Pages 1--57 from AmeriHealth HMO

Serving: All of New Jersey
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
FK1 Self Only FK2 Self and Family

RI 73-065

This Plan has received "Excellent"
accreditation from the NCQA. See the
2001 Guide for more information on
NCQA.

For changes
in benefits
see page 6. 1
1 Page 2 3
2001 AmeriHealth HMO 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………. ............................................................... 4
Plain Language………………………………………………………………............................................................... 4
Section 1. Facts about this HMO plan .......................................................................................................................... 5
How We pay providers ................................................................................................................................ 5
Who provides my health care ...................................................................................................................... 5
Patients' Bill of Rights ................................................................................................................................. 5
Service Area................................................................................................................................................. 6
Outside service area ..................................................................................................................................... 6
Section 2. How We change for 2001………………………………………................................................................. 6
Program-wide changes................................................................................................................................. 6
Changes to this Plan..................................................................................................................................... 6
Section 3. How you get care …………... ..................................................................................................................... 7
Identification cards ...................................................................................................................................... 7
Where you get covered care......................................................................................................................... 7

Plan providers........................................................................................................................................ 7
Plan facilities ......................................................................................................................................... 7
What you must do to get covered care......................................................................................................... 7

Primary care .......................................................................................................................................... 7
Specialty care ........................................................................................................................................ 7
Hospital care.......................................................................................................................................... 8
Circumstances beyond our control............................................................................................................... 9
Services requiring our prior approval .......................................................................................................... 9
Section 4. Your costs for covered services ................................................................................................................. 10

Copayments ..................................................................................................................................... 10
Deductible ....................................................................................................................................... 10
Coinsurance .................................................................................................................................... 10
Your out-of-pocket maximum ................................................................................................................... 10
Section 5. Benefits…………………………………………………………............................................................... 11
Overview.................................................................................................................................................... 11
(a) Medical services and supplies provided by physicians and other health care professionals ........... 12
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 22
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 26
(d) Emergency services/ accidents......................................................................................................... 29
(e) Mental health and substance abuse benefits .................................................................................... 31
(f) Prescription drug benefits ............................................................................................................... 34
(g) Special features ............................................................................................................................... 37
(h) Dental benefits ................................................................................................................................ 38 2
2 Page 3 4
2001 AmeriHealth HMO 3 Table of Contents
(i) Non-FEHB benefits available to Plan members.............................................................................. 40
Section 6. General exclusions --Things We Do Not Cover ...................................................................................... 41
Section 7. Filing a claim for covered services ............................................................................................................ 42
Section 8. The disputed claims process ...................................................................................................................... 43
Section 9. Coordinating benefits with other coverage ................................................................................................ 45
When you have…

Other health coverage ......................................................................................................................... 45
What is Medicare? .............................................................................................................................. 45
The Original Medicare Plan................................................................................................................ 45
Medicare Managed Care Plan............................................................................................................. 47
Enrollment in Medicare Part B ........................................................................................................... 47
TRICARE/ Workers' Compensation/ Medicaid........................................................................................... 47
Other Government agencies....................................................................................................................... 48
When others are responsible for injuries.................................................................................................... 48
Section 10. Definitions of terms we use in this brochure............................................................................................ 49
Section 11. FEHB facts............................................................................................................................................... 50
Coverage information ................................................................................................................................ 50

No pre-existing condition limitation.................................................................................................. 50
Where you get information about enrolling in the FEHB Program................................................... 50
Types of coverage available for you and your family........................................................................ 50
When benefits and premiums start..................................................................................................... 51
Your medical and claims records are confidential ............................................................................. 51
When you retire ................................................................................................................................ 51

When you lose benefits .............................................................................................................................. 51
When FEHB coverage ends ............................................................................................................... 51
Spouse equity coverage .................................................................................................................... 51
Temporary Continuation of Coverage (TCC) ................................................................................... 51
Converting to individual coverage.................................................................................................... 52
Getting a Certificate of Group Health Plan Coverage....................................................................... 52

Inspector General Advisory ......................................................................................................................................... 52
Index ................................................................................................................................................................ 53
Summary of benefits .................................................................................................................................................... 55
2001 Rate Information for AmeriHealth HMO, Inc. .................................................................................... Back cover 3
3 Page 4 5
2001 AmeriHealth HMO 4 Introduction/ Plain Language
Introduction
AmeriHealth HMO, Inc.
1901 Market Street
Philadelphia, PA 19103

This brochure describes the benefits of AmeriHealth HMO, Inc. under our contract (CS 1893) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2001, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 57. Rates are shown at the end of this brochure.

