Pages 1--24 from (1) Pages

Serving All of New Jersey
Enrollment in this plan is limited see page 5 for requirements
AL C OMMITT
I ON A C C R E D I T E D B Y
EE

Enrollment code NAT
FOR

FK1 Self Only CE
FK2 Self and Family

QUAL
I TY ASSUR AN

This plan is accredited by NCQA
See the FEHB Guide
for more information on NCQA

Special Notice AmeriHealth HMO has discontinued serving the State of Delaware Enrollment
code SP has been discontinued Enrollees of AmeriHealth HMO enrolled in code SP must select
another health benefits carrier during the 1999 FEHB Open Season in order to be covered by
health insurance for year 2000

Visit the OPM website at http www opm gov
and
our website at http www amerihealth com

Authorized for distribution by the
United States

Office of
Personnel Federal Employees
Management Health Benefits Program
Retirement and Insurance Services

RI 73 065

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AmeriHealth HMO 2000
Table of Contents

Introduction 3
Plain Language 3
How To Use This Brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How We Change For 2000 4
Section 3 How To Get Benefits 5
Section 4 What To Do If We Deny Your Claim Or Request For Service 7
Section 5 Benefits 9
Section 6 General Exclusions Things We Don t Cover 18
Section 7 Limitations Rules That Affect Your Benefits 18
Section 8 FEHB FACTS 19
Inspector General Advisory Stop Health Care Fraud 22
Summary of Benefits Inside Back Cover
Premiums Back Cover

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AmeriHealth HMO 2000
Introduction
AmeriHealth HMO Inc
1901 Market Street 36th floor
Philadelphia PA 19101 1480

This brochure describes the benefits you can receive from AmeriHealth HMO Inc under its contract CS 1893 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 3 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government s communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical
terms you and other personal pronouns active voice and short sentences

We refer to AmeriHealth HMO Inc as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan s benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don t cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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AmeriHealth HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventive
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pacopayments
and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan s benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician or group of physicians hospital or other
provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when
prescribing any course of treatment

Section 2 How We Change For 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care changes office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until
the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you
may add a brief statement to it If they do not provide you your records call us and we will assist
you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to Your share of AmeriHealth s non postal premium will increase by 70.0 for Self Only or 14.7 this Plan for Self and Family

The copay for a doctor s office visit is now 10 per visit for visits to a primary care doctor and
15 per visit for visits to a specialist doctor Previously the copay was 5 per visit to all Plan
doctors
The copay for a doctor s house call is now 15 per visit Previously the copay was 10 per visit
ammogram screening is now covered once per year for female members of the Plan age 65 and
over Previously mammograms for female members age 65 and over were covered once evertwo
years With this change now all female members of this plan age 40 and over are covered for
one mammogram each year
The annual out of pocket maximum payment for members of this Plan is now 1,000 per
individual and 2,000 per family Previously the annual maximum was 650 per person
The brochure now states that the following are excluded from coverage

1 Charges for completing insurance forms
2 Appetite suppressants
3 Radial keratotomy
4 Customized durable medical equipment

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AmeriHealth HMO 2000
The Plan now provides services for serious mental illnesses Serious mental illnesses are any of
the following biologically based mental illnesses as defined by the American Psychiatric
Association in the most recent edition of the Diagnostic and Statistical Manual DSM
schizophrenia bipolar disorder obsessive compulsive disorder major depressive disorder panic
disorder schizo affective disorder paranoia and other psychotic disorders pervasive
developmental disorder and autism and any other mental illness that is considered to be serious
mental illness by law Outpatient care has a copay of 15 for each covered visit Inpatient care
has no dollar or day limit when you are hospitalized under the care of a Plan doctor This is a
benefit addition to the current Mental Conditions Benefit

Section 3 How To Get Benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our Plan s service area service area is all of New Jersey

Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care
services however as an AmeriHealth HMO member you have access to physician care through a
nationwide network of HMO s in which AmeriHealth HMO participates This nationwide network of
HMO s is one of the largest HMO networks in the country offering coverage in more than 200 U S
cities If you become ill while visiting one of these cities contact the network at 1 800 446 6872
This number is also found on the back of your I D card The network referral coordinator will
schedule an appointment with a network physician in the area from which you are calling No office
visit copayment will be required and you will not need to file a claim form Also your prescription
drug card works in more than 52,000 pharmacies in the U S

If you or a covered family member move outside of our service area you can enroll in another plan
If your dependents live out of the area for example if your child goes to college in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates
in other areas If you or a family member move you do not have to wait until Open Season to change
plans Contact your employing or retirement office

How much do I pafor You must share the cost of some services This is called either a copayment a set dollar amount or services coinsurance a set percentage of charges Please remember you must pay this amount when you

receive services except for an emergency visit which results in an admission to the hospital
After you pay 1,000 in copayments per individual or 2,000 in copayments per family you do not
have to make any further payments for that person for certain services for the rest of the year This is
called a catastrophic limit However copayments for your prescription drugs and dental services do
not count toward these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments since you are responsible for informing us
when you reach the limits

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AmeriHealth HMO 2000
Do I have to submit You normally won t have to submit claims to us unless you receive emergency services from a claims provider who doesn t contract with us If you file a claim please send us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year
you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides mhealth AmeriHealth HMO is an individual practice plan IPP HMO The Plan is comprised of over 29,000 care private practice doctor sites who practice from their own private offices Over 7,900 of these doctors

are participating as primary care doctors A wide range of specialty care is represented throughout the
Plan Inpatient services are provided by 185 hospitals conveniently located throughout the Plan s
service area

The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care doctor to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other providers are covered only when there has been
a referral by the member s primary care doctor except for eye exams dental care and visits to the
OB GYN for preventive care routine maternity or for problems related to gynecological conditions
when medically necessary Non routine care provided by Reproductive Endocrinologists InfertilitSpecialists
and Gynecologic Oncologists continue to require a referral from the primary care
physician Treatment for mental conditions and substance abuse may be obtained directlfrom
Magellan Behavioral Health formerly Green Spring Health Management Services call
800 809 9954

What do I do if Call us We will help you select a new one my primary care

physician leaves the Plan

What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist to go into the hospital will make the necessary hospital arrangements and supervise your care
What do I do First call our customer service department at 800 877 9829 in New Jersey If you are new to the if I m in the hospital FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program
when I join this Plan and are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized
How do I get specialtcare Your primary care physician will arrange your referral to a specialist When you receive a referral from your primary care doctor you must return to the primary care doctor after the consultation All

follow up care must be provided or arranged by the primary care doctor On referrals the primarcare
doctor will give specific instructions to the consultant as to what services are authorized If the
consultant suggests additional services or visits you must first check with your primary care doctor
Do not go to the specialist unless your primary care doctor has arranged for and the plan has issued
an authorization for the referral in advance

If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan Referral to a participating specialist is given at the primary care
doctor s discretion if non Plan specialists or or consultants are required the primary care doctor will
arrange appropriate referrals

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AmeriHealth HMO 2000
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a I am seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when with us you must receive treatment from a specialist who does Generally we will not pay for you to I enroll see a specialist who does not participate with our Plan

What do I do Call your primary care physician who will arrange for you to see another specialist You may receive if my specialist leaves services from your current specialist until we can make arrangements for you to see someone else
the Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
provider leaves the the provider unless the termination is for cause If you are in the second or third trimester of Plan or this Plan pregnancy you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If
you are in your second or third trimester your new plan will pay for the OB GYN care you receive
from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist medical services or recommending follow up care Before giving approval we consider if the service is medicallnecessary

and if it follows generally accepted medical practice
How do you decide if a To establish if a biological medical device drug or procedure is experimental investigative or service is experimental not a technology assessment is performed The results of the assessment provide the basis for the
or investigational determination of the service s status e g medically effective experimental etc Technologassessment is the review and evaluation of available data from multiple sources using industrstandard
criteria to assess the medical effectiveness of the service Sources of data used in technologassessment
include but are not limited to clinical trials position papers or articles published by local
and or nationally accepted medical organizations or peer reviewed journals information supplied bgovernment
agencies as well as regional and national experts and or panels and if applicable
literature supplied by the manufacturer

Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or won t pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review OPM will determine if we correctly applied the terms of our contract when we denied your claim or

a denial request for service

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AmeriHealth HMO 2000
What if I have a serious Call us at 800 877 9829 and we will expedite our review or life threatening
condition and you haven t responded to
my request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM s
care and my condition health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern Time is serious or life Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or
threatening death if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We did not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information

What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are request

1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person s representative They must send a copy of the person s specific written consent with the
review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contract Division III P O Box 436 Washington D C 20044
OPM

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AmeriHealth HMO 2000
What if OPM upholds OPM s decision is final There are no other administrative appeals If OPM agrees with our decision the Plan s denial your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies

What laws Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its apply if I file review on the record that was before OPM when OPM made its decision on your claim You marecover
a lawsuit only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and the Chapter 89 of Title 5 United States Code allows OPM to use the information it collects from you Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the

review process becomes a permanent part of your disputed claims file and is subject to the provisions
of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the
court record

Section 5 Benefits
Medical and Surgical Benefits

What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copafor

visits to a primary doctor or a 15 copay for visits to a specialist doctor but no additional copafor
laboratory tests and X rays You pay a 15 copay per visit for visits to a primary care doctor after
hours Within the service area house calls will be provided if in the judgment of the Plan doctor
such care is necessary and appropriate you pay a 15 copay for a doctor s house call nothing for
home visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care periodic check ups and routine gynecological care
ammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 and over one mammogram every year In addition
to routine screenings mammograms are covered when prescribed by the doctor as medicallnecessary
to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor The 15 office visit copay applies only to the first visit for
obstetrical care The mother at her option may remain in the hospital up to 48 hours after a
regular delivery and 96 hours after caesarean delivery Inpatient stays will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be
provided after coverage under the Plan has ended Ordinary nursery care of the newborn child
during the covered portion of the mother s hospital confinement for maternity will be covered
under either a Self Only or Self and Family enrollment other care of an infant who requires
definitive treatment will be covered only if the infant is covered under a Self and Familenrollment

Voluntary sterilization and family planning service
Diagnosis and treatment of diseases of the eye

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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AmeriHealth HMO 2000
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver lung single or double and pancreas transplants
allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic or
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 Related medical and hospital
expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo masectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therap
Surgical treatment of morbid obesit
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers is provided at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring

within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures
excision of tumors and cysts and extractions of impacted teeth partially or totally covered by bone
All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome Preapproval by the Plan is required

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member s appearance and if the
condition can reasonably be expected to be corrected by such surgery Preapproval by the Plan is
required

A patient and her attending physician may decide whether to have breast reconstruction surgerfollowing
a mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance

Short term rehabilitative therapy pulmonary physical speech and occupational is provided on an
inpatient or outpatient basis for up to 60 consecutive days per condition if significant improvement
can be expected within two months you pay nothing Speech therapy is limited to treatment of
certain speech impairments of organic origin Occupational therapy is limited to services that assist
the member to achieve and maintain self care and improved functioning in other activities of dailliving

Chiropractic services will be provided for up to 60 consecutive days per condition if significant
improvement can be expected in the two month period

Diagnosis and treatment of infertility is covered the following types of artificial insemination
are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine
insemination IUI you pay a 15 copay per visit cost of donor sperm is not covered Non injectable
fertility drugs are covered under the Prescription Drug Benefit Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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AmeriHealth HMO 2000
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided for up to 12 weeks you pay nothing Preapproval by the Plan is required

