Coventry Health Care of Louisiana Formerly Maxicare Louisiana http:// www. chcla. com
2002
Serving: The New Orleans, Slidell and Baton Rouge area
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 6 for requirements.
Enrollment
codes for this Plan:
Baton Rouge area JA1 Self Only
JA2 Self and Family
New Orleans area BJ1 Self Only
BJ2 Self and Family
Special Notice: Effective contract year 2002 Coventry Health Care of
Louisiana split their service and enrollment are into two rating areas.
Enrollment code BJ is
assigned to the New Orleans service and enrollment
area. Enrollment code JA is assigned to the Baton Rouge service and enrollment.
During the 2001 Open Season
Federal subscribers in the current code JA that
reside in the parishes in the New Orleans service and enrollment area must
make a positive election to enroll in the new enrollment code BJ.
For changes in benefits,
See page 7.
A Health Maintenance Organization
RI 73-244 1
1 Page
2 3
2002 Coventry Healthcare of
Louisiana 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….
............................................................... 4
Plain
Language………………………………………………………………...............................................................
4
Inspector General Advisory
...........................................................................................................................................
4
Section 1. Facts about this HMO plan
..........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Your
Rights..................................................................................................................................................
6
Service
Area.................................................................................................................................................
6
Section 2. How we change for
2002………………………………………..................................................................
7
Changes to this
Plan.....................................................................................................................................
7
Section 3. How you get care …………...
.....................................................................................................................
9
Identification
cards.......................................................................................................................................
9
Where you get covered
care.........................................................................................................................
9
Plan
providers........................................................................................................................................
9
Plan facilities
.........................................................................................................................................
9
What you must do to get covered care
.........................................................................................................
9
Primary
care...........................................................................................................................................
9
Specialty
care.........................................................................................................................................
9
Hospital care
........................................................................................................................................
10
Circumstances beyond our
control.............................................................................................................
10
Services requiring our prior approval
........................................................................................................
10
Section 4. Your costs for covered services
.................................................................................................................
11
Copayments
.........................................................................................................................................
11
Deductible............................................................................................................................................
11
Coinsurance
.........................................................................................................................................
11
Your out-of-pocket
maximum....................................................................................................................
11
Section 5.
Benefits…………………………………………………………...............................................................
12
Overview....................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals ........... 13
(b) Surgical and anesthesia services
provided by physicians and other health care professionals........ 20
(c)
Services provided by a hospital or other facility, and ambulance
services...................................... 23
(d) Emergency services/
accidents
.........................................................................................................
26
(e) Mental health and substance abuse benefits
....................................................................................
28
(f) Prescription drug
benefits................................................................................................................
30
(g) Special
Features...............................................................................................................................
32
(h) Non-FEHB benefits available to Plan
members..............................................................................
33
Section 6. General exclusions --things we don't
cover..............................................................................................
34 2
2 Page 3 4
2002 Coventry Health Care of Louisiana, Inc. 3 Table
of Contents
Section 7. Filing a claim for covered
services............................................................................................................
35
Section 8. The disputed claims
process......................................................................................................................
36
Section 9. Coordinating benefits with other
coverage................................................................................................
38
When you have…
Other health coverage
........................................................................................................................
38
Original Medicare
..............................................................................................................................
38
Medicare managed care
plan..............................................................................................................
40
TRICARE/ Workers'Compensation/ Medicaid
...........................................................................................
40
Other Government agencies
......................................................................................................................
41
When others are responsible for
injuries...................................................................................................
41
Section 10. Definitions of terms we use in this
brochure...........................................................................................
42
Section 11. FEHB
facts..............................................................................................................................................
43
Coverage
information................................................................................................................................
43
No pre-existing condition limitation
..................................................................................................
43
Where you get information about enrolling in the FEHB Program
................................................... 43
Types of coverage
available for you and your
family........................................................................
43
When benefits and premiums start
.....................................................................................................
44
Your medical and claims records are confidential
............................................................................. 44
When you
retire..................................................................................................................................
44
When you lose benefits .....................................Could not
acquire words on page 4
........................................................................................
44
When FEHB coverage ends
...............................................................................................................
44
Spouse equity
coverage......................................................................................................................
44
Temporary Continuation of Coverage (TCC)
....................................................................................
44
Converting to individual coverage
.....................................................................................................
45
Getting a Certificate of Group Health Plan
Coverage........................................................................
45
Long term care insurance is coming later in 2002
......................................................................................................
46
Department of Defense/ FEHB Demonstration Project
...............................................................................................
47
Notes
...........................................................................................................................................................................
49
Index
...........................................................................................................................................................................
50
Summary of benefits
...................................................................................................................................................
51
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
4 Page 5 6
2002 Coventry Healthcare of Louisiana 5 Section 1
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300 The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
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.
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from
non-Plan providers, you may have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain
under contract with us.
