project
................................................................................................
61
Index
............................................................................................................................................................................
63
Summary of benefits
....................................................................................................................................................
64
Rates…………………………………………………………………………………………………………..
Back cover
BlueCHOICE, a name HMO Missouri, Inc. uses to do business, and Alliance Blue
Cross Blue Shield, the name RightCHOICE ®
Managed Care, Inc. uses to do
business in Missouri, are independent licensees of the Blue Cross and Blue
Shield Association. 3
3 Page
4 5
2001 BlueCHOICE 4
Introduction/ Plain Language
Introduction
BlueCHOICE
1831 Chestnut Street
St. Louis, Missouri 63103-2275
This brochure describes the benefits of BlueCHOICE HMO under our contract (CS
2838) 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, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 64. Rates are
shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical
terms, we use common
words. "You" means the enrollee or family member; "we" means
BlueCHOICE.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
2001 BlueCHOICE 5 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 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, hospitals and other types of providers 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. We reimburse primary
care physicians through capitation, which includes the majority of services the
primary care physician renders. We compensate certain services, such as
immunizations or cardiac diagnostic testing
in the office as fee for
service.
Who provides my health care?
This plan is an individual-practice
Plan. All participating doctors practice in their own offices in the community.
Unless it is an emergency, benefits are available only from doctors,
hospitals and other health care providers that are
in the BlueCHOICE
network. The Plan arranges with doctors and hospitals to provide medical care
for both the
prevention of disease and the treatment of serious illness.
You must select a primary care doctor for each covered family member.
Approximately 1,200 primary care
physicians participate in BlueCHOICE. For
most care, you must contact your primary care doctor for a referral or
authorization before seeing any other doctor for specialty care or
nonemergency hospital services. A wide variety of
specialists are
participating Plan doctors. Many are Board certified as indicated in the
BlueCHOICE directory. If you
need hospital care, your Plan primary doctor
will admit you to a participating hospital where he/ she has admitting
privileges.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's
Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You
may get information
about us, our networks, providers, and facilities. OPM's
FEHB Web site (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.
About the plan and care management: Blue Cross and Blue Shield of
Missouri, the parent company of Alliance
Blue Cross Blue Shield, has been in
the health insurance industry for more than 60 years. We began as St. Louis Blue
Cross in 1936. In 1945, Missouri Medical Service, commonly known as Blue
Shield, began business in the St. Louis
area. The two companies merged in
1986, forming Blue Cross and Blue Shield of Missouri, a not-for-profit health
service corporation. In 1994, Blue Cross and Blue Shield of Missouri formed
a new managed care company,
RightCHOICE Managed Care Inc., doing business as
Alliance Blue Cross Blue Shield, as a for-profit subsidiary.
BlueCHOICE, the
for-profit HMO subsidiary of Alliance Blue Cross Blue Shield, began operations
in 1988. 5
5 Page 6
7
2001 BlueCHOICE 6 Section 1
Utilization management services include:
Precertifications of
medical/ surgical, mental health, rehabilitation, skilled nursing, outpatient
and home health
care
Concurrent review of medical/ surgical, mental
health, rehabilitation, skilled nursing, outpatient and home health
care
Retrospective review
Discharge planning
Alternative care planning
Individual case management
Appeal for denial of payment due to lack of
medical necessity
Medical review
Our contracts with network providers require them to handle all
certifications for BlueCHOICE members. You will
not have to be concerned
about managed care procedures as long as your receive care from network
providers.
We offer special programs to help members with health conditions such as
asthma, heart disease and high-risk
pregnancy. These are voluntary programs
to help members manage their particular health condition. These programs
are
explained in Section 5( g).
Accreditation status: BlueCHOICE is accredited by the National
Committee for Quality Assurance (NCQA). The comprehensive review process
evaluates how well a plan manages its benefits. The accreditation process
evaluates
more than 60 standards in the following six categories:
quality management and improvement
physician qualifications and
evaluation
members' rights and responsibilities
preventive health
services
utilization management and
medical records
Networks, providers and facilities: The BlueCHOICE network includes
approximately 1,200 primary physicians,
3,000 specialists and 66 hospitals.
Approximately 77 percent of network physicians are Board Certified and 90
percent are accepting new patients. The physician's Board status and whether
or not he/ she is accepting new patients
are included in the BlueCHOICE
provider directory.
We have established credentialing polices that require us to select and
recredential physicians every two years,
based on an evaluation of
their experience and training, board certification and staff privileges at
network hospitals.
Our program goals are to support the development and
maintenance of credentialing and recredentialing standards for
our
participating providers, review the qualifications of potential participating
providers against established standards,
and to reassess the qualifications
and performance of our network providers.
Our credentialing criteria for network hospitals include
accreditation by the Joint Committee on Accreditation of
Health Care
Organizations (JCAHO), Medicare certification, effective utilization management
pricing, geographic
location, scope of services and utilization experience.
If you want more information about us, call 1-800-932-4480. You may also view
the BlueCHOICE directory on our
Web site at www. AllianceBlue. com/ prov_
directories. 6
6 Page
7 8
2001 BlueCHOICE 7 Section 1
Service Area
To enroll with us, you must live in the
BlueCHOICE service area or within a 30-mile radius of a BlueCHOICE
network
hospital. Our service area is:
The St. Louis Area, including the Missouri counties of
Crawford, Franklin, Gasconade, Jefferson, Lincoln,
Montgomery, Pike, St.
Charles, St. Francois, St. Louis (City and County), Ste. Genevieve, Warren and
Washington;
the Central Missouri Area counties of Adair, Audrain,
Boone, Callaway, Camden, Chariton, Cole, Cooper, Howard,
Linn, Macon,
Maries, Miller, Moniteau, Monroe, Morgan, Osage, Phelps, Pulaski, Putnam,
Randolph, Schuyler and
Sullivan; the Southwest Missouri Area counties
of Barry, Barton, Cedar, Christian, Dade, Dallas, Douglas, Greene,
Hickory,
Jasper, Laclede, Lawrence, McDonald, Newton, Ozark, Polk, Stone, Taney, Texas,
Webster and Wright; and
the Southeast Missouri Area counties of
Butler, Carter, Ripley and Wayne.
You may also enroll with us if you live in the Illinois counties of Madison
or St. Clair and work in Missouri.
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 or urgent care. We will not pay for any other
health care services.
If you or a covered family member moves outside 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. As a BlueCHOICE member, you may
have access to
physician care through BluesCONNECT®, a network of Blue Cross and Blue
Shield HMOs.
BluesCONNECT is one of the largest HMO networks in the country,
offering coverage in more than 200 U. S. cities.
If you become ill while
visiting one of these cities, contact the BluesCONNECT Away From Home Care
coordinator
at 1-800-446-6872. The Away From Home Care number is also found
on the back of your ID card. The Away From
Home Care referral coordinator
will assist you in locating a BluesCONNECT physician in the area from which you
are calling. No office visit copay will be required and you will not need to
file a claim. If you or a family member
moves, you do not have to wait until
Open Season to change plans. Contact your employment or retirement office. 7
7 Page 8 9
2001 BlueCHOICE 8 Section 2
Section
2. How we change for 2001
Program-wide changes
The plain language
team reorganized the brochure and the way we describe our benefits. We hope this
will make it easier for you to compare plans.
This year, the Federal Employees Health Benefits Program is implementing
network mental health and substance abuse parity. This means that your coverage
for mental health, substance abuse, medical, surgical, and hospital
services
from providers in our plan network will be the same with regard to copays and
day and visit limitations
when you follow a treatment plan that we approve.
Previously, we placed shorter day or visit limitations on
mental
health and substance abuse services than we did on services to treat physical
illness, injury, or disease.
Many health care organizations have turned their attention this past year to
improving health care quality and patient safety. OPM asked all FEHB plans to
join them in this effort. You can find specific information on our
patient safety activities by calling us at 1-800-932-4480. You can find out
more about patient safety on the OPM
Web site, www. opm. gov/ insure. To
improve your health care, take these five steps:
Speak up if you have questions or concerns. Keep a list of all the medicines
you take.
