A Health Maintenance Organization
For changes benefits
in page 4
see
Serving Arizona
You must live in one of the service areas on page 5 to enroll in this Plan and must enroll in the area where you live
Tucson and Southern Arizona
Enrollment Code
TD1
TD2
Central Arizona
Enrollment Code
2S1
2S2
Special Notice
The Plan services the following counties in Arizona Cochise Graham Greenlee Pima Santa Cruz and
Maricopa Also individuals who live in zip codes 85217 85219 and 85220 in Pinal County may select United
HealthCare of Arizona
Visit the OPM Website at http www opm gov insure
Visit this Plan's Website at http www unitedhealthcareaz com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service RI 73 556
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United HealthCare of Arizona 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we dont cover 17
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB facts 18
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits Inside Back Cover
Premiums Back Cover
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United HealthCare of Arizona 2000
Introduction
United HealthCare of Arizona Inc
3141 N Third Ave
Phoenix AZ 850134345
This brochure describes the benefits you can receive from United HealthCare of Arizona Inc under its contract CS2619 with the
Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the
official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in t his
brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 4 United HealthCare of Arizona Inc Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Governments communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to United HealthCare of Arizona Inc as this Plan throughout this brochure even though in other legal documents you
will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plans
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about nonFEHB benefits
6 General exclusions Things we dont cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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United HealthCare of Arizona 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams wellbaby care and immunizations as well as treatment for ill ness
and injury
You will not have to submit claim forms or pay bills unless you receive emergency services from noncontracted providers
However you must pay copayments listed in this brochure When you receive emergency services from noncontracted providers
you may have to submit claim forms
You should join an HMO because you prefer the plans 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
andor remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
Section 2 How we change for 2000
Programwide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the third trimester of pregnancy you may be able to continue seeing your OBGYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your
records you may add a brief statement to it If they do not provide you your records call us and
we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Your share of the nonpostal premium will increase Your share of the standard option premium
Plan for enrollment code 2S will increase by 179 for Self Only or 117 for Self and Family and for enrollment code TD it will increase 15 for Self Only or 14 for Self and Family
You pay a 10 copay for generic formulary drugs a 20 copay for brand name formulary drugs
and a 60 copay for all nonformulary drugs for a 90 day mailorder supply
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United HealthCare of Arizona 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Our
Plans service service area is
area
Tucson and Southern Arizona This area includes Pima Santa Cruz Cochise Graham Greenlee
counties and portions of Pinal County in zip codes 85245 85623 85618 and 85631
Enrollment Code
TD1
TD2
Central Arizona This area includes Maricopa county and zip codes 85217 85219 and 85220 in
Pinal County
Enrollment Code
2S1
2S2
You must enroll in the area where you live
Ordinarily you must get care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care only We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a feeforservice plan or an HMO that has agreements with
affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office
How much do I You must share the cost of some services This is called a copayment a set dollar amount or
pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
After you pay 1000 for one family member or 3000 per family 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 or vision care 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
Do I have to You normally wont have to submit claims to us unless you receive services outside the area
submit claims Emergency services by noncontracted physicians in the service area require claims to be submitted by you only if you have been required to pay for the services and not allowed to pay your copay If
you file a claim please send us all of the documents for your claim as soon as possible You must
submit claims by December 31 of the year after the year you received the service Either OPM or
we can extend this deadline if you show that circumstances beyond your control prevented you from
filing on time
Who provides my United HealthCare is a mixed model prepayment MMP Plan This means you have the option of
health care selecting your primary care doctor from the group practice list or you may select your primary care doctor from the list of individual practice doctors You have approximately 1000 primary care
doctors in Arizona to choose from in varied locations and access to over 2000 specialists who
provide care on referral from your primary care doctor
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United HealthCare of Arizona 2000
The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care doctor to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other Plan providers are covered only when there has
been a referral by the members primary care doctor except a woman may see her Plan obstetrician
gynecologist directly In addition you do not need a referral from your primary care physician
when utilizing benefits for the treatment of mental conditions or substance abuse Call the Plans
member services department at 18887804333 for more information
The Plans provider directory lists primary care doctors generally family practitioners
pediatricians and internists with their locations and phone numbers Directories are updated on a
regular basis and are available at the time of enrollment or upon request by calling the Member
Services Department at 18887804333 you can also find out if your doctor participates with this
Plan by calling this number Also you may check the provider directory at our website at