How we pay providers
We contract with
individual physicians, medical groups, and hospitals to provide the benefits in
this brochure. These Plan providers accept a negotiated payment from us, and you
will only be responsible for your copayments or
coinsurance.
If you have
any questions regarding choosing a doctor, please call our Member Services
Department at 800/ 341-6613.
The Plan's provider directory lists primary
care doctors (generally family practitioners, pediatricians, and internists)
with their locations and phone numbers, and notes whether or not the doctor is
accepting new patients. Directories are
updated on a regular basis and are
available at the time of enrollment or upon request by calling the Member
Services Department at 800/ 341-6613; you can also find out if your doctor
participates with this Plan by calling this number. If
you are interested in
receiving care from a specific provider who is listed in the directory, call the
provider to verify that he or she still participates with the Plan and is
accepting new patients. Important note: When you enroll in this
Plan,
services (except for emergency benefits) are provided through the Plan's
delivery system; the continued availability and/ or participation of any one
doctor, hospital, or other provider, cannot be guaranteed.
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. 5
5 Page 6 7
2002 Coventry Healthcare of Louisiana 6 Section 1
Your Rights
OPM requires that all FEHB Plans provide certain information to their
FEHB members. You may get information about us, our networks, providers, and
facilities. OPM's FEHB website (www. opm. gov/
insure) lists the specific types
of information that we must make
available to you. Some of the required information is listed below.
Coventry Health Care is a Federally qualified health maintenance
organization (HMO) Profit status – For profit
If you want more information about us, call 800/ 341-6613, or write to
Coventry Health Care of Louisiana, Inc., 2424 Edenborn Ave., Suite 350,
Metairie, LA 70001. You may also contact us by fax at 504/ 834-2694.
Service Area
To enroll with us, you must live or work in our
service area. This is where our providers practice. New Orleans service area:
Jefferson, Orleans, Plaquemines, St. Bernard, St. Charles and St. Tammany.
Baton Rouge service area: Ascension, Livington, St. John the Baptist, East
Baton Rouge, West Baton Rouge, Assumption, East Feliciana, Iberville, Lafayette,
Pointe Coupee, St. Helena, St. James, Tangipahoa, Vermillion, West
Feliciana
and Washington.
Ordinarily, you must get your care from providers who
contract with us. If you receive care outside our service area, we will pay only
for emergency care benefits. We will not pay for any other health care services
out of our service
area unless the services have prior plan approval.
If
you or a covered family member move outside of our service area, you can enroll
in another plan. If your dependents live out of the area (for example, if your
child goes to college in another state), you should consider
enrolling in a
fee-for-service plan or an HMO that has agreements with affiliates in other
areas. If you or a family member move, you do not have to wait until Open Season
to change plans. Contact your employing or retirement
office. 6
6 Page 7 8
2002 Coventry Health Care of Louisiana, Inc. 7
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout this brochure; any language change not shown here is a
clarification that does not change benefits.
Changes to this Plan
Your share of the non-Postal premium for Enrollment Code JA will increase by
55% for Self Only or 62. 1% for Self and Family, and for the Enrollment Code BJ
the percentage increase/ decrease is N/ A.
The plan will be split the current service and enrollment area into two
rating areas; New Orleans, and Baton Rouge. See page 6.
The physician office
visit copay will increase from $10 to $15 per visit.
Lab and x-rays provided
during office visits are now covered at no charge. Previously, lab and x-rays
were covered at $2 copay.
Durable medical equipment is covered at no charge up to a $1,000 maximum per
calendar year. Previously, durable medical equipment was covered at 20% of
charges up to a $750 maximum per
calendar year.
Prosthetic devices are covered at no charge up to a $1,000 maximum per
calendar year. Previously, prosthetic devices were covered at 50% of charges.
Allergy testing is now covered at 50% of charges. Previously, allergy testing
was covered at $10 copay.
Short-term rehabilitative therapies (physical,
speech and occupational) are now covered at 20% of charges. Previously,
short-term rehabilitative therapies (physical, speech and occupational) were
covered
at $10 copay.
Inpatient hospitalization is now covered at a $100
copay per day up to a $300 maximum per admission. Previously, inpatient
hospitalization was covered at nothing.
Outpatient surgery is now covered at a $50 copay. Previously, outpatient
surgery was covered at nothing.
Emergency room visits at a hospital (within
or outside the service area) is now covered at $50 copay per visit. Previously,
emergency room visits at a hospital (within or outside the service area) were
covered at
50% of charges up to $50 copay.
Emergency services at an
urgent care center are now covered at $50 copay per visit. Previously, emergency
services at an urgent care center are now covered at $25 copay per visit.
Ambulance services are now covered at $50 copay. Previously, ambulance
services were covered at $25 copay.
Prescription drugs benefit is now
covered at a $10 for generic, $20 for brand name, $45 for non-formulary.
Previously, prescription drugs benefit was covered at $7 for generic, $15 for
brand name, $25
for non-formulary.
Chiropractic care is now covered at
$15 copay per visit. Previously, chiropractic care was not a covered.