Make sure you get the results of any test or procedure. Talk with your doctor
and health care team about your options if you need hospital care.
Make sure
you understand what will happen if you need surgery.
We clarified the
language to show that anyone who needs a mastectomy may choose to have the
procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure. Previously, the
language referenced only women.
Changes to this Plan
Your share of the non-postal premium will
decrease by 14.7% for Self only and 7.8% for Self and Family. Benefits have been
added for newborn hearing screening, rescreening and initial amplification. The
$10 office-visit
copay applies.
The copay for an allergy injection in the physician's
office has been reduced from $10 to $3, without an office visit. The $10 copay
will remain if you receive any other covered care during the visit.
Two network hospitals have closed: Normandy Community Hospital and Compton
Heights Hospital. Added as of December 1, 1999: Skaggs Community Health Center
in Branson, Missouri.
Added as of August 1, 2000: Madison Medical Center in
Frederickstown, Missouri. Added the Southwest Missouri county of Texas to the
service area. 8
8 Page
9 10
2001 BlueCHOICE 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
1-800-932-4480.
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 primary care physicians, specialists
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
annually. The BlueCHOICE directory is also on our Web site,
www.
AllianceBlue. com. The online directory is updated daily.
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 annually.
The list is also on
our Web site.
What you must do to get covered care 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.
Use the directory or Web site to select a physician convenient to you.
Write the physician's office code number in the space provided on your
Provider Selection Card. You'll find the office number listed before each
primary care physician's name. See the Selection Card for instructions.
Primary care Your primary care physician can be a family or general
practitioner, internist, pediatrician or geriatrician. 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. You can change your primary
care
physician at any time. We will send you a new ID card with your new
doctor's name and phone number on the front.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see a network OB/ GYN for any
medically necessary
OB/ GYN care without a referral. And you may go to a
network eye care
provider for one routine vision exam each calendar year
without a
referral. 9
9 Page
10 11
2001 BlueCHOICE 10
Section 3
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 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).
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.
If you think you have a mental health or substance abuse problem, we
encourage you to see your primary care physician, who will coordinate
your care. Your primary care physician may treat you or recommend that
you call our mental health and substance abuse benefits manger.
If you do not wish to go through your primary care physician for care,
you may call our mental health and substance abuse benefits manager
directly at 1-800-965-2583. A trained professional will evaluate your
needs and authorize your care.
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. 10
10 Page 11 12
2001 BlueCHOICE 11 Section 3
If you
are in the hospital when your enrollment in our Plan begins, call
our
customer service department immediately at 1-800-932-4480. 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.
Services requiring our prior approval 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, is
medically necessary, and follows
generally accepted medical practice.
We call this review and approval process precertification and
recertification. Your physician must obtain precertification before you
can receive certain types of care, such as:
Inpatient hospital care
Outpatient hospital care
Care in a
freestanding surgery center or skilled nursing facility
Home health care
Your physician must obtain recertification if your care needs to continue
longer than originally certified.
Your BlueCHOICE primary care physician or specialist will handle all
certification requirements for you. However, if you receive emergency
care at a non-network facility, you will need to contact us for approval.
Please see Section 5( d) for further information. 11
11 Page 12 13
2001 BlueCHOICE 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 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 We do
not have coinsurance.
Your out-of-pocket maximum and copayments After you pay 100% of your
annual premium in copayments for one family
member, or 100% of your annual
premium for two or more family
members, you do not have to make any further
payments for certain
services for the rest of the year. This is called a
catastrophic limit.
However, copayments for your prescription drugs and
dental services do
not count toward these limits and you must continue to
make these
payments.
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the limits. 12
12 Page 13 14
2001 BlueCHOICE 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our
benefits changed this year and page 64 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
1-800-932-4480.
(a) Medical services and supplies provided by physicians and other health
care professionals.......................... 14-24
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 Rehabilitative therapies
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Alternative
treatments Educational classes & programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 25-29
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services..................................................... 30-32
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Skilled nursing care facility Sub-acute care benefits
Hospice care
Ambulance
(d) Emergency services/ accidents
........................................................................................................................
33-36
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits.................................
.................................................................. 37-39
(f)
Prescription drug
benefits..................................................................................................................................
40-42
(g) Special
features......................................................................................................................................................
43
Away From Home Care Take Charge SM Asthma Program RightSteps CardioCall SM
(h) Dental benefits
......................................................................................................................................................
44
(i) Non-FEHB benefits available to Plan members
...................................................................................................
45
Summary of benefits
....................................................................................................................................................
64 13
13 Page 14
15
2001 BlueCHOICE 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.
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
Office medical consultations
Second surgical opinion
$10 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Initial examination of a
newborn child covered under a family enrollment
Nothing
At home $10 per visit
Not covered:
Care that is not medically
necessary
Care that is investigational
Care from a non-network provider
without prior approval from us
All charges.
Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2001 BlueCHOICE 15 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine Pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit
Preventive care, adult
Routine screenings, such as:
Blood lead
level – One annually*
Total blood cholesterol – once every three
years, ages 19 through 64*
Colorectal cancer screening, including
Fecal occult blood test
$10 per office visit
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 – annual* $10 per office visit
*or more frequently
if recommended by your BlueCHOICE physician. 15
15
Page 16 17
2001
BlueCHOICE 16 Section 5( a)
Preventive care, adult
(Continued) You pay
Routine mammogram – once per
calendar year or more frequently if recommended by a physician $10 per visit
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
– ages 19 and over is based on medical necessity
Influenza/ Pneumococcal vaccines
Nothing ($ 10 office visit copay
applies to any other covered
services)
Not covered:
Physical exams required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.
Immunizations for travel or occupational reasons.
All charges.
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics Nothing ($ 10 office visit
copay applies to any other covered
services)
Examinations, such as:
Eye exams to determine the need for vision
correction
Ear exams to determine the need for hearing correction
Newborn hearing screening, rescreening and initial amplification
Examinations done on the day of immunizations
Well-child care charges
for routine examinations, immunizations and care (through age 22)
Not covered:
Physical exams required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.
Immunizations for travel or occupational reasons.
$10 per office visit 16
16 Page 17 18
2001 BlueCHOICE
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:
You do not need to precertify your normal delivery; see page 11 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary. If you leave in less than
48 hours (or 96 hours
after a cesarean delivery), we will cover two
home visits by a registered
nurse provided through a network home
health agency.
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).
$10 (for first office visit only)
Nothing
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
Voluntary sterilization
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)
$10 per office visit
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling, voluntary abortions and related care.
All charges. 17
17 Page 18 19
2001 BlueCHOICE 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of
infertility, limited to:
in vitro fertilization
gamete intrafallopian tube transfer (GIFT)
zygote intrafallopian tube transfer
However, we will only cover these
treatments if you or your spouse:
(1) have not been able to become pregnant
or sustain a pregnancy
through reasonable, less costly and medically
appropriate covered
infertility treatment;
(2) have not undergone four completed oocyte retrievals (except if a
live
birth follows a completed oocyte retrieval, then we will cover
two more
completed oocyte retrievals); and
(3) have the procedures performed at medical facilities that conform to
the American College of Obstetrics and Gynecology guidelines or to
the
American Fertility Society's minimum standards for in vitro
fertilization.
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination
(ICI)
intrauterine insemination (IUI)
Oral fertility drugs
and injectable fertility drugs
Note: Preauthorization is required for fertility medication.
$10 per office visit
Nothing
We cover fertility drugs under the
prescription drug benefit. Please
refer to Section 5( f).
Not covered
Cost of donor sperm
All charges.