Orthopedic devices such as braces are covered but are limited to the initial device only
Prosthetic devices such as artificial limbs are covered but are limited to the initial device only
lenses following cataract surgery breast prosthesis and surgical bras as well as their replacement are
covered

Standard durable medical equipment such as wheelchairs and hospital beds are covered but are
limited to the initial device only

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterilit
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives not replaced by the member
Hearing aids
Long term rehabilitation services
Homemaker services
Foot orthotics
Provider s charges for missed appointments or for completing insurance forms
Appetite suppressants
Radial keratotom
Customized durable medical equipment

Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered

including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for up to 180 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medicallappropriate

as determined by a Plan doctor and approved by the Plan You pay nothing All necessarservices
are covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided

under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness
with a life expectancy of approximately six months or less

Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
service Preapproval by the Plan is required unless for emergency

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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AmeriHealth HMO 2000
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is
procedures a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which

hospitalization would be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate

See page 14 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member

Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or

surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if the service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone

system or go to the nearest hospital emergency room
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

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay 35 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care
copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because the service area of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working dafollowing
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

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AmeriHealth HMO 2000
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 35 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergecny care
copay is waived
What is covered Emergency care at a doctor s office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services

Ambulance service approved by the Plan
Prescription drugs related to covered services for emergency or urgent care obtained outside the
Plan s service area see the Prescription Drug Benefit on page 14

What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen

before leaving the service area
edical and hospital costs resulting from a normal full term delivery of a baby outside the
service area

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers
upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
you are required to pay for the services submit itemized bills and your receipts to the Plan along with
an explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If
it is denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan s decision you
may request reconsideration in accordance with the disputed claims procedure described on page 6

Mental Conditions Substance Abuse Benefits
Treatment for mental conditions including serious mental illness and substance is coordinated by Magellan Behavioral Health
formerly Green Spring Health Services or other behavioral health administrator designated by the Plan Magellan Behavioral
Health acting as behavioral health administrator for AmeriHealth HMO Inc manages all care related to mental health and substance
abuse services Questions about related benefits and pre certification should be addressed to Magellan Behavioral Health at
1 800 809 9954

Mental conditions What is a serious A serious mental illness is any of the following biologically based mental illnesses as defined by the
mental illness American Psychiatric Association in the most recent edition of the Diagnostic and Statistical Manual DSM schizophrenia bipolar disorder obsessive compulsive disorder major depressive disorder
panic disorder paranoia and psychotic disorders pervasive developmental disorder and autism
schizo affective disorder and any other mental illness that is considered to be serious mental illness
by law

What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness serious mental
illness or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care For other than serious mental illness services up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 25 copay for each covered visit all

charges thereafter For serious mental illness services you pay a 15 copay for each covered visit
There is no visit limit

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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AmeriHealth HMO 2000
Inpatient care For other than serious mental illness services up to 35 days of hospitalization each calendar year you pay nothing for the first 35 days all charges thereafter Inpatient days may be exchanged on a
1 for 2 basis for additional outpatient mental health visits For serious mental illness services there is
no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition

Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the
What is covered medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other illness or condition and to the extent shown below the services necessary for

diagnosis and treatment
Outpatient care Up to 60 full visits per calendar year subject to a lifetime maximum of 120 full visits You pay a 15 copay for each visit

Residential Up to 30 days per calendar year in a residential alcohol and or drug treatment rehabilitation center
Rehabilitation approved by the Plan subject to a lifetime maximum of 90 days Based on medical necessity members may receive up to 15 additional substance abuse days per calendar year by exchanging antwo

available outpatient substance abuse visits for one inpatient treatment facility day You pay
nothing during the benefit period all charges thereafter

Detoxification Outpatient and inpatient treatment is provided for up to seven days per episode subject to a lifetime
services benefit maximum of four episodes
What is not covered Treatment that is not authorized by the mental health and substance abuse vendor

Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply or 120 unit supply or maximum allowed dosage as prescribed blaw

whichever is less You pay a 5 copay per prescription unit or refill
MAINTENANCE DRUGS Up to a 90 day supply of maintenance medications may be purchased at
a participating pharmacy you pay a 15 copay per 90 day supply Refills will be dispensed only if
75 of the previously dispensed quantity has been consumed

DRUG FORMULARY Drugs are dispensed in accordance with the Plan s drug formulary Non
formulary drugs will be covered when prescribed by a Plan doctor This Plan s formulary is a list of
select FDA approved drugs that the Plan has researched and found to be safe effective and help
contain costs Each medication is reviewed based on the drug s efficacy safety profile and cost The
Plan s Pharmacy and Therapeutics Committee ensures the formulary promotes rational therapeutic
alternatives the appropriate use of generics and discourages the unnecessary use of high cost
alternatives

MAIL ORDER A Mail Order program is available for up to a 90 day supply of maintenance
medications You pay a 5 copay per 90 day supply

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs up to a three cycle supply may be obtained for a single
copay charge

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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AmeriHealth HMO 2000
Contraceptive devices such as diaphragms and IUDs you pay a 5 copay for the device and a
15 copay for the office visit
Implanted time release medications such as Norplant You pay a 5 copay for the implant and a
15 copay for the office visit There is no charge when the device is implanted during a covered
hospitalization Removal of the implanted time release medication before the end of the expected
life is not covered unless medically necessary and approved by the Plan
Insulin with a copay charge applied to each vial
Diabetic supplies including syringes needles glucose test tablets and test tape Benedict s
solution or equivalent and acetone test tablets and glucometers
Disposable needles and syringes needed to inject covered prescribed medication
Prenatal and pediatric vitamins
Non injectable fertility drugs
Intravenous fluids and medication for home use provided under home health services at no
charge and some covered injectable drugs are covered under Medical and Surgical Benefits

Limited benefits Drugs from a non participating pharmacy Covered drugs or supplies furnished by a non participating pharmacy are covered when you submit acceptable proof of payment with a direct reimbursement

form Reimbursement for covered drugs or supplies will not exceed 100 of the usual and customarcharge
less the drug copay You will be entitled to reimbursement only if your purchase is related to
covered services for emergency care or urgent care obtained outside of the Plan s service area All
claims for payment must be received within 90 days of the date of purchase Direct reimbursement
forms may be obtained by contacting the Plan s Member Service Department

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies

Vitamins and nutritional substances that can be purchased without a prescription
edical supplies such as dressings and antiseptics
Injectable fertility drugs
Contraceptive devices except diaphragms and IUDs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation

Other Benefits
Dental care
What is covered The following dental services are covered when provided by participating Plan general dentists You pay a 5 copay per office visit

Preventive services Oral examination and diagnosis limited to once in 6 months prophylaxis teeth cleaning to include scaling and polishing limited to once in six months topical fluoride includes child and adult oral
hygiene instruction
Diagnostic services Complete series x rays intraoral occlusal film bitewings limited to once in 6 months emergencexaminations
panoramic film cephalometric film

Restorative Amalgam silver restoration to primary and permanent teeth anterior and posterior composite restoration to primary and permanent teeth pin restoration sedative restoration per tooth

emergency treatment palliative
Out of area The program will reimburse member for dental services in connection with dental emergencies dental services requiring palliative treatment relieve pain when the member is 50 miles or more from the member s

Primary Dental Office up to a maximum of 50 for each occurrence less the 5 copay
To receive payment for Out of Area Dental Services the member must submit a receipt to
AmeriHealth HMO Member Services The receipt must itemize charges and dental services
performed

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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AmeriHealth HMO 2000
Accidental injurbenefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth
The need for these services must result from an accidental injury You pay a 15 copay per visit
What is not Other dental services not shown as covered covered

Vision care
What is covered In addition to the Medical and Surgical Benefits provided for diagnosis and treatment of diseases of the eye one eye refraction every two calendar years to provide a written lens prescription may be

obtained from Plan providers Call Customer Service at 888 393 2583 for information on Plan
providers You pay a 15 copay per visit