Tubal
ligations are now covered at a $100 copay. Previously, tubal ligations were
covered at a $200 copay.
The out-of-pocket maximum copayments have changed to $1,000 from $1,500 per
person.
We no longer limit total blood cholesterol tests to certain age
groups. (Section 5( a)) 7
7 Page
8 9
2002 Coventry Health Care of
Louisiana, Inc. 8 Section 2
We increased speech therapy benefits by
removing the requirement that services must be required to restore functional
speech. (Section 5( a)).
We now cover certain intestinal transplants.
(Section 5( f)).
We changed the address for sending disputed claims to OPM.
8
8 Page 9 10
2002 Coventry Health Care of Louisiana, Inc. 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 800/ 341-
6613.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, deductibles, and/ or
coinsurance, and you will not have
to file claims.
Plan providers
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. This list is also on our website at www. chcla. com.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. This list is also on our website at www. chcla. com.
What you must do to get It depends on the type of care you need.
covered care
Primary care Coventry does not require you to select a primary care
physician
Specialty care You may see any specialist in the network
without a referral.
Here are other things you should know about specialty care:
If you are
under treatment for an acute episode of care and lose access to your specialist
because we:
terminate our contract with your specialist for other than cause;
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 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. 9
9 Page
10 11
2002 Coventry Health Care of
Louisiana, Inc. 10 Section 3
Hospital care Your provider will
make necessary hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of
facility.
If you are in
the hospital when your enrollment in our Plan begins, call our customer service
department immediately at 800/ 341-6613. 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 For certain services your physician must obtain
approval from us. Before prior approval giving approval, we consider if
the service is covered, medically
necessary, and follows generally accepted
medical practice.
We call this review and approval process prior
authorization. Your physician must obtain prior authorization for the following
services:
institution services such as a hospital stay.
Your physician
must get the Plan's approval before sending you to a hospital, or recommended
follow-up care. Before giving approval, we
consider if the service is
medically necessary, and if it follows generally accepted medical practice.
If you obtain services from a specialist, hospital or other health care
provider, the services will be covered only if medically necessary and
authorized, except in the case of emergency medical services and urgent
care. Certain services, such as inpatient hospital services, outpatient
surgeries/ treatments, skilled nursing facilities, home health services,
durable medical equipment, certain diagnostic tests and subacute care
also
require approval of the utilization review department before the services are
initiated. 10
10 Page
11 12
2002 Coventry Health Care of
Louisiana, Inc. 11 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 $15
per office visit and when you go in the hospital, you
pay $100 per day
(maximum of $300) per admission.
Deductible We do not have a
deductible.
Coinsurance Coinsurance is the percentage of our
negotiated fee that you must pay for your care.
Example: In our plan, you pay 50% of our allowance for infertility services
and allergy testing.
Your catastrophic out-of-pocket maximum for
deductibles, coinsurance
and copayments
After your coinsurance totals $1, 000 per person or $3,
000 per family enrollment in any calendar year, you do not have to pay any more
for
covered services. However, copayments do not count toward your out-of-pocket
maximum, and you must continue to pay copayments for those
services. The
following does apply to your out of pocket:
Allergy testing Infertility
Services
Short Term Therapies 11
11 Page 12 13
2002 Coventry
Health Care of Louisiana, Inc. 12 Section 5
Section 5. Benefits
--OVERVIEW (See page 7 for how our benefits changed this year and page
51 for a benefits summary.)
NOTE: This benefits section is
divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. Also read the General Exclusions in
Section 6; they apply to the benefits in the
following subsections. To
obtain claims forms, claims filing advice, or more information about our
benefits, contact us at 800/ 341-6613 or at our website at www. chcla. com.
(a) Medical services and supplies provided by physicians and other health
care professionals........................... 13-19
Diagnostic and treatment
services Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care Family planning
Infertility
services Allergy care
Treatment therapies Physical and occupational
therapies
Speech therapy Hearing services (testing, treatment, and
supplies) Vision
services (testing, treatment, and
supplies) Foot care
Orthopedic and
prosthetic devices Durable medical equipment (DME)
Home health services
Educational classes and programs
Chiropractic
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 20-22
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
..................................................... 23-25
Inpatient
hospital Outpatient hospital or ambulatory surgical
center
Extended care
benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
........................................................................................................................
26-27 Medical emergency
(e) Mental health and substance abuse benefits
...................................................................................................
28-29
(f) Prescription drug benefits
..................................................................................Could
not acquire words on page 13 ............................................. 30-31
(g) Special Features
....................................................................................................................................................
32
(h) Non-FEHB benefits available to Plan members
...................................................................................................
33
Summary of benefits
....................................................................................................................................................