Allergy care
Testing and treatment
Allergy injection
$10 per office visit
$3 per visit ($ 10 office visit copay
applies to any other covered
services)
Allergy serum Nothing
Not covered: Provocative food testing and
sublingual allergy
desensitization
All charges. 18
18 Page 19 20
2001 BlueCHOICE 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 28.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Before
administering any GHT treatment, your BlueCHOICE
physician needs to obtain
authorization by submitting a written request
to our Provider Services Unit.
Please check with your BlueCHOICE
physician before receiving GHT treatment.
We will not cover GHT or related services and supplies unless you have
received prior authorization.
Nothing
$10 per visit outpatient
$10 per visit outpatient
Nothing
Nothing
Not covered:
Therapy that is not listed as covered in this
booklet. For example,
massage therapy or exercise conditioning.
All charges. 19
19 Page 20 21
2001 BlueCHOICE
20 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
Up to
two consecutive months per condition for care provided by:
qualified
physical therapists;
speech therapists; and
occupational therapists.
Note: We only cover therapy to restore bodily function or speech
when
there has been a total or partial loss of bodily function or
functional
speech due to illness or injury.
Cardiac rehabilitation following, but not limited to, a heart
transplant,
bypass surgery or a myocardial infarction, is
provided for one consecutive
12-week program per calendar
year
Pulmonary rehabilitation for up to 14 sessions within 12
months and then
one session every 3 months thereafter
$10 per office visit
Not covered:
Long-term rehabilitative therapy
Exercise programs
All charges.
Hearing services (testing, treatment, and supplies)
Routine
hearing exams
Newborn hearing, screening, rescreening and initial
amplification
$10 per office visit
Not covered:
Hearing aids, testing and examinations for them,
except for newborns
All charges. 20
20
Page 21 22
2001
BlueCHOICE 21 Section 5( a)
Vision services (testing,
treatment, and supplies) You pay
Routine eye exam (one per calendar
year)
Eyeglasses and contact lenses are covered up to $35 per 24-month
period. Reduced-cost glasses or contact lenses from selected
providers.
$10 per office visit
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 (see
preventive care)
Annual eye refractions
$10 per office visit
Not covered:
Eye exercises and orthoptics
Radial
keratotomy and other refractive surgery, including LASIK procedures
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic 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. 21
21 Page 22 23
2001 BlueCHOICE
22 Section 5( a)
Orthopedic and prosthetic devices You pay
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, and
surgically implanted breast implant following mastectomy.
Note: We pay
internal prosthetic devices as hospital benefits; see
Section 5 (c) for
payment information. See 5( b) for coverage of the
surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing
Not covered:
orthopedic and corrective shoes
arch
supports
cochlear implants
foot orthotics
heel
pads and heel cups
lumbosacral supports
orthotic devices
used primarily for convenience, comfort or for participation in athletics
corsets, trusses, elastic stockings, support hose, and other supportive
devices
All charges. 22
22 Page 23 24
2001 BlueCHOICE
23 Section 5( a)
Durable medical equipment (DME) You pay
We cover the use of standard models of the durable medical equipment
(DME) and medical supplies listed below when medically necessary to
treat certain conditions.
Your primary care physician or network specialist must give you a
prescription for the equipment or supplies. You must obtain the
equipment or supplies from a network DME provider.
We only provide benefits up to our allowed amount for supplies and for
basic models of equipment. If you want other than the basic model, you
must pay your copay and any charges above the allowed amount for the
basic equipment. We determine what is a basic model.
Following is a list of covered equipment and medical supplies. The
copay
is shown at right.
Air flotation mattress and alternating pressure pump
Apnea monitor (1)
Bi-directional Positive Airway Pressure (BIPAP) apparatus (1)
Bill
phototherapy system (1)
Blood glucose monitor (1)
Bone growth stimulator
(electrical) (2)
Canes
Commode (bedside)
Continuous Passive Motion
(CPM) Devices
Continuous Positive Airway Pressure (CPAP) apparatus (1)
Replacement CPAP apparatus
Continuous Positive Airway Pressure (CPAP)
humidifier
Crutches
Enteral feeding equipment
Enteral feeding
supplies
Formulas for treatment of phenylketonuria or any inherited disease
of amino and organic acids, one month supply per copayment
Hospital bed
(electric)
Hospital bed (nonelectric)
Incontinence cathethers and
irrigation supplies, one month supply
per copayment (1)
Insulin pump (2)
Insulin pump supplies (2)
Intermittent Positive Pressure Breathing
Apparatus (IPPB) (1)
Lymphedema pumps/ lymphedema sleeves
Mattress
overlays
Medical and post-surgical dressings, irrigation supplies, and
dressing tape, one month supply per copayment
Nebulizer compressor (1)
Neuromuscular Electronic Stimulator (NMES)
Ostomy supplies, all types,
one month supply per copayment
Oxygen, one month supply per copayment
Patient lifts
Peak flow meters
Pulmoaids
Spacers for Metered
Dose Inhalers (MDI)
Sphygmomanometer for gestational hypertension
Suction catheters, one month supply per copayment (1)
Suction equipment
$10 to $100
$ 10
$ 25
$ 50
$ 25
$ 25
$100
$ 10
$ 10
$ 25
$ 25
$ 25
$ 25
$ 10
$ 25
$ 10
$ 15
$ 50
$ 25
$ 10
$100
$ 25
$ 25
$ 50
$ 25
$ 10
$ 25
$ 25
$ 10
$ 50
$ 25
$ 10
$ 10
$ 10
$ 25
$ 10
$ 25 23
23 Page
24 25
2001 BlueCHOICE 24
Section 5( a)
Transcutaneous Electrical Nerve Stimulator (TENS) Units
Traction devices
Walkers
Wheelchairs (electric)
Wheelchairs
(non-electric)
Wheelchair gel pads
The maximum benefit for a medically necessary nonstandard
wheelchair is
$2,000. The regular copay for a manual or electric
wheelchair applies. (2)
(1) Includes initial provision of nonpharmaceutical medically necessary
supplies.
(2) Subject to review by BlueCHOICE. To obtain more information,
you may
contact us at 1-800-932-4480.
$ 25
$ 25
$ 10
$ 50
$ 25
$ 10
$ 10
Not covered:
Dialysis equipment (rental or purchase) Equipment or
supplies that are not listed as covered
Nonstandard models of equipment
All charges.
Copay plus any charges above the
allowed amount
for the basic
equipment.
Home health services
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. Your physician
will
periodically review the program for appropriateness and need.
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;
Nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.
All charges.
Alternative treatments
See Non-FEHB benefits, page 45.
Educational classes and programs
See Non-FEHB benefits, page
45. 24
24 Page
25 26
2001 BlueCHOICE 25
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.
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. , surgical center, etc.).
Please refer to the
precertification information shown in Section 3 to be sure which services
require precertification and identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
Treatment of
fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedure
Biopsy
procedure 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) – Orthopedic braces
and prosthetic devices for device coverage information.
$10 per office visit
(Nothing if care is provided in
hospital)
Surgical procedures continued on next page. 25
25 Page 26 27
2001 BlueCHOICE 26 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Norplant (a surgically implanted contraceptive)
and intrauterine
devices (IUDs) Note: Devices are covered under 5( a).
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.
$10 per office visit
(Nothing if care is provided in
hospital)
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.
$10 per office visit
(Nothing if care is provided in
hospital)
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
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.
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 26
26 Page 27 28
2001 BlueCHOICE
27 Section 5( b)
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;
Extractions of teeth that interfere with radiation therapy;
Treatment of trauma resulting in injuries to the jaw, cheeks, lips,
tongue,
roof and floor of the mouth;
Treatment of bony impactions; Surgical
correction of anatomical abnormalities for treatment of
temporomandibular disease when approved in advance by
BlueCHOICE; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
General anesthesia for certain dental patients, limited to:
Children
through age 4 Severely disabled people; and
People with medical or behavioral conditions that require hospitalization or
general anesthesia for dental care.
The general anesthesia must be provided in a network hospital, network
freestanding surgery center or dentist's office. A primary care
physician referral is required. The dental procedures themselves are not
covered.