wwwunitedhealthcareazcom If you are interested in receiving care from a specific provider who is
listed in the directory call the provider to verify that he or she still participates with the Plan and is
accepting new patients Important note When you enroll in this Plan services except for
emergency benefits are provided through the Plans delivery system the continued availability and
or participation of any one doctor hospital or other provider cannot be guaranteed
If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered
services until the Plan can arrange with you for you to be seen by another participating doctor
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or
to go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if Im in First call our customer service department at 18887804333 If you are new to the FEHB
the hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program and are
this Plan switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist When you receive a referral
care from your primary care doctor you must return to the primary care doctor after the consultation All followup care must be provided or authorized by the primary care doctor On referrals the
primary care doctor will give specific instructions to the consultant as to what services are
authorized If additional services or visits are suggested by the consultant you must first check with
your primary care doctor Do not go to the specialist unless your primary care doctor has arranged
for and the Plan has issued an authorization for the referral in advance
If you 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
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United HealthCare of Arizona 2000
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a
seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue
serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
provider leaves the Plan the provider unless the termination is for cause If you are in the second or third trimester of
or this Plan leaves the pregnancy you may continue to see your OBGYN until the end of your postpartum care
Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OBGYN care
you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or recommending followup care In addition your Plan doctor must obtain authorization from the Plan before you receive durable medical equipment prosthetic devices or orthopedic devices from
the Plans vendor Before giving approval we consider if the service is medically necessary and if
it follows generally accepted medical practice
How do you decide if a The Plan uses peerreviewed medical literature United States Food and Drug Administration
service is experimental guidelines and applicable national or regional policy to make its experimentalinvestigative
or investigational determinations
Section 4 What to do if we deny your claim or request for service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
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When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a serious Call us at 18887804333 and we will expedite our review
or life threatening
condition and you havent
responded to my request
for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform
my request for care and OPM so that they can give your claim expedited treatment too Alternatively you call OPMs health
my condition is serious or benefits Contract Division IV at 202 6060737 between 8 am and 5 pm Serious or life
life threatening threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We did not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
persons representative They must send a copy of the persons specific written consent with the
review request
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs
disputed claim to OPM Contract Division IV PO Box 436 Washington DC 20044
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What if OPM OPMs decision is final There are no other administrative appeals If OPM agrees with our
upholds the Plans decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record
Section 5 Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay
but no additional copay for laboratory tests and xrays Within the service area house calls will be
provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a
10 copay for a doctors house call nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including wellbaby care and periodic checkups
Mammograms are covered as follows the office visit copay is waived for mammograms for
women age 35 through 39 one baseline mammogram during these five years for women age 40
through 49 one mammogram every two years or more frequently if recommended by a
provider One mammogram for women 50 and older every year or whenever medically
necessary as ordered by a plan provider In addition to routine screening mammograms are
covered when prescribed by a plan provider as medically necessary to diagnose or treat your
illness
Routine immunizations and boosters copay waived
Consultations by specialists
Diagnostic procedures such as laboratory tests and Xrays copay waived
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48
hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be
extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits
will not be provided after coverage under the Plan has ended Ordinary nursery care of the
newborn child during the covered portion of the mothers hospital confinement for maternity will
be covered under either a Self Only or Self and Family enrollment other care of an infant who
requires definitive treatment will be covered only if the infant is covered under a Self and
Family enrollment
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Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
the office visit copay for allergy injections will be waived
The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of
the devices are covered except for cochlear devices
Cornea heart heartlung single and double lung pancreas kidney and liver transplants
allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic or
nonlymphocytic leukemia advanced Hodgkins lymphoma advanced nonHodgkins lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and
testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered
when approved by the Plans medical director Related medical and hospital expenses of the
donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis copay waived
Chemotherapy radiation therapy and inhalation therapy stays will be extended if medically
necessary
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need copay waived
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers at no additional cost to you
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of