What is not Corrective lenses or frames covered Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Non FEHB Benefits Available to Plan Members

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AmeriHealth HMO 2000
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums
These benefits are not subject to the FEHB disputed claims procedure

AmeriHealth HMO also offers members these Distinct Enhancement Opportunities
Weight Management Reimbursement AmeriHealth HMO s Weight Management Reimbursement program gives you the option of participating in any weight management program offered by an AmeriHealth network hospital or Weight
Watchers 100 reimbursement of all fees up to 200 when you reach and maintain goal weight
New Fitness Reimbursement Program To give members added incentive to maintain an active lifestyle we will reimburse members up to 150 of their annual fitness club fees Members can now enjoy the flexibility of joining anfitness
club and working out at multiple fitness clubs Visits can be recorded by swipe card computer printout telephone or
logbook

Smoking Cessation If you smoke quitting is one of the best things you can do for your health Better yet when you kick the habit we ll help foot the bill You can get up to 200 back when you complete your choice of a variety of proven
smoking cessation programs And to give you even more incentive we now will reimburse you the costs of nicotine replacement
products If you choose a smoking cessation program that costs less than 200 you use the difference toward the purchase of
nicotine replacement products such as the patch or chewing gum

Vision Care Up to a 35 allowance for eyeglasses or contact lenses every 2 calendar years members maximize their benefit by using participating providers

Baby FootSteps Program AmeriHealth HMO members can receive educational materials and free gifts for you and your baby in our prenatal program Plus you can receive a 100 reimbursement up to 40 of the cost of a childbirth class
Mother s Option AmeriHealth HMO pregnant mothers have the option of a 24 or 48 hour length of stay for a normal delivery and a 3 or 4 day length of stay for a cesarean delivery If member opts for a 24 hour stay for a normal delivery the
mother will receive 2 home care visits If member opts for a 3 day stay for a cesarean delivery the mother will receive 1 home
care visit

Child Safety Offers tips on how to reduce children s risk for household accidents such as burns injuries from firearms choking and accidental poisonings Our newly enhanced Child Safety brochure includes a child identification record Mr Yuk
stickers to place on poisonous substances tips for safe bicycling and more
American Red Cross CPR and First Aid Course Discounts AmeriHealth HMO members can receive 30 off any course offered by the American Red Cross

Alternative Health Discounts In response to our members interest in alternative health services we developed our Alternative Health Directory which includes a list of practitioners who offer members up to 40 percent discounts on
acupuncture massage therapy and nutritional counseling
Medicare Prepaid Plan Enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 18 annuitants and former spouses with FEHB coverage and Medicare Part B may elect
to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may than later re
enroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this
Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before you join
the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for
information on changing your FEHB enrollment Contact us at 1 800 898 3492 for information on Plan benefits under the
Medicare plan and the cost of that enrollment If you are Medicare eligible and are interested in enrolling in a Medicare HMO
sponsored by this Plan without dropping your enrollment in this Plan s FEHB plan call 1 800 898 3492 for information on the
benefits available under the Medicare HMO

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT

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AmeriHealth HMO 2000
Section 6 General Exclusions Things We Don t Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you
later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re
enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan
offered by this Plan see page 17

Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage coverage You must tell us if you or a family member has double coverage You must also send us documents

about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan
is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we
may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage

Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control
provide them In that case we will make all reasonable efforts to provide you with necessary care

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AmeriHealth HMO 2000
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the

primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies
indirectly pays for

If you have a If you have a malpractice claim because of services you did or did not receive from a Plan provider it malpractice claim must go to binding arbitration Contact us about how to begin our binding arbitration process

Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right information about to information about your health plan its networks providers and facilities You can also find out
your HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM s website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 877 9829 or write to AmeriHealth HMO
Inc P O Box 41574 Philadelphia PA 19101 1574 You may also visit our website at
www amerihealth com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an

enrolling informed decision about in the FEHB
When you may change your enrollment Program
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment

We 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

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AmeriHealth HMO 2000
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled retire
in the FEHB Program for the last five years of your Federal service If you do not meet this
requirement you may be eligible for other forms of coverage such as Temporary Continuation of
Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are available
unmarried dependent children under age 22 including any foster or step children your employing or for my family and me
retirement office authorizes coverage for Under certain circumstances you may also get coverage for
a disabled child 22 years of age or older who is incapable of self support which is also authorized byour
employing or retirement office

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove familmembers
from your coverage for any reason including divorce No new enrollment form is
necessary

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled
in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access claims records to it

confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form
SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter

What if I paid a Your old plan s deductible continues until our coverage begins deductible under mold

plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you
enrolled in this Plan solely because you had the condition before you enrolled

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AmeriHealth HMO 2000
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits under coverage your former spouse s enrollment But you may be eligible for your own FEHB coverage under the

spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse s
employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you

can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not
elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

Key points You can pick a new plan about TCC If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within
60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will than send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline

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AmeriHealth HMO 2000
How can I convert to You may convert to an individual policy if individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
pay your premium you cannot convert
You decided not to elect or receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health

Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 877 9829 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300

U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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AmeriHealth HMO 2000
Summary of Benefits for AmeriHealth 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of
this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or da care limit Includes in hospital doctor care room and board general nursing
care private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 11
Extended Care All necessary services up to 180 days per calendar year You pay nothing 11

Mental Diagnosis and treatment of acute psychiatric conditions for up to 1 35 days Conditions for other than serious mental illnesses 2 no day limit for serious mental
illnesses You pay nothing 14
Substance Abuse Up to 30 days per calendar year in a residential alcohol drug treatment rehabilitation center subject to a lifetime maximum of 90 days You pa

nothing 14
Outpatient Comprehensive range of services such as diagnosis and treatment of illness care or injury including specialist s care preventive care including well babcare

periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit to a
primary care doctor or a 15 copay per office visit for specialty care 15 per house call by a doctor 9

Home Health Care All necessary visits by nurses and health aides You pay nothing 9
Mental Up to 20 outpatient days per year for other than serious mental illnesses Conditions You pay a 25 copay per visit For serious mental illnesses you pay a 15

copay per visit There is no visit limit 13
Substance Abuse Up to 60 full visits per calendar year to Plan mental health providers for follow up care and counseling subject to a lifetime maximum of

of 120 visits You pay a 15 copay per visit 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 35 copay to the hospital for each

emergency room visit and any charges for services that are not covered by this Plan 12

Prescription drugs Drugs prescribed by any doctor and obtained at a participating pharmacy You pay a 5 copay per prescription unit or refill A Mail Order program is
available for up to a 90 day supply of maintenance medications You pa a 5 copay per 90 day supply 14

Dental care Accidental injury benefit you pay a 15 copay per visit Preventive Diagnostic and Restorative dental care you pay a 5 copay per visit 15
Vision care Refractions once every two years You pay a 15 copay per visit 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per person or 2,000

per family per calendar year covered benefits will be provided at 100 This copay maximum does not include prescription drugs or
dental services 5

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AmeriHealth HMO 2000
Authorized for distribution by the
United States Office of
Personnel Management

2000 Rate Information for
AmeriHealth HMO Inc

FEHB Benefits of this Plan are described in brochure 73 65
The 2000 rates for this Plan follow Non Postal rates apply to most non Postal enrollees If you are in a special
enrollment category refer to an FEHB Guide or contact the agency that maintains your health benefits enrollment
Postal rates apply to all USPS career employees and do not apply to non career Postal employees Postal
retirees or associate members of any Postal employees organization

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Self Only FK1 78.83 59.25 170.80 128.37 93.06 45.02 93.26 44.82
Self and Family FK2 175.97 130.68 381.27 283.14 207.74 98.91 201.02 105.63

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