$10 per office visit
(Nothing if care is provided in
hospital.)
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. 27
27 Page 28 29
2001 BlueCHOICE
28 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/
pancreas
Liver
Lung: single –double
Pancreas
Allogeneic bone marrow transplant, if the treatment is part of a National
Cancer Institute (NCI) phase III or IV trial, or the
treatment is available elsewhere as part of a NCI phase III or IV
trial.
Donor screening tests and donor search expenses are also
covered for
allogeneic 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
Note: Autologous bone marrow or stem cell transplants after high-dose
chemotherapy to treat breast cancer, and related care, must be received
at St. Louis University Hospital/ SLU Care.
All care for transplants must be coordinated through BlueCHOICE in
writing. The physician should send a letter to the BlueCHOICE
Medical
Director requesting precertification.
If you live outside the St. Louis metropolitan area, we may cover up to
$10,000 in reasonable and necessary expenses for transportation,
lodging
and meals while you are away from home for the transplant.
This must be
approved in advance by Case Management.
Note: We cover related medical and hospital expenses of the donor when
we
cover the recipient.
Nothing
Not covered:
Implants of artificial organs
Transplants not listed as covered
Organ donation expenses unless this program is covering the organ
transplantation.
All charges 28
28 Page 29 30
2001 BlueCHOICE
29 Section 5( b)
Anesthesia You pay
Professional
services provided in –
Hospital (inpatient)
General anesthesia for certain dental patients,
limited to:
Children through age 4 Severely disabled people; and
People with medical or behavioral conditions that require hospitalization or
general anesthesia for dental care.
The general anesthesia must be provided in a network hospital, network
freestanding surgery center or dentist's office. A primary care
physician referral is required. The dental procedures themselves are not
covered.
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
Nothing
$10 per office visit 29
29 Page 30 31
2001 BlueCHOICE
30 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, unless it is an emergency, (see
Section 5( d)).
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
Section 5( a) or (b).
Please refer to Section 3 to be sure which services require precertification.
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. 30
30 Page 31 32
2001 BlueCHOICE 31 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, extended care
facilities, schools
Personal comfort items, such as telephone,
television, barber services, guest meals and guest 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 31
31 Page
32 33
2001 BlueCHOICE 32
Section 5( c)
Skilled nursing care facility/ Sub-acute care
benefits You pay
Skilled nursing facility (SNF)/ Sub-acute care:
We cover treatment in a network skilled nursing facility (SNF) for a
condition that otherwise would require hospital confinement.
You may transfer directly from the hospital. If you do not, your
primary
care physician must obtain advance approval from
BlueCHOICE.
We will cover the care only as long as it is medically necessary. We
will
notify you if we determine SNF care is no longer necessary. Then
we will not
cover any SNF charges after the date in the notice.
We cover the following SNF services:
Semiprivate room and board (We will
cover a private room if
BlueCHOICE agrees in advance that it is medically
necessary. If
not, you are responsible for any difference between the
private
room and the semiprivate room.)
General nursing care
Drugs,
medications, biologicals, supplies, equipment and services
ordered by the
attending network physician with the primary care
physician's prior
authorization.
Nothing
Not covered: custodial care All charges
Hospice care
When a terminally ill member's life expectancy has reached six months
or less, the member may benefit from hospice care. This care provides
pain control and emotional support.
Your primary care physician must obtain advance approval from
BlueCHOICE.
You must go to a network hospital or receive care from
a network home health
agency licensed to provide hospice care. The
hospice provider will write a
treatment plan for your signature.
BlueCHOICE and your primary care
physician must coordinate your
care.
We also cover inpatient hospice care for short-term pain control.
Nothing
Not covered: Independent nursing, homemaker services; bereavement
services
All charges
Ambulance
Local professional ambulance service when medically
appropriate Nothing 32
32 Page
33 34
2001 BlueCHOICE 33
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.
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 at network hospitals
within our service area: If possible, when an unexpected condition arises,
call your primary care physician– unless you believe any
delay would
be harmful. This applies even if it's after office hours. Your primary care
physician will tell
you whether to go to the emergency room. Your primary
care physician's number is listed on the front of
your ID card.
If you need additional care after an emergency condition is stabilized,
precertification is required. Your
BlueCHOICE physician will handle this for
you. We will make a decision about the care within 30
minutes after we
receive all the necessary information.
When you need care right away but it is not an emergency, always call your
primary care physician. Your
primary care physician may have you come into
the office for an urgent appointment. An urgent
appointment is one scheduled
with a physician for the same day or during hours not normally used for
appointments.
Emergencies at non-network hospitals (inside or outside our service area):
If possible, when an unexpected condition arises, call your primary care
physician unless you believe any
delay would be harmful. This applies even
if it's after office hours. Your primary care physician will tell
you
whether to go to the emergency room. Your primary care physician's number is
listed on the front of
your ID card.
If you receive emergency care before you call your primary care physician,
you or a family member should
notify your primary care physician as soon as
possible. We encourage you to try to call within 24 hours.
Your primary care
physician's number is listed on the front of your ID card.
If you need additional care after an emergency condition is stabilized,
precertification is required. We
will make a decision about the care within
30 minutes after we receive all the necessary information.
If you are admitted as an inpatient to a non-network hospital as a result of
an emergency, you, your doctor
or a family member should call BlueCHOICE as
soon as possible for precertification of the case.
BlueCHOICE will cover
your care until you are stabilized. Then you must transfer to a BlueCHOICE
network hospital. The transfer must be coordinated through BlueCHOICE in
advance. 33
33 Page
34 35
2001 BlueCHOICE 34
Section 5( d)
BlueCHOICE will not provide benefits for continued care
at a non-network hospital after you are stable
enough to transfer.
When you need care right away but it is not an emergency, always call your
primary care physician. Your
primary care physician may have you come into
the office for an urgent appointment. An urgent
appointment is one scheduled
with a physician for the same day or during hours not normally used for
appointments. 34
34 Page
35 36
2001 BlueCHOICE 35
Section 5( d)
Benefit Description You pay
Emergency within 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
Hospital observation
If you need follow-up care after emergency
treatment, call your primary
care physician. If your primary care physician
cannot provide the care,
he or she will give you a written referral to a
network specialist.
If you are treated in the emergency room and then held for observation,
only one copay will be charged.
If you receive follow-up care without a written referral from your
primary care physician, you must pay all charges.
$10 per office visit
$10 per office visit
$50 at emergency
room( waived if
admitted)
$50 (waived if admitted)
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
Hospital observation
If you need follow-up care after emergency
treatment, call your primary
care physician. If your primary care physician
cannot provide the care,
he or she will give you a written referral to a
network specialist.
If you are treated in the emergency room and then held for observation,
only one copay will be charged.
After your condition is stabilized, you, the hospital, a family member or
a friend must call us for approval of continued care.
Benefits are available only until BlueCHOICE determines that your
condition has improved enough for you to travel back to the
BlueCHOICE
service area.
If you receive follow-up care without a written referral from your
primary care physician, you must pay all charges.
$10 per office visit
$10 per office visit
$50 at emergency
room( waived if
admitted)
$50 (waived if admitted) 35
35 Page 36 37
2001 BlueCHOICE
36 Section 5( d)
Emergency outside our area (continued)
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. Transportation by air ambulance must be approved in
advance by BlueCHOICE.
See 5( c) for non-emergency service.
Nothing 36
36 Page
37 38
2001 BlueCHOICE 37
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve
"parity" with other
benefits. This means that we will provide mental health and substance abuse
benefits differently than in the past.
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
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE 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.
Copayments are the same as
for any other illness or
condition.