Plain Language
The President and Vice President are making the Government's communication more responsive, accessible, and
understandable to the public by requiring agencies to use plain language. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical
terms, we use common words. "You" means the enrollee or family member; "we" means AmeriHealth HMO, Inc.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan
with other FEHB plans, you will find that the brochures have the same format and similar information to make
comparisons easier.

If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 AmeriHealth HMO 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, 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.

Who provides my health care?
AmeriHealth HMO is an individual practice plan (IPP) HMO. The Plan is comprised of over 29,000 private practice
doctor sites who practice from their own private offices. Over 7,900 of these doctors are participating at 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.

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/ Infertility Specialists, and Gynecologic
Oncologists continue to require a referral from the primary care physician. Treatment for mental conditions and
substance abuse may be obtained directly from Magellan Behavioral Health at 1-800-809-9954. Magellan Behavioral
Health, or any other mental health administrator for AmeriHealth HMO, manages all care related to mental health and
substance abuse services. Magellan Behavioral Health will determine what specialty care is appropriate and which
specialists will be utilized.

Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's
Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you.

If you want more information about us, call 1-800-877-9829, or write to AmeriHealth HMO, Inc., P. O. Box 41574,
Philadelphia, PA 19103. You may also visit our website at www. amerihealth. com. 5
5 Page 6 7
2001 AmeriHealth HMO 6 Section 2
Service Area
To enroll with us, you must live in or work in our service area. This is where our providers practice. Our service area
is the state of New Jersey.

Outside Service Area
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.

Section 2. How We change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to copays, day and visit limitations
when you follow a treatment plan that we approve. Previously, we placed higher patient cost sharing and shorter
day or visit limitations on mental health and substance abuse services than we did on services to treat physical
illness, injury, or disease.

Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our

patient safety activities by calling 1-800-877-9829, or checking our website at www. amerihealth. com . You can
find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take
these five steps:

.Speak up if you have questions or concerns.
Keep a list of all the medicines you take.
Make sure you get the results of any test or procedure.
Talk with your doctor and health care team about your options if you need hospital care.
Make sure you understand what will happen if you need surgery.
We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the

language referenced only women.
Changes to this Plan
Your share of the non-Postal premium will increase by 26. 4% for Self Only or 24. 4% for Self and Family

There are no other changes to the Plan for 2001. 6
6 Page 7 8
2001 AmeriHealth HMO 7 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 1-800-
877-9829.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. The list is also
on our website.

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care. Members are not responsible for payment of
services if the provider does not obtain preauthorization of services.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. 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/ Infertility Specialists, and Gynecologic Oncologists
continues to require a referral from the primary care physician.
Treatment for mental conditions and substance abuse may be obtained
directly from Magellan Behavioral Health at 1-800-809-9954. 7
7 Page 8 9
2001 AmeriHealth HMO 8 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval
beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-877-9829. 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 8
8 Page 9 10
2001 AmeriHealth HMO 9 Section 3
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our prior Your primary care physician has authority to refer you for most approval services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service
is covered, medically necessary, and follows generally accepted
medical practice.
.
We call this review and approval process preauthorization. Your
physician must obtain preauthorization for services such as:

All Non-Emergency Hospital Admissions All Obstetrical Admissions
All Same Day Surgery/ Short Procedure Unit Admissions Outpatient Therapies: Speech, Cardiac, Pulmonary, Respiratory,
Home Infusion
Other Facility Services: Skilled Nursing, Home Health, Hospice, Birthing Center

Rental/ Purchase of Durable Medical Equipment and Prosthesis (purchase over $100.00 and all rentals)
Non-Emergency Ambulance Services Spinal Manipulation Services
Inpatient Psychiatric Care Inpatient Alcohol and Substance Abuse Treatment
Some Medications that have specific uses and are administered in Outpatient Settings or Physician Offices

Your physician must get our approval before sending you to a hospital,
referring you to a specialist, or recommending follow-up care. Before
giving approval, we consider if the service is medically necessary, and if
it follows generally accepted medical practice. Members are not
responsible for payment of services if the provider does not obtain
preauthorization services. 9
9 Page 10 11
2001 AmeriHealth HMO 10 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

Copayments A copayment is a fixed amount of money you pay to the provider when
you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit or a copayment of $15 per office visit to
a specialist.

Deductible We do not have a deductible.