51 12
12 Page 13
14
13 Page 14 15
2002 Coventry
Health Care of Louisiana, Inc. 14 Section 5
Preventive care, adult
You pay
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
$15 per office visit
Sigmoidoscopy, screening – every five years starting at age 50 $15 per office
visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and
older $15 per office visit
Routine mammogram –covered for women age 35 and
older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$15 per office visit
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages 19 and over (except as provider for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$15 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All Charges
Preventive care, children
Childhood immunizations recommended
by the American Academy of Pediatrics $15 per office visit
Well-child care charges for routine examinations, immunizations and care
under age 22)
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( under age 22)
$15 per office visit 14
14 Page 15 16
2002 Coventry
Health Care of Louisiana, Inc. 15 Section 5
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 27 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.
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).
$15 per office visit
Family planning
A broad range of voluntary family planning
services, limited to:
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Diaphragm (fitting
only)
Note: We cover oral contraceptives under the prescription drug benefit.
$15 per office visit
Elective Sterilization, Male or Female $100 copay
Not covered:
reversal of voluntary surgical sterilization, genetic counseling, or
Intrauterine devices (IUDs)., All charges. 15
15
Page 16 17
2002
Coventry Health Care of Louisiana, Inc. 16 Section 5
Infertility
services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
50% of charges
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote
ZIFT
Zygote transfer
Services and supplies related to excluded
ART procedures
Cost of donor sperm
Cost of donor egg
Fertility
Drugs
All charges.
Allergy care
Testing
Allergy injection and treatments
50%
of charges
$15 per office visit
Allergy serum Nothing
Not covered:
provocative food testing and sublingual allergy desensitization All charges.
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone marrow transplants
are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Oxygen for home use and equipment
Growth hormone therapy (GHT)
Note:
Growth hormone is covered under the prescription drug benefit
$15 per office visit 16
16 Page 17 18
2002 Coventry
Health Care of Louisiana, Inc. 17 Section 5
Physical and occupational
therapies You pay
60 days per condition for the services of each of the
following:
physical therapists and
occupational therapists.
Note: We
only cover therapy to restore bodily function when there has been a total or
partial loss of bodily function due to illness or
injury.
Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 60 days, for
physical therapy
20% of charges
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
60 days from the original onset of accident or
injury 20% of charges
Hearing services
Hearing testing for children through age 17 $15
per office visit
Not covered: hearing aids All charges.
Vision services
Diagnosis and treatment of diseases of the eye $15
per office visit
Prosthetic devices, such as lenses following cataract removal 50% of charges
Not covered:
Eyeglasses or contact lenses or the fitting of
contact lenses
Eye exercises and orthoptics
Radial
keratotomy and other refractive surgery
Annual eye refractions
All charges.
Foot care You pay
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.
$15 per office visit 17
17 Page 18 19
2002 Coventry
Health Care of Louisiana, Inc. 18 Section 5
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.
Orthopedic and prosthetic devices
Artificial limbs and eyes
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
Note: See 5( b) for coverage of the surgery to insert the device.
Orthopedic devices, such as:
Braces
Foot orthotics
Corrective
orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ)
pain dysfunction syndrome.
Nothing up to $1,000 per calendar year
Not covered:
heel pads and heel cups
lumbosacral
supports
corsets, trusses, elastic stockings, support hose, and other
supportive devices
All charges. 18
18 Page 19 20
2002 Coventry
Health Care of Louisiana, Inc. 19 Section 5
Durable medical equipment
(DME) You pay
Rental or purchase, at our option, including repair and
adjustment, of durable medical equipment prescribed by your Plan physician, such
as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose
monitors; and
insulin pumps.
Note: Call us at 800/ 341-6613 as soon as your Plan physician prescribes this
equipment.
Nothing up to $1,000 per calendar year
Not covered:
Motorized wheel chairs
All charges.
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.),
or licensed
vocational nurse (L. V. N.).
Services include oxygen therapy, intravenous
therapy and medications.
Nothing
Not covered: nursing care requested by, or for the convenience of,
the patient or
the patient's family; home care primarily for personal
assistance that does not include a
medical component and is not diagnostic,
therapeutic or rehabilitative .
Nursing aides
All charges.
Chiropractic
Manipulation of the spine and extremities
After initial evaluation, treatment plan must be submitted to Coventry Health
Care to authorize additional visits.
$15 per office visit 19
19 Page 20 21
2002 Coventry Health Care of Louisiana, Inc. 20
Section 5
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. hospital, surgical
center, etc.).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME
SURGICAL PROCEDURES. Please refer to the prior authorization information shown
in Section 3 to be sure
which services require prior authorization and identify which surgeries
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment
of fractures, including casting
Normal pre-and post-operative care by the
surgeon
Endoscopy procedures
Biopsy procedures
Removal of tumors and
cysts
Correction of congenital anomalies (see reconstructive surgery)
Insertion of internal prostethic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
Treatment of burns
$15 per office visit
Surgical procedures You pay
Voluntary family planning $100
copayment
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 20
20 Page 21 22
2002 Coventry
Health Care of Louisiana, Inc. 21 Section 5
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 and cleft palate; birth
marks webbed fingers; and webbed toes.