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 37
37 Page 38 39
2001 BlueCHOICE 38 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests $10 per office visit or test
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, residential
treatment, full-day hospitalization, facility
based intensive outpatient
treatment
Nothing on inpatient basis;
$10 per visit for outpatient
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 generally will 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 follow
your treatment
plan and all the following authorization processes:
If you think you have a mental health or substance abuse problem, we
encourage you to see your primary care physician. Your primary care
physician may treat you or may recommend that you call our mental
health
and substance abuse benefits manager.
If you do not wish to go through your primary care physician for mental
illness or substance abuse care, to receive benefits you must call our
mental health and substance abuse benefits manager before you receive
care. This number is 1-800-965-2583, and is also listed on your ID card.
Network providers will handle all authorizations for you. However, your
benefits allow up to two visits each calendar year to diagnose and assess
a mental health condition, in or out of network, without authorization.
Mental health providers are included in the BlueCHOICE directory. 38
38 Page 39 40
2001 BlueCHOICE 39 Section 5( e)
Special transitional benefit If a mental health or substance
abuse professional provider is treating you under our plan as of January 1,
2001, you will be eligible for continued
coverage with your provider for up
to 90 days under the following
condition:
If your mental health or substance abuse professional provider with
whom
you are currently in treatment leaves the plan at our request for
other than
cause.
If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
Limitation If you do not go to your primary care physician or do not
call our mental health and substance abuse benefits manager before you receive
care,
benefits will be provided only for medically necessary emergency room
treatment. However, your benefits allow up to two visits each calendar year
to diagnose and assess a mental health condition, in or out of network,
without authorization. 39
39 Page 40 41
2001 BlueCHOICE
40 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.
Some prescription drugs are covered only if your physician
obtains prior authorization from us. In addition, coverage for some drugs is
provided in limited quantities.
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 or plan dentist
must write the prescription, unless it is an emergency.
Where you can obtain them. You must fill the prescription at a plan
pharmacy, or by mail for a maintenance medication. For the same copay, you can
also use the Internet to place your
prescription orders through PlanetRx, at
www. PlanetRx. com.
Most maintenance drugs are available through mail
order. To find out if a certain maintenance drug is available by mail order,
call 1-800-655-1936.
We use an incentive-based three-tier formulary. A formulary is a list
of preferred drugs chosen for use based upon their effectiveness, safety and
cost. Drugs are prescribed by Plan doctors and
dispensed in accordance with
BlueCHOICE's drug formulary. Nonpreferred brand-name drugs will
be covered
when prescribed by a Plan doctor. The Plan must authorize a nonpreferred
brand-name
drug before it may be dispensed. It is the prescribing doctor's
responsibility to obtain the Plan's
authorization. You pay a $5 copay per
prescription unit or refill for generic drugs; $10 for preferred
brand-name
drugs; and $15 for nonpreferred brand-name drugs. When a generic drug is
available
but you or your physician request the brand-name drug, you pay the
price difference between the
generic and brand-name drug as well as the $5
copay per prescription or refill unless your physician
has obtained
prior authorization for the brand-name drug. When the physician has obtained the
prior
authorization, you pay only the appropriate brand copay.
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 30-day supply for retail or one
commercially prepared unit (i. e., one inhaler, one vial ophthalmic
medication or insulin); and are
available at $5 for generic; $10 for
preferred brand-name; and $15 for nonpreferred brand-name.
Mail order prescription drugs are dispensed for up to a 90-day supply, and
are available at $10 for
generic; $20 for preferred brand-name; and $30 for
nonpreferred brand-name.
When you have to file a claim. Follow the same procedures for filing a
prescription drug claim found in Section 7.
Prescription drug benefits begin on the next page. 40
40 Page 41 42
2001 BlueCHOICE 41 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
and online program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as
excluded below.
Drugs that under state law are dispensed only with a written prescription
from a physician or other lawful provider.
Insulin Disposable needles and syringes for the administration of covered
medications, including insulin
Drugs for sexual dysfunction (See Limited
Drug Benefits below) FDA-approved prescription drugs and devices for birth
control
Diabetic test strips, lancets Intravenous fluids and medication for home use
(provided under
home health services at no charge) and some injectable drugs
are
covered under Medical and Surgical Benefits.
Please note:
Most prescriptions are limited to a 30-day supply
each time the prescription is filled.
Refills your doctor authorizes are covered for up to 12 months from the
original prescription date. Then a new prescription is required.
Some
prescription drugs are covered only if your physician obtains prior
authorization from us. In addition, coverage for some drugs is
provided in
limited quantities.
Limited Drug Benefits Prescription benefits for
the treatment of sexual dysfunction will only be
available with prior
authorization where sexual dysfunction is secondary
to a medical condition
and the medical history and work-up is
documented. You must receive prior
authorization before receiving any
prescription for the treatment of sexual
dysfunction. If approved, four
prescribed treatments per month will be
available and subject to the
nonpreferred brand-name copayment.
Retail (up to a 30-day supply)
$5 generic
$10 preferred brand
$15
nonpreferred brand
Mail order and online (up to a 90-
day supply)
$10 generic
$20
preferred brand
$30 nonpreferred brand
Note: If there is no generic
equivalent available, you will still
have to pay the brand-name copay. 41
41 Page 42 43
2001 BlueCHOICE
42 Section 5( f)
Covered medications and supplies
(continued) You pay
Here are some things to keep in mind
about our prescription drug
program:
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, whether or not
your physician has 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, unless your
physician has obtained prior authorization for the
brand-name drug.
We have an incentive-based, three-tier formulary. If your physician believes
a name-brand product is necessary or there is no
generic available, your
physician may prescribe a name-brand drug
from a formulary list. This list
of name-brand drugs is a preferred
list of drugs that we selected to meet
patient needs at a lower cost.
To order a copy of our Preferred Drug List,
please call Client
Services at 1-800-932-4480 or visit our Web site at
www. AllianceBlue. com/ member_ services.
Not covered:
Drugs for which there is a nonprescription equivalent
available
Drugs obtained at a non-Plan pharmacy (except out-of-area).
Reimbursement for prescriptions purchased out-of-area will be
covered up
to the allowed amount after a $25 copayment. Vitamins and nutritional
substances that can be purchased without a
prescription
Medical equipment, devices and supplies such as dressings
and
antiseptics
Drugs for cosmetic purposes
Drugs to enhance
athletic performance
Test agents and devices
Prescription smoking
cessation aids
Appetite suppressants and other drugs for weight loss
All Charges 42
42 Page 43 44
2001 BlueCHOICE
43 Section 5( g)
Section 5 (g). Special Features
Feature
Description
Away From Home Care BlueCHOICE offers its members medical
care in emergency and urgent situations when traveling outside the service area.
Also, members who are traveling for an extended time or who are on
an
extended work assignment in another city may be eligible to apply
for a
Guest Membership in a local Blue Cross and Blue Shield HMO.
The Guest
Membership also temporarily covers dependent children
who are away at school
or living in another city. For more
information, see Section 1.
RightSteps This is a voluntary program that strives to help
mothers-to-be avoid potential problems during pregnancy. Pregnant women who
choose to
participate are asked to complete a questionnaire within 20 weeks
of
becoming pregnant. An obstetrical registered nurse will then contact the
member periodically to provide information on pregnancy and childbirth.
We encourage the member to have early, regular prenatal care and to pay
attention to her lifestyle behaviors. Mothers-to-be who participate in the
program will also receive a nationally recognized book on pregnancy,
childbirth and infant care; up to a $40 reimbursement for the cost of a
childbirth or parenting class; and a gift from us after the baby arrives.
Take Charge SM Asthma
Program
Our goal is to help our members
who have asthma manage their disease
more successfully. Working with the
patient's physician, we provide case
management services to severe
asthmatics through frequent phone calls,
individual care plans, home health
visits (as approved by the patient's
doctor), durable medical equipment
benefits and asthma educational
material. Adults and children with mild or
moderate asthma receive
asthma educational materials as requested.
CardioCall SM BlueCHOICE also offers a service based on studies that
show telephone management and education can reduce the risks associated with
heart
attacks. CardioCall uses an automated telephone system to call members
at risk for heart attacks and who voluntarily enrolled in the program.