fractures and excision of tumors and cysts All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered including any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the members appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her
attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance
Shortterm rehabilitative therapy physical speech and occupational is provided on an inpatient
or outpatient basis for up to two months per condition if significant improvement can be expected
within two months you pay a 10 copay per outpatient session Speech therapy is limited to
treatment of certain speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain selfcare and improved functioning in other
activities of daily living
Diagnosis and treatment of infertility is covered you pay 50 of charges The following types of
artificial insemination are covered intracervical ICI intrauterine IUI you pay 50 of charges
The cost of donor sperm is not covered fertility drugs are not covered Other assisted reproductive
technology ART procedures that enable a woman with otherwise untreatable infertility to become
pregnant through other artificial conception procedures such as in vitro fertilization and embryo
10 transfer are not covered
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Durable medical equipment such as wheelchairs and hospital beds orthopedic devices such as
braces and prosthetic devices such as artificial limbs breast prostheses and surgical bras and
external lenses following cataract removal are covered for the initial piece only Adjustments
repairs duplicates or replacements are not covered You pay nothing
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided for a 60 consecutive day period if significant improvement can be expected you pay a
10 copay per outpatient session
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgicallyinduced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Longterm rehabilitative therapy
Chiropractic services see Non FEHB Benefits
Foot orthotics
Homemaker services
Hospital Extended Care Benefit
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
Hospital care including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year in
conjunction with care in a hospice facility when fulltime skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan Each day of skilled nursing care will reduce the number of days
available under hospice care You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in a hospice facility in
conjunction with care in a skilled nursing facility Care in a hospice facility is available for up to
100 days per calendar year Each day of inpatient hospice care will reduce the number of days
available under Extended care Services include inpatient care and family counseling these services
are provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness with a life expectancy of approximately six months or less
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Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
Inpatient dental hospitalization but not the cost of the professional dental services Conditions for which
procedures hospitalization would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 14 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially lifethreatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies
Service Area if you are unable to contact your doctor contact the local emergency system eg the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency
room personnel that you are a Plan member so they can notify the Plan You or a family member
should notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been
timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in nonPlan facilities and Plan doctors believe care can be better
provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full
Benefits are available for care from nonPlan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any followup care recommended by nonPlan providers must be
approved by the Plan or provided by the Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 25 per hospital emergency room visit or 10 per urgent care center visit for emergency services
that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
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Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the Service Area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan doctor believes care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any followup care recommended by nonPlan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 25 per hospital emergency room visit for emergency services that are covered benefits of this Plan
If the emergency results in admission to a hospital the emergency care copay is waived
What is covered Emergency care at a doctors office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service if approved by the Plan
What is not Elective care or nonemergency care
covered Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal fullterm delivery of a baby outside the
service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care
nonPlan providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along
with an explanation of the services and the identification information from your ID card Payment
will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is
denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plans decision you
may request reconsideration in accordance with the disputed claims procedure described on page 7
Mental Conditions Substance Abuse Benefits
Mental Conditions To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
What is covered Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
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The medical management of mental conditions will be covered under the Plans medical and
surgical benefits provisions Related drug costs will be covered under the Plans prescription drug
benefits and any costs for psychological testing or psychotherapy will be covered under the Plans
mental conditions benefits
Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay a 20 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all
charges thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively shortterm treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a
shortterm psychiatric condition
Substance Abuse This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric aspects of substance abuse including alcoholism and drug addiction the
What is covered same as for any other illness or condition Services for the psychiatric aspects are provided in conjunction with the Mental conditions benefit shown above Outpatient visits to Plan providers for
treatment are covered as well as inpatient services necessary for diagnosis and treatment The