$15 per office visit
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.
See above.
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to: Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
$15 per office visit
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involved in treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome
All charges. 21
21 Page 22 23
2002 Coventry
Health Care of Louisiana, Inc. 22 Section 5
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/
Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor)
bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants
(small intestine) and the small intestine with the liver or small intestine with
multiple organs such as the liver,
stomach, and pancreas.
Limited
Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian
cancer may be provided in an NCI approved clinical
trial at a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
$15 per office visit
Not covered: Donor screening tests and donor search expenses,
except those
performed for the actual donor
Implants of
artificial organs
Transplants not listed as covered
All charges
Anesthesia You pay
Professional services provided in -
Hospital (inpatient) Nothing
Professional services
Hospital
outpatient department
Skilled nursing facility Ambulatory surgical center
Office
$15 per office visit 22
22 Page 23 24
2002 Coventry
Health Care of Louisiana, Inc. 23 Section 5
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.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services
require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
$100 per day, $300 maximum per admission nothing for other
services 23
23 Page 24 25
2002 Coventry Health Care of Louisiana, Inc. 24
Section 5
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 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 (Note: calendar year deductible applies.)
$100 per day, $300 maximum per admission nothing for other
services
Not covered: Custodial care
Non-covered facilities, such
as nursing homes, schools Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
Blood
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms $50 copayment
Prescribed drugs and medicines Diagnostic laboratory tests, X-rays, and
pathology services
Administration of blood, blood plasma, and other
biologicals 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 24
24 Page
25 26
2002 Coventry Health Care of
Louisiana, Inc. 25 Section 5
Extended care benefits/ skilled nursing
care facility benefits You pay
Comprehensive range of benefits when
full-time skilled nursing care is necessary and confinement in a skilled nursing
facility is in lieu of
hospitalization (for up to 100 days).
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.
Nothing
Not covered: custodial care All charges
Hospice care
Supportive and palliative care
NOTE: We cover care for a terminally
ill member in the home or hospice facility. Services include inpatient and
outpatient care, and
family counseling. 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.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Benefits are provided for ambulance transportation
when ordered or authorized by a Plan doctor $50 copay 25
25 Page 26 27
2002 Coventry Health Care of Louisiana, Inc. 26
Section 5
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 within our service area:
If you are in an emergency situation, contact the local emergency system (e.
g., the 911 telephone system) or go to the nearest hospital emergency room. Be
sure to
tell the emergency room personnel that you are a Plan member so they
can notify the Plan.
If you need to be hospitalized in a non-Plan facility,
the Plan must be notified within 24 hours or on the first working day following
your admission, unless it was not reasonably possible to notify the Plan within
that
time. If you are hospitalized in non-Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital, you will be transferred
when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this
Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must
be notified within 24 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If a Plan doctor
believes care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers. 26
26 Page 27 28
2002 Coventry Health Care of Louisiana, Inc. 27
Section 5
Benefit Description You pay
Emergency within our
service area
Emergency care at a doctor's office $15 per office visit
Emergency care
as an outpatient or inpatient at a hospital, including doctors' services $50
copay per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office $15 per office visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 copay per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Benefits are provided for ambulance transportation when
ordered or authorized by a Plan doctor $50 copay 27
27
Page 28 29
2002
Coventry Health Care of Louisiana, Inc. 28 Section 5
Section 5 (e).
Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for
similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered 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 PRIOR AUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$15 per office visit
Mental health and substance abuse benefits continued on next page. 28
28 Page 29 30
2002 Coventry Health Care of Louisiana, Inc. 29
Section 5
Mental health and substance abuse benefits
(Continued) You pay
Diagnostic tests $15 per office visit
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, half-way house,
residential treatment, full-day hospitalization, facility based intensive
outpatient treatment
We may allow Members to exchange one inpatient day of treatment for four
(4) outpatient visits or exchange four (4) outpatient visits for one inpatient
day of treatment. We may also allow a Member to exchange two (2) days of
Transitional Partial Hospitalization or two (2) days of residential
treatment center hospitalization for each inpatient day of treatment.
$100 per day, $300 maximum per admission. Nothing for
other services.
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Prior authorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all our authorization processes. To receive a
mental health referral, please call 1-800-245-
8327.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 29
29 Page
30 31
2002 Coventry Health Care of
Louisiana, Inc. 30 Section 5
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.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
Who can write your prescription.
A Plan physician must write the prescription.
Where you can obtain
them. You must fill the prescription at a contracted Plan pharmacy or by
mail for maintenance medication.
We use a formulary. We use a committee of doctors, pharmacists and
other health care professionals to develop a formulary that gives you access to
quality medications. FDA-approved
brand-name and generic medications are
reviewed for safety, side effects, effectiveness and overall value. We
continually update the formulary based on the latest research. If your doctor
prescribes a
medication that is not on the list, you can get that
medication, but you will share in a greater portion of the cost.