These members receive telephone calls over six to nine months. Each call
is confidential and takes only five to 10 minutes. After each call, the
member receives a personalized letter recapping the information reviewed
during the call and educational information. The member's doctor also
receives a copy of each report.
Note: Special programs such as
RightSteps , Take Charge SM
Asthma Program and
CardioCall SM are voluntary
programs that are
available to
members who have primary
health coverage through
BlueCHOICE. 43
43 Page
44 45
2001 BlueCHOICE 44
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.
Plan dentists must provide or arrange your care.
We cover hospitalization
for dental procedures only when a nondental 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
Dental Benefits
Service You pay
The following dental services are covered when
provided by your
participating Plan primary dentist:
Office visit for oral examination, limited to two
visits per calendar
year
Oral prophylaxis (cleaning) as necessary, limited to
two visits per
calendar year
Topical application of fluorides is limited to two
courses of treatment
per calendar year, limited to
children under age 18
Oral hygiene instruction
Dietary advice and counseling
Consultations
with Primary Dentist
Not Covered: Any procedures or services not listed.
$ 5 per office visit 44
44 Page 45 46
2001 BlueCHOICE
Section 5( i) 45
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 the FEHB out-of-pocket maximum.
Your
medical program copay does not apply to these services. You must pay
for the services or supplies when you receive
them.
Wellness and Education Programs
Eat Smart: Learn to eat right and
control your weight. You'll get $75 if you achieve your weight loss goal through
a
participating facility.
Breathe Easy: Smoking cessation classes offered in cooperation with
local health care providers teach you some
helpful tips for kicking the
habit. Earn $50 for regular class attendance and for quitting smoking.
Physical Fitness: If you are 18 or older, we will reimburse you 25%
(up to $100) for a single membership and 50%
of annual dues (up to $200) for
a family membership at the health club of your choice.
Self-Help Educational Information: Free literature is available on a
variety of subjects, including stress, alcohol,
drugs and cholesterol.
Discounted Services
Hearing Aids: Free hearing evaluations and
savings on hearing aids are available through Accent Hearing Network
providers and HearAmerica providers.
Vision Care: BlueCHOICE members may receive discounts on eye exams,
lenses and frames by showing their ID
card at a participating vision center.
Members also can receive discounts off the regular retail price for all eye care
accessories, including contact lens solutions and non-prescription
sunglasses. Members can obtain discounted eye
wear and eye care services
through Access Eye Care network, Unity Health Eye Care network or Crown
Optical.*
*Savings on LASIK surgery are available to members through Crown Optical.
Members pay only $1,249 per eye at a
Crown Laser Center. For more
information, contact Crown at 1-800-232-4526.
Alternative Health Programs through American Specialty Health Networks:
BlueCHOICE provides access to an
alternative health care discount
program through American Specialty Health Networks (ASHN). BlueCHOICE
members can pay discounted fees when they see chiropractors, acupuncturists
and massage therapists in ASHN's
credentialed network. Members receive
ASHN's toll-free telephone number to request provider directories and
program brochures when they enroll.
In addition, members can access ASHN's national network of fitness clubs at
the clubs' lowest membership rates.
Additionally, members can try the
fitness facilities at no charge for one full week.
Additional discounts are available for everything from educational videos to
herbal supplements ordered through the
Internet. Just go to www.
AllianceBlue. com/ discountprograms for additional information.
For more information on any of the special programs described on this page,
call Client Services at 1-800-932-4480.
Note: We may receive payments
from the providers of these discount programs to cover administrative and
related
costs associated with offering the programs and services to members.
We do not select or recommend providers for
the discount programs and do not
recommend or prescribe the services or treatments provided. We encourage
members to consult with their physician about any of these services or
products. 45
45 Page
46 47
2001 BlueCHOICE Section 6 46
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.
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 the
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest.
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 46
46 Page 47 48
2001 BlueCHOICE
47 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.
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 and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 1-800-932-4480.
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 BlueCHOICE can
extend this deadline if you show that circumstances beyond your control
prevented you from filing on time.
How to file a claim:
You can obtain claim forms by calling Client
Services at 1-800-932-
4480. The back of the claim form has complete filing
instructions.
You can use the same claim form to file a claim for all your health care
benefits.
You may submit claims for more than one person in the same envelope.
However, you must submit a separate claim form for each person.
Attach each person's bill to the correct form.
Complete the claim form fully and accurately. You must check "yes"
or
"no" for each question. If you do not answer a question, we may
have to
return your claim to you. This is also true if you do not provide
additional information required.
When you write in your identification number on the claim form, be sure
to include the first three digits.
We can only accept itemized bills. Each bill must show: the name of the
patient; the name and address of the provider of care; a description of
each service and the date provided; a diagnosis; and the charge for each
service.
Canceled checks and nonitemized bills that show only "balance due"
or
"for professional services rendered" are not sufficient.
Include all bills for covered services not previously submitted.
If you
have paid the provider, mark each bill "paid."
In some cases, we
will pay you directly for covered services. In other
cases, we will pay the
provider.
Please keep copies of the completed claim form and itemized bills.
Send
your claims to the address shown on the form. 47
47
Page 48 49
2001
BlueCHOICE 48 Section 7
Prescription drugs
Major
chains and independent pharmacies belong to your pharmacy
network. At these
pharmacies, if you show your BlueCHOICE ID card,
you should only be
responsible for paying your share of the cost. The
pharmacy should file your
claim, and we will pay the pharmacy directly.
At a Non-Network Pharmacy: If you go to a non-network pharmacy in an
urgent or emergency situation outside the BlueCHOICE service area, you
are responsible for paying for your prescription at the time of service and
then filing a claim. Your program will not provide benefits if you use a
non-network
pharmacy within the BlueCHOICE service area.
You can obtain a Prescription Drug Claim Form by calling Client Services at
1-800-932-4480.
You can file up to three prescriptions on each form. Please do not use a
regular health benefits claim form to file your prescription drug claim.
If
you do, your claim may be denied.
Please fill out a separate claim form for each person and pharmacy.
Be
sure to provide all the information requested for each prescription.
You may
need to have the pharmacy complete the form or get the
information from the
pharmacy.
Then you or the pharmacist should fill out the pharmacy's name, address
and National Association of Board of Pharmacy (NABP) number.
On the completed form, tape your original itemized prescription
drug
receipt( s). Please do not send cash register receipts, canceled
checks,
bottle labels, copies of the original prescription drug receipts, or
your
own itemization of charges.
The receipt( s) must show: *the prescription number *the patient's name
*the name of the drug *the quantity and unit dose *the strength of the
drug
Sign the claim form. Then mail it and your receipt( s) to the address
shown on the form.
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. 48
48 Page
49 50
2001 BlueCHOICE 49
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
Ask us in writing to reconsider our initial
decision. You must:
(a) Write to us within six months from the date of our
decision; and
(b) Send your request to us at: BlueCHOICE Grievance Unit
P. O. Box 66828
St. Louis, MO 63166-6828
(c) Include a statement
about why you believe our initial decision was wrong, base 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.
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).
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.
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us— if we did not answer that
request in some way within 30 days; or
120 days after we asked for
additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II,
P. O. Box 436, Washington, D. C.
20044-0436.
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. 49
49
Page 50 51
2001
BlueCHOICE 50 Section 8
The Disputed Claims process
(Continued)
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 provide 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.
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.
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. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review process to
support its 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
1-800-932-4480 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
it can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818
between 8 a. m. and 5 p. m. Eastern time. 50
50
Page 51 52
2001
BlueCHOICE 51 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. All programs together will not pay more than
100% of
allowable expenses. The allowable expense is the maximum
amount that a plan
will pay for covered services.
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.
Part B (Medical Insurance). Most people pay monthly for Part B.
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 The Original Medicare Plan is available
everywhere in the United States.