Mental conditions benefits visitday limitations are copays that apply to any covered substance
abuse care
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31day or a 100 unit supply whichever is less You pay a 5 copay per
prescription unit or refill for generic formulary drugs a 10 copay for brand formulary drugs and a
30 copay for all nonformulary drugs that are approved by the FDA and not listed as a drug not
covered
The Plan uses formulary that includes generic and preferred name brand drugs Your doctor can ask
for exceptions to the formulary All nonformulary drugs will be automatically authorized by the
Plan if they are approved by the FDA prescribed by a contracted provider at a contracted
pharmacy and not listed as a drug not covered
Members may obtain maintenance prescription medications through the Plans Mail Order Program
Maintenance medications are drugs used on a continual basis for the treatment of chronic health
conditions such as high blood pressure ulcers or diabetes You pay a 10 copay of generic
formulary drugs a 20 copay for brand name formulary drugs and a 60 copay for all non
formulary drugs for a 90day supply of drugs that are approved by the FDA and not listed as a drug
not covered To participate in this program call the Plan at 18887804333
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United HealthCare of Arizona 2000
Members who take prescription medications daily may obtain extended supplies of the drugs from a
participating pharmacy before leaving on vacation by paying the cost of the prescription drug
copayment for each additional month Members with the Prescription Drug Benefit may obtain a
new thirtyone 31 day prescription plus up to a ninetythree 93 day supply of refills at one visit
to a participating pharmacy Members are limited to one 1 extended supply per prescription per
contract year and must pay the number of copayments equal to the supply of the medication Not
all medications are available through the extended supply option For detailed explanation of this
option please call Member Services at 18887804333 Covered medications and accessories
include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs up to a threecycle supply may be obtained at one time with a copay
charge applied to each cycle
Diaphragms limited to one per member per calendar year
Prenatal vitamins that require a prescription
Ostomy supplies
Chemstrips and lancets
Insulin
Disposable needles and syringes needed to inject covered prescribed medication including
insulin
Additional benefits Norplant implants are covered You pay a 200 office visit copay
IUDs are covered You pay a 50 office visit copay
Injectable contraceptive drugs are covered You pay a 10 office visit copay
Cervical caps are covered You pay a 10 copay
Intravenous fluids and medications for home use and some injectable drugs are covered under
Medical and Surgical Benefits
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a nonPlan pharmacy except for outofarea emergencies
Vitamins except for prenatal vitamins and nutritional substances that can be purchased without
a prescription
Medical supplies such as dressings and antiseptics except for ostomy supplies
Contraceptive devices except as shown above
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Fertility drugs
Diabetic supplies except for needles syringes chemstrips and lancets
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United HealthCare of Arizona 2000
Other Benefits
Dental Care Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury not biting or chewing Services
Accidental injury must be received within six months of the date that such injury occurs You pay a 10 copay per
benefit not routine visit
dental care
Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refraction to provide a written lens prescription may be obtained from Plan
What is covered providers once every calendar year You pay a 10 copay per visit
What is not covered Corrective lenses or frames
Eye exercises
NonFEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are
made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles optout
maximum benefits or outofpocket maximums These benefits are not subject to the FEHB disputed claims procedure
Health and wellness benefits are available For more information contact the Plan at 18887804333
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through
Medicare As indicated on page 17 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to
drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later
reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join
this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before
you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your
retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan Contact us
at 18887804333 for information on the Medicare prepaid plan and the cost of that enrollment
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping
your enrollment in this Plans FEHB plan please call 18887804333 for information on the benefits available under the
Medicare HMO
Vision care One eye exam is provided through network ophthalmologists once every calendar year for a 10 copay
Discounts on eyewear are available through contracted providers Please see Vision brochure
Chiropractic services Chiropractic services will be covered through contracted chiropractors The benefit will include
coverage as follows spinal manipulation and chiropractic therapy provided by participating chiropractors for the treatment
of an injury or illness for a 10 copayment per office visit limited to 24 visits per contract year NOT COVERED in this
chiropractic benefit are massage therapy preventivemaintenance care and care for a chronic condition Please see the
Chiropractic brochure and provider listing
Benefits on this page are not part of the FEHB contract
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United HealthCare of Arizona 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by nonPlan providers except for authorized referrals or emergencies see Emergency Benefits or eligible selfreferred
services a women may see her Plan obstetriciangynecologist directly members may utilize benefits for the treatment of mental
conditions or substance abuse directly members may self refer to a Plan ophthalmologist for an annual eye exam
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the
fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a MedicareChoice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
MedicareChoice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a MedicareChoice plan contact your retirement office If you
later want to reenroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the MedicareChoice service area you may re
enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on MedicareChoice plans contact your local Social Security Administration
SSA office or request it from SSA at 18006386833
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
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United HealthCare of Arizona 2000
If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer
we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers compensation We do not cover services that
You need because of a workplacerelated disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for
Section 8 FEHB facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also find
your HMO out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPMs website
wwwopmgov lists the specific types of information that we must make available to you
If you want specific information about us call 18887804333 or write to United HealthCare of
Arizona Member Services 3141 N 3rd Ave Phoenix AZ 85013 You may also contact Member
Services by fax at 16026516174 or visit our website at wwwunitedhealthcareazcom
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United HealthCare of Arizona 2000
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the an informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We dont determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation
of Coverage which is described later in this section
What types of SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are available unmarried dependent children under age 22 including any foster or step children your employing or
for me and my retirement office authorizes coverage for Under certain circumstances you may also get coverage
family for a disabled child 22 years of age or older who is incapable of selfsupport
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the following will have access
claims records to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating andor prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
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United HealthCare of Arizona 2000
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form
cards SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a Your old plans deductible continues until our coverage begins
deductible under my
old plan
Preexisting We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan Your enrollment ends unless you cancel your enrollment or
ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage under your former spouses 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
exspouses employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 7927 which describes TCC and the RI 705 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2percent administrative charge The government
does not share your costs
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United HealthCare of Arizona 2000
You receive another 31day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this
notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within
60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling
in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60day deadline
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not notify
you You must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have
to answer questions about your health and we will not impose a waiting period or limit your
coverage due to preexisting conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
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United HealthCare of Arizona 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 18887804333 or TDD 18005887868 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
2024183300
US 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 they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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Summary of Benefits for United HealthCare of Arizona 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS
Benefits Plan pays provides Page
Inpatient Hospital
care Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care private room and private
nursing care if medically necessary diagnostic tests drugs and medical supplies use of
operating room intensive care and complete maternity care You pay nothing 11
Extended Care All necessary services for up to 100 days per year You pay nothing 11
Mental
Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 13 14
Substance Abuse Covered under Mental Conditions 13 14
Outpatient
care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays complete maternity care You pay a
10 copay per office visit or house call by a doctor 9 10
Home Health
Care All necessary visits by nurses and health aides You pay nothing 10
Mental
Conditions Up to 40 outpatient visits per year You pay a 20 copay per visit 13 14
Substance Abuse Covered under Mental Conditions 13 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You
pay a 25 copay to the hospital for each emergency room visit and any charges for services
that are not covered by this Plan 12 13
Prescription drugs The prescription drugs will be dispensed as follows You pay a 5 copay for generic
formulary drugs a 10 copay for brand formulary drugs and a 30 copay for all
nonformulary drugs approved by the FDA and not listed as a drug not covered 14 15
Vision care One refraction every calendar year You pay a 10 copay per visit 16
Chiropractic Care Up to 24 visits per calendar year at 10 copay visit for an acute condition when
treatment has been authorized 16
Out of pocket limit Copayments and coinsurance are required for a few benefits however after your out ofpocket
expenses reach a maximum of 1,000 per Self Only or 3,000 per Self and Family
enrollment per calendar year covered benefits will be provided at 100 5
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2000 Rate Information for
United HealthCare of Arizona Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Catagory B rates will apply for certain career employees If you are a
career postal employee but not a member of a special postal employment class refer to the catagory definitions
in The Guide to Federal Employees Health Benefits Plans for United States Postal Employees RI 70 2
to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment
classes or associate members of any postal employee organization Such persons not subject to postal rates
must refer to the applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Tucson Southern Arizona
Self Only TD1 54.19 18.06 117.41 39.13 64.12 8.13 64.12 8.13
Self and Family TD2 151.72 50.57 328.73 109.57 179.53 22.76 179.53 22.76
Central Arizona
Self Only 2S1 58.16 19.39 126.02 42.01 68.83 8.72 68.83 8.72
Self and Family 2S2 165.77 55.25 359.16 119.72 196.16 24.86 196.16 24.86
24 24