These are the dispensing limitations. The quantity of each
prescription is limited to that sufficient to treat the acute phase of illness
or a 30-day supply maximum, whichever is less, per copayment.
Prescription drug benefits begin on the next page. 30
30 Page 31 32
2002 Coventry Health Care of Louisiana, Inc. 31
Section 5
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:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as excluded
below.
Insulin
Insulin syringes and medication Disposable needles and syringes for
the administration of covered
medications Drugs for sexual dysfunction (see
Note below)
Contraceptive drugs and devices
Note: Contact the Plan for
drug dose limits for sexual dysfunction.
$10 per generic
$20 per formulary name brand
$45 per non-formulary
Note: If there is no generic equivalent available, you will still
have to
pay the brand name copay.
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, you have to pay the
difference in cost between the name
brand drug and the generic.
We
administer a 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. You must pay a $45 copay for a non-formulary drug. To order a prescription
drug
brochure, call 800/ 341-6613.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
Vitamins and nutritional substances that can be purchased without a
prescription
Nonprescription medicines
All Charges 31
31 Page 32 33
2002 Coventry Health Care of Louisiana, Inc. 32
Section 5
Section 5 (g). Special features
Flexible benefits
option Under the flexible benefits option, we determine the most effective
way to provide services.
We may identify medically appropriate alternatives
to traditional care and coordinate other benefits as a less
costly alternative benefit.
Alternative benefits are subject to our
ongoing review.
By approving an alternative benefit, we cannot guarantee you
will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular
contract benefits.
Our
decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call First Help at 1-800-622-9528 and talk with a
registered nurse who will discuss treatment options and answer your health
questions. 32
32 Page
33 34
2002 Coventry Health Care of
Louisiana, Inc. 33 Section 5
Section 5 (h). Non-FEHB benefits
available to Plan members
The benefits on this page are not part of the
FEHB contract or premium, and you cannot file an FEHB disputed claim about
them. Fees you pay for these services do not count toward FEHB deductibles
or out-of-pocket
maximums.
Vision care You are eligible to receive substantial discounts on eyeglasses,
contact lenses and non-prescription items
such as sunglasses and contact
lens solutions. Please read the flyer that describes your extra Vision Care
benefit.
Dental care You are eligible to receive substantial discounts on dental care,
including diagnostic and preventative, restorative,
crowns, endodontics,
peridontics, prosthodontics and orthodontics. Please read the accompanying flyer
that
describes Dental Care benefits available through this program.
Health Club You are eligible to receive discount memberships from
participating health clubs. 33
33 Page 34 35
2002 Coventry
Health Care of Louisiana, Inc. 34 Section 6
Section 6. General
exclusions --things we don't cover
The exclusions in this section apply
to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary
to prevent, diagnose, or
treat your illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest;
Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 34
34 Page 35 36
35 Page 36 37
2002 Coventry Health Care of Louisiana, Inc. 36
Section 8
Section 8. The disputed claims process
Follow this
Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: CHC Louisiana, Inc., 2424
Edenborn Ave., Suite 350, Metairie, LA 70001; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we
will send you a copy of
our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3610.
36
36 Page 37 38
2002 Coventry Health Care of Louisiana, Inc. 37
Section 8
Send OPM the following information:
A statement about why
you believe our decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 800/ 341-6613 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time.
The Disputed Claims Process, (continued) 37
37
Page 38 39
2002
Coventry Health Care of Louisiana, Inc. 38 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free Part A insurance.
(Someone who was a Federal employee on January
1, 1983 or since
automatically qualifies.) Otherwise, if you are 65 or older, you may be able to
buy it. Contact 1-800-MEDICARE for more
information.
Part B (Medical
Insurance). Most people pay monthly for Part B. Generally, Part B premiums are
withheld from your monthly Social
Security check or your retirement check.
If you are eligible for
Medicare, you may have choices in how you get your health care. Medicare managed
care plan 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 (Part A or Part B) The Original Medicare
Plan (Original Medicare) is available everywhere
in the United States. It is
the way everyone used to get Medicare benefits and is the way most people get
their Medicare Part A and Part B benefits
now. You may go to any doctor,
specialist, or hospital that accepts Medicare. The Original Medicare Plan pays
its share and you pay your
share. Some things are not covered under Original
Medicare, like prescription drugs. 38
38 Page 39 40
2002 Coventry
Health Care of Louisiana, Inc. 39 Section 9
When you are enrolled in
Original Medicare along with this plan, you still need to follow the rules in
this brochure for us to cover your care.
The following chart illustrates
whether the 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 solely because 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, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse
of an active employee 39
39 Page 40 41
2002 Coventry Health Care of Louisiana, Inc. 40 Section 9
Medicare managed care plan If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan – a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary, even out of the managed
care plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments, coinsurance, or
deductibles.