It is the way most people get their
Medicare Part A and Part B benefits.
You may go to any doctor, specialist,
or hospital that accepts Medicare.
Medicare pays its share and you pay your
share. Some things are not
covered under Original Medicare, like
prescription drugs.
When you are enrolled in this Plan and Original Medicare, 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 and you will still be
responsible for the Plan's copayments.
(Primary payer chart begins on next page.) 51
51 Page 52 53
2001 BlueCHOICE 52 Section 9
The
following chart illustrates whether Original Medicare or this Plan should be the
primary payer for you according
to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements
correctly.
Primary Payer Chart
Then the primary payer is… A. When either
you— or your covered spouse— are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solelybecause of a disability),
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…………………………………………………
……….
b) Are an active
employee…………………………………………
……………….. …….
Filing a claim
When this Plan is primary and you have a claim for
covered services that you must file yourself, please follow the
claim filing
instruction in Section 7.
Once you receive an Explanation of Benefits (EOB) from us, then file a claim
for your Medicare benefits. (For
information on filing a Medicare claim,
contact your Social Security office.) When Original Medicare is primary you
must submit your claims to Medicare first. The federal government requires
most health care providers and suppliers
to file your Medicare claims for
you. So in most cases, you shouldn't need to file a claim to obtain your
Medicare
benefits.
Also, in most cases, you shouldn't need to
file to receive the benefits of this program. If the services or supplies
are
covered by Medicare, the Medicare carrier will usually forward your
medical claim to us. Then we will provide the
benefits of this program
automatically in most cases. 52
52 Page 53 54
2001 BlueCHOICE
53 Section 9
You should not submit a claim for benefits of
this program if your Medicare EOB states, in part: "This information is
being sent to your private insurer." This note means that the Medicare
carrier is submitting your claim to us. Then we
can provide the benefits of
this program. If this note is on your Medicare EOB, please do not submit
a claim to us.
Also, please let your providers of care know that they should
not submit your claim to us. When we receive duplicate
claims, this
increases costs.
Your Medicare EOB may not indicate that your claim has been referred to
supplemental claims processing. In that
case, you should file your own
claim.
To File Your Own Claim
To file, send us a copy of your Medicare
EOB. Include a completed claim form and copies of your itemized bills.
Send
the information to the address shown on the claim form.
You should also file
a claim if you receive services or supplies that are not covered by Medicare but
are covered by
this program. Send a completed claim form and copies of your
itemized bills to us. 53
53 Page 54 55
2001 BlueCHOICE
54 Section 9
Medicare managed care plan If you are
eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from 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 cover all
Medicare Part A and B
benefits. Some cover extras, like prescription
drugs. To learn more about
enrolling in a Medicare managed care plan,
contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a
Medicare managed care plan, the
following options are available to you:
This Plan and another Plan's Medicare managed care plan: You
may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when
your Medicare managed
care plan is primary, even out of the managed
care plan's network and/ or
service area (if you use our Plan providers),
but you will still be
responsible for copayments.
Suspended FEHB coverage and 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+ Choice plan service area.
Enrollment in Note: If you choose not to enroll in Medicare Part B,
you can still be Medicare Part B covered under the FEHB Program. We
cannot require you to enroll in
Medicare.
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 disease 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.
Once OWCP or similar agency pays its
maximum benefits for your
treatment, we will cover your benefits. You must
use our providers.
Medicaid When you have this Plan and Medicaid, we pay first. 54
54 Page 55 56
2001 BlueCHOICE 55 Section 9
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 for injuries medical or
hospital care for injuries or illness caused by another person,
you must
reimburse us for any expenses we paid. However, we will
cover the cost of
treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 55
55 Page 56 57
2001 BlueCHOICE
56 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.
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.
Custodial care Services that do not seek to cure, but are
provided primarily for the convenience of the patient or his or her family, the
maintenance of the
patient, or to assist the patient in meeting his or her
activities of daily
living, rather than primarily for therapeutic value in
the treatment of a
Condition. Custodial Care includes, but is not limited
to, help in
walking, bathing, dressing, eating, preparation of special
diets,
supervision over self-administration of medications not requiring
constant attention of trained medical personnel, or acting as a companion
or sitter.
Note: BlueCHOICE will have the sole discretion to determine whether
Care is Custodial Care. BlueCHOICE may consult with professional
peer
review committees or other appropriate sources for
recommendations.
Experimental or investigational services A drug, device or biological
product is experimental or investigational if
the drug, device, or
biological product cannot be lawfully marketed
without approval of the U. S.
Food and Drug Administration (FDA) and
approval for marketing has not been
given at the time it is furnished.
Approval means all forms of acceptance by
the FDA.
An FDA-approved drug, device or biological product (for use other than
its intended purpose and labeled indications), or medical treatment or
procedure is experimental or investigational if
1) reliable evidence shows that it is the subject of ongoing phase I, II
or III clinical trials or under study to determine its maximum
tolerated
dose, its toxicity, its safety, or
2) reliable evidence shows that the
consensus of opinion among
experts regarding the drug, device, or biological
product or
medical treatment or procedure is that further studies or
clinical
trials are necessary to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy, or its efficacy as compared with the
standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the
authorized medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol( s) of another
facility
studying substantially the same drug, device or medical treatment
or
procedure; or the written informed consent used by the treating facility
or
by another facility studying substantially the same drug, device or
medical treatment or procedure. 56
56 Page 57 58
2001 BlueCHOICE
57 Section 10
FDA-approved drugs, devices, or biological products
used for their
intended purpose and labeled indication and those that have
received
FDA approval subject to postmarketing approval clinical trials, and
devices classified by the FDA as "Category B Non-experimental/
Investigational Devices" are not considered experimental or
investigational.
Group health coverage A health benefit plan that is offered to
employees through their place of employment or to the membership of a sponsoring
organization such as a
union or association.
Medical necessity We only cover care that is medically necessary. But
it does not cover all medically necessary care. Even if the type of care is
covered in general,
the care is not covered if we determine it was not
medically necessary in
a specific case. BlueCHOICE must agree that care was
medically
necessary.
However, in some cases, you will not have to pay for care that was not
medically necessary. In these cases, the provider is responsible. You do
not need to pay if all of the following are true:
You obtained
the proper referral for the care.
BlueCHOICE did not notify you in advance
that the care was not
medically necessary.
The services would have been
covered if they were medically
necessary.
To be medically necessary, care must be provided to diagnose or treat a
condition. Also, the type and level of care must be necessary and
appropriate. We use current standards of medical practice to decide
necessity and appropriateness. The type and level of care must not be
more than what is necessary.
For example, surgery may not be medically necessary for your condition
if
your provider has not tried more conservative treatment. Also,
inpatient
care is not medically necessary if appropriate care is available
on an
outpatient basis.
Plan allowance The maximum amount we will pay for covered services.
Us/ We Us and we refer to BlueCHOICE.
You You refers to
the enrollee and each covered family member. 57
57
Page 58 59
2001
BlueCHOICE 58 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you a
Guide to Federal Employees
FEHB Program Health Benefits
Plans, brochures for other plans, and other materials you need to make an
informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or
retirement office authorizes
coverage for. Under certain circumstances,
you may also continue coverage
for a disabled child 22 years of age or
older who is incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from
your coverage for any reason, including divorce, or when your child
under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 58
58 Page
59 60
2001 BlueCHOICE 59
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you are new premiums start to this Plan, your
coverage and premiums begin on the first day of your
first pay period that
starts on or after January 1. Annuitants' premiums
begin on January 1.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you
may be
eligible for other forms of coverage, such as temporary continuation
of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
TCC If you leave Federal service, or if you lose coverage because you
no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you
are not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or
retirement office or from www. opm. gov/ insure. 59
59 Page 60 61
2001 BlueCHOICE 60 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 Group Health Plan 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.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has
charged you for services you did not receive, billed you twice
for the
same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 1-800-932-4480
and
explain the situation.