Suspended FEHB coverage to
enroll in a Medicare managed care plan: If you are an annuitant or former
spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed
care plan, eliminating your FEHB premium. (OPM does not contribute to your
Medicare
managed care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season
unless you involuntarily lose coverage or move out of the
Medicare managed
care plan service area.
If you do not enroll in If you do not have
one or both Parts of Medicare, you can still be Medicare Part A or Part B
covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can't get premium-free Part A, we will not ask
you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related injury 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 care. You must use our
providers.
Medicaid When you have this Plan and Medicaid, we pay first. 40
40 Page 41 42
2002 Coventry Health Care of Louisiana, Inc. 41
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 medical
or hospital care for injuries for injuries or illness caused by another
person, you must reimburse us
for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation
procedures. 41
41 Page
42 43
2002 Coventry Health Care of
Louisiana, Inc. 42 Section 10
Section 10. Definitions of terms we use
in this brochure
Calendar year January 1 through December 31 of the same
year. For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we
provide benefits for, as described in this brochure.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 12.
Experimental or A health product or service is deemed experimental or
investigational investigational services and excluded from coverage under
this Agreement if one or more of the
following conditions are met: (i) any
drug not approved for use by the FDA; any drug that is classified as IND
(investigational new drug) by the
FDA; (ii) any drug requiring
pre-authorization that is proposed for off-label prescribing; (iii) any health
product or service that is subject to
Investigational Review Board (IRB)
review or approval; (iv) any health product or service that is subject of a
clinical trial that meets criteria for
Phase I, II or III as set forth by
FDA regulations; or (v) any health product or service that does not have a
demonstrated value based on
clinical evidence reported by peer-review
medical literature and by generally recognized academic experts.
Group health 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. You must arrange for the other coverage
within 63 days of leaving this Plan. Your new plan must reduce or eliminate
waiting periods, limitations or exclusions for health related
conditions
based on the information in the certificate.
If you have been enrolled with
us for less than 12 months, but were previously enrolled in other FEHB plans,
you may request a certificate
from them, as well.
Us/ We Us and we refer to Coventry Health Care of Louisiana, Inc.
You You refers to the enrollee and each covered family member. 42
42 Page 43 44
2002 Coventry Health Care of Louisiana, Inc. 43
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. 43
43 Page
44 45
2002 Coventry Health Care of
Louisiana, Inc. 44 Section 11
When benefits and The benefits in
this brochure are effective on January 1. If you joined premiums start
this Plan during Open Season, your coverage begins on the first day of
your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any other
time
during the year, your employing office will tell you the effective date of
coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only 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.
Temporary continuation of coverage
(TCC) If you leave Federal
service, or if you lose coverage because you no longer qualify as a family
member, you may be eligible for Temporary
Continuation of Coverage (TCC).
For example, you can receive TCC if you are not able to continue your FEHB
enrollment after you retire, if
you lose your job, or if you are a covered
dependent child and you turn 22 or marry, etc. 44
44
Page 45 46
2002 Coventry Health Care of Louisiana, Inc. 45 Section 11
You may
not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees, from your employing or
retirement office or from www. opm. gov/ insure.
It explains what you have
to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity law
ends. (If you canceled your coverage or did not pay your premium, you cannot
convert)
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Health Plan Coverage (HIPPA) is a Federal law
that offers limited Federal protections for
health coverage availability and
continuity to people who lose employer group coverage. If you leave the FEHB
Program, we will give you a
Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this certificate
when getting
health insurance or other health care coverage. Your new plan
must reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as
you enroll within 63 days of losing coverage under this Plan. If you
have
been enrolled with us for less than 12 months, but were previously enrolled in
other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB program. See also the FEHB website
(www. opm. gov/ insure/ health); refer
tot he "TCC and HIPAA" frequently asked question. These highlighted
HIPAA rules, such as the requirement
that Federal employees must exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under
HIPAA, and have information about Federal and State agencies
you can contact for more information. 45
45 Page 46 47
2002 Coventry Health Care of Louisiana, Inc. 46 Long Term Care
Long Term Care Insurance Is Coming Later in 2002!
The
Office of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in October 2002. As part of its educational effort,
OPM asks you to consider these questions:
What is long term care
(LTC) insurance? It's insurance to help pay for long term care services you
may need if you can't take care of yourself because of
an extended illness
or injury, or an age-related disease such as Alzheimer's. LTC insurance can
provide broad, flexible benefits for care in a nursing home, in an assisted
living facility, in
your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
I'm healthy. I won't need long term care. Or, will I? 76% of Americans
believe they will never need long term care, but the facts are that about half
of them will.
And it's not just the old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you will
never need long term care, but you should have a plan just in case. LTC
insurance may be vital to your financial and retirement planning.
Is long term care expensive? Yes. A year in a nursing home can exceed
$50,000 and only three 8-hour shifts a week can exceed $20,000 a
year,
that's before inflation! LTC can easily exhaust your savings but LTC insurance
can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of
your FEHB brochure. Custodial care, assisted
living, or continuing home
health care for activities of daily living are not covered. Limited stays in
skilled nursing facilities can be covered in some circumstances.
Medicare
only covers skilled nursing home care after a hospitalization with a 100 day
limit. Medicaid covers LTC for those who meet their state's guidelines, but
restricts covered services and where they
can be received. LTC insurance can
provide choices of care and preserve your independence.
When will I get
more information? Employees will get more information from their agencies
during the late summer/ early fall of 2002.
Retirees will receive
information at home.
How can I find out more about the program NOW? A
toll-free telephone number will begin in mid-2002. You can learn more about the
program now at
www. opm. gov/
insure/ ltc
Many FEHB enrollees think their health plan and/ or Medicare covers long-term
care. Unfortunately, they are WRONG! How are YOU planning to pay for the
future custodial or chronic care you may need? Consider buying long term care
insurance. 46
46 Page
47 48
2002 Coventry Health Care of
Louisiana, Inc. 47 DoD
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, 2002. 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
When you can join You may enroll under
the FEHB/ DoD Demonstration Project during the 2000 open season, November 12,
2001, through December 10, 2001. Your coverage
will begin January 1, 2002.
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 open season. Your coverage
will begin January 1, 2002.
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. 47
47 Page
48 49
2002 Coventry Health Care of Louisiana, Inc. 48 DoD
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 2002 Guide to Federal Employees Health Benefits Plans Participating in
the DoD/ FEHB Demonstration Project," on the
OPM web site at www. opm. gov.
Temporary Continuation
Of Coverage( TCC) 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. 48
48 Page 49 50
2002 Coventry Health Care of Louisiana, Inc. 49
Notes
Notes: 49
49 Page 50 51
2002 Coventry
Health Care of Louisiana, Inc. 50 Index
Index
Do not rely on
this page; it is for your convenience and may not show all pages where the terms
appear.
Allergy tests 16 Ambulance 25
Anesthesia
22 Autologous bone marrow
transplant 22 Biopsies 20
Blood
and blood plasma 24 Breast cancer 22
Changes for 2001 7
Chiropractic 19
Chemotherapy 16 Claims 35
Coinsurance 11 Congenital anomalies 20
Contraceptive
devices and drugs 31 Crutches 19
Deductible 11 Definitions
42
Dental care 33 Department of Defense 47
Diagnostic services 13 Disputed claims review 36
Donor
expenses (transplants) 22 Dressings 24
Durable medical
equipment (DME) 19
Educational classes and programs 12
Effective date of enrollment 44
Emergency 26 Experimental
or investigational 42
Eyeglasses 17 Family planning 15
General Exclusions 34 Hearing services 17
Home health services 19 Hospice care 25
Home nursing care
19 Hospital 23
Immunizations 14 Infertility 16
Inhospital physician care 23 Inpatient Hospital Benefits 23
Insulin 31 Laboratory and pathological
services 13
Mammograms 14
Medically necessary 10 Medicare 38
Mental Conditions/ Substance Abuse Benefits 28
Newborn care
15 Non-FEHB Benefits 33
Nurse Licensed Practical Nurse 19
Registered Nurse 19 Nursery charges 15
Obstetrical
care 15 Occupational therapy 17
Office visits 13
Oral and maxillofacial surgery 21
Orthopedic devices 18
Out-of-pocket expenses 11
Outpatient facility care 24
Oxygen 26
Pap test 14 Physical examination 13
Physical therapy 17 Physician 13
Precertification 20
Preventive care, adult 14
Preventive care, children 14
Prescription drugs 30
Preventive services 14 Prior
authorization 10
Prosthetic devices 18 Psychologist 28
Radiation therapy 16 Rehabilitation therapies 17
Room
and board 23 Second surgical opinion 13
Skilled nursing
facility care 25 Speech therapy 17
Splints 24
Subrogation 41
Substance abuse 28 Surgery 20
Oral 21 Outpatient 24
Reconstructive 21
Syringes 31
Temporary continuation of coverage 48
Transplants 22 Treatment therapies 16
Vision services
17 Wheelchairs 19
Workers' compensation 40 X-rays 13 50
50 Page 51 52
51 Page 52
2002 Rate Information for Coventry
Health Care of Louisiana, 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 career Postal Service employees.
Most employees should refer to the FEHB Guide for United States Postal Service
Employees, RI 70-2. Different postal rates apply and special FEHB guides are
published for
Postal Service Nurses, RI 70-2B; and for Postal Service
Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Baton Rouge
Self Only JA1 $97.86 $36.38 $212.03 $78.82 $115. 52 $18.72
Self and Family JA2 $223.41 $88.36 $484.06 $191.44 $263. 75 $48.02
New Orleans
Self Only BJ1 $86.63 $28.87 $187.69 $62.56 $102. 51 $12.99
Self and Family BJ2 $201.20 $67.06 $435.92 $145. 31 $238. 08 $30.18 52