If we do not resolve the issue, call THE HEALTH
CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud
Hotline, 1900
E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 60
60
Page 61 62
2001
BlueCHOICE 61 DoD/ FEHB Demonstration Project
Department of
Defense/ FEHB Demonstration Project
What is it? The Department of
Defense/ FEHB Demonstration Project allows some active and retired uniformed
service members and their dependents to enroll in the FEHB
Program. The
demonstration will last for three years and began with the 1999
open season
for the year 2000. Open season enrollments will be effective January
1,
2001. DoD and OPM have set up some special procedures to implement the
Demonstration Project, noted below. Otherwise, the provisions described in
this
brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service
member and are eligible for Medicare;
You are a qualified former spouse of
an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed
service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health
Benefits Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico Fort
Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt
County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair
County, IA Coffee County, GA area
When you can join You may enroll
under the FEHB/ DoD Demonstration Project during the 2000 open season, November
13, 2000, through December 11, 2000. Your coverage
will begin January 1,
2001. DoD has set-up an Information Processing Center
(IPC) in Iowa to
provide you with information about how to enroll. IPC staff will
verify your
eligibility and provide you with FEHB Program information, plan
brochures,
enrollment instructions and forms. The toll-free phone number for the
IPC is
1-877/ DOD-FEHB (1-877/ 363-3342).
You may select coverage for yourself (Self Only) or for you and your family
(Self
and Family) during the 2000 and 2001 open seasons. Your coverage will
begin
January 1 of the year following the open season during which you
enrolled.
If you become eligible for the DoD/ FEHB Demonstration Project outside of
open
season, contact the IPC to find out how to enroll and when your
coverage will
begin.
DoD has a Web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations and zip code lists at
www.
tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2001 Guide to Federal Employees
Health 61
61 Page
62 63
2001 BlueCHOICE 62 DoD/
FEHB Demonstration Project
Benefits Plans Participating in the DoD/ FEHB
Demonstration Project," on the
OPM Web site at www. opm. gov.
TCC eligibility See Section 11, FEHB Facts; it explains Temporary
Continuation of Coverage (TCC). Under this DoD/ FEHB Demonstration Project the
only individual eligible
for TCC is one who ceases to be eligible as
a "member of family" under your self
and family enrollment. This
occurs when a child turns 22, for example, or if you
divorce and your spouse
does not qualify to enroll as an unremarried former
spouse under Title 10,
United States Code. For these individuals, TCC begins the
day after their
enrollment in the DoD/ FEHB Demonstration Project ends. TCC
enrollment
terminates after 36 months or the end of the Demonstration Project,
whichever occurs first. You, your child, or another person must notify the
IPC
when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project
area,
you cancel your coverage, or your coverage is terminated for any
reason. TCC is
not available when the demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 62
62 Page 63 64
2001 BlueCHOICE 63 Index
Index
Do not rely on this page; it is for your convenience and does not
explain your benefit coverage.
Allergy tests 8, 18 Alternative treatment 45
Ambulance 30, 32, 36
Anesthesia 25, 27, 29, 31
Autologous bone marrow transplant 19, 28
Blood
and blood plasma 15, 31 Casts 25, 31
Changes for 2001 8 Chemotherapy 19, 28
Childbirth 43 Cholesterol tests 15, 45
Claims 9, 13, 47, 48, 49, 50, 52,
53, 59
Coinsurance 12 Colorectal cancer screening 15
Congenital
anomalies 25, 26 Contraceptive devices and drugs 17,
26 Coordination of
benefits 51
Covered charges 12 Covered providers 6, 38
Crutches 23
Deductible 12 Definitions 56
Dental care 27, 29, 44 Diagnostic services 14, 15, 31,
37, 38 Disputed
claims review 49, 50
Donor expenses (transplants) 28 Dressings 31
Durable medical equipment (DME) 23, 43
Educational classes and
programs 45 Effective date of enrollment 9,
56 Emergency 5, 7, 11, 33, 34,
35,
36 Experimental or investigational
46, 56, 57 Eyeglasses 21
Family planning 17 Fecal occult blood test 15
General
Exclusions 46 Hearing services 20
Home health services 24 Hospice
care 32
Hospital 30, 31, 32, 33, 51 Immunizations 16
Infertility
18 Inhospital physician care 14
Inpatient hospital benefits 30, 31 Insulin
40, 41
Laboratory and pathological services 15
Magnetic Resonance
Imagings (MRIs) 15
Mail order prescription drugs 40, 64
Mammograms 15 Maternity benefits 17,
31
Medicaid 55 Medically necessary 57
Medicare 51, 52, 53, 54 Mental
conditions/ substance
abuse benefits 8, 10, 37, 38, 39
Newborn care 14,
17 Non-FEHB benefits 45
Obstetrical care 17 Occupational therapy 20
Ocular injury 21 Office visits 14
Oral and maxillofacial surgery 27
Orthopedic devices 22
Ostomy and catheter supplies 23 Out-of-pocket expenses
12
Outpatient facility care 31 Oxygen 23, 24, 31
Pap test 15
Physical examination 15, 16
Physical therapy 20 Precertification 11
Preventive care, adult 15, 16 Preventive care, children 16
Prescription
drugs 40, 41, 48 Prior approval 11
Prostate cancer screening 15 Prosthetic
devices 22
Psychologist 37 Radiation therapy 19
Rehabilitation
therapies 20 Renal dialysis 19
Room and board 30, 32 Second surgical
opinion 14
Skilled nursing facility care 32 Smoking cessation 45
Speech
therapy 20 Splints 31
Sterilization procedures 17, 26 Subrogation 35
Substance abuse 10, 37, 38, 39 Surgery 25
Anesthesia 25, 29 Oral 26
Outpatient 31 Reconstructive 26
Syringes 41 Temporary
continuation of
coverage 59, 62 Transplants 28
Treatment therapies
19 Vision services 21
Well child care 16
Wheelchairs 24 Workers' compensation 52, 54
X-rays 15, 31 63
63 Page 64 65
2001 BlueCHOICE 64
Summary of benefits
for BlueCHOICE -2001
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 14
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing
Outpatient surgery and
endoscopic procedures; $10 copay
if no general anesthesia is
required.
30
31
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$ 50 per visit
$ 50 per visit
35
35
Mental health and substance abuse
treatment...................................... Regular cost sharing 37
Prescription drugs
.................................................................................
Mail order
.............................................................................................
$5 generic
$10 preferred brand name
$15 nonpreferred brand name
$10 generic
$20 preferred brand name
$30 nonpreferred brand name
40
Dental Care
.......................................................................................
Preventive care only; $5 copay 44
Vision Care
.......................................................................................
Routine eye exam (one per
calendar year); $10 per office
visit.
Eyeglasses and contact
lenses are covered up to $35 per
24-month period.
Reduced-cost
glasses or contact lenses from
selected providers.
21 64
64 Page
65 66
2001 BlueCHOICE 65
Special features:
Away From Home Care
RightSteps
Take Charge SM
Asthma Program
CardioCall SM
43
Protection against catastrophic costs
(your out-of-pocket
maximum)......................................................... After you pay
100% of your annual
premium in copayments for one
family member, or 100%
of your
annual premium for two or more
family members, you do not have
to make any further payments for
certain services for the rest of the
year. Some costs do not count
toward this protection.
12 65
65 Page
66 67
2001 BlueCHOICE 66
Notes 66
66 Page
67 68
2001 BlueCHOICE 67
Notes 67
67 Page
68
2001 BlueCHOICE 68
2001 Rate Information for
BlueCHOICE
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 and Tool & Die employees (see RI
70-2B); and for
Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization. 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
St Louis/ Central/ SW/ Poplar Bluff area
Self Only 9G1 $83.64 $27.88
$181.22 $60.41 $98.97 $12.55
Self and Family 9G2 $181.08 $60.36 $392.34
$130.78 $214. 28 $27.16 68
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