Coinsurance We do not have a coinsurance.

Your out-of-pocket maximum After your copayments total $1,000 per person or $2,000 per family enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for these services:

Prescription drugs Dental services

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 10
10 Page 11 12
2001 AmeriHealth HMO 11 Section 5
Section 5. Benefits --OVERVIEW
(See page 6 for how our benefits changed this year and page 56 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 1-800-877-9829 or at our website at www. amerihealth. com .

(a) Medical services and supplies provided by physicians and other health care professionals................................. 12-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies

Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................. 22-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services........................................................... 27-29

Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents .............................................................................................................................. 30-31
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ......................................................................................................... 32-34
(f) Prescription drug benefits ..................................................................................................................................... 35-37
(g) Special features.......................................................................................................................................................... 38
Services for deaf and hearing impaired Reciprocity benefit

Travel benefit (h) Dental benefits ...................................................................................................................................................... 39-40

(i) Non-FEHB benefits available to Plan members ................................................................................................... 41-42
Summary of benefits ......................................................................................................................................................... 57 11
11 Page 12 13
2001 AmeriHealth HMO 12 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations

Second surgical opinion

$10 per office visit to your primary care
physician

$10 per office visit to your primary care
physician

$15 per office visit to a specialist

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment

$10 per office visit

At home $15 per home visit
Not covered:
Charges for missed appointments
Charges for completion of insurance forms

All charges 12
12 Page 13 14
2001 AmeriHealth HMO 13 Section 5( a)
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these
services during your office visit;
otherwise, $10 per visit

Preventive care, adult
Routine screenings, such as:
Blood lead level – One annually
Total Blood Cholesterol – once every three years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test

$10 per office visit

Sigmoidoscopy, screening – every five years starting at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $10 per office visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$15 per office visit 13
13 Page 14 15
2001 AmeriHealth HMO 14 Section 5( a)
Preventive care, adult (Continued) You pay
Routine mammogram –covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period
At age 40 and older, one every calendar year

Nothing if you receive these
services during your office visit;
otherwise, $10 per visit

Not covered:
Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
All charges.

Routine Adult Immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over
Immunizations as recommended by the Center for Disease Control and /or AmeriHealth.

$10 per office visit

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

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 (through age 22)
Well-child care charges for routine examinations, immunizations and care (through age 22)

$10 per office visit 14
14 Page 15 16
2001 AmeriHealth HMO 15 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You 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 copayment applies to first
visit only

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
Voluntary sterilization
Surgically implanted contraceptives. Insertion and removal covered under Medical. – Drug covered under Rx

Injectable contraceptive drugs – Covered under Rx
Intrauterine devices (IUDs) and Diaphrams – Device covered under Rx

$15 per office visit

Not covered:
Reversal of voluntary surgical sterilization
Genetic Counseling
Removal of surgically implanted time-release medication before the end of the expected life, unless medically necessary and
approved by the Plan.

All charges. 15
15 Page 16 17
2001 AmeriHealth HMO 16 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.

$15 per office visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded ART procedures

Cost of donor sperm
Injectable fertility drugs

All charges.

Allergy care
Testing and treatment
Allergy injection
$15 per office visit

Allergy serum Nothing
Not covered:
Provocative food testing
Sublingual allergy desensitization

All charges. 16
16 Page 17 18
2001 AmeriHealth HMO 17 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow are limited to those transplants listed under Organ/ Tissue
Transplants on page 24.

Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment.
If we determine GHT is not medically necessary, we will not cover the
GHT or related services and supplies. See Services requiring our prior
approval in Section 3.

Nothing

Not covered: See Section 6 General Exclusions All charges. 17
17 Page 18 19
2001 AmeriHealth HMO 18 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy, and speech therapy --
60 consecutive days per condition if significant improvement can be expected in the two month period for the services of each of the

following:
qualified physical therapists;
speech therapists; and
occupational therapists.
Note: We only cover therapy to restore bodily function or speech
when there has been a total or partial loss of bodily function or
functional speech due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 12
weeks.

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

Nothing

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges.

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit

Not covered:
All other hearing testing Hearing aids, testing and examinations for them
All charges. 18
18 Page 19 20
2001 AmeriHealth HMO 19 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One eye refraction every two calendar years. $15 per office visit

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such
as for cataracts)

Nothing

Eye exam to determine the need for vision correction for children through age 17 (see preventive care) $10 per office visit
Not covered:
Eyeglasses or contact lenses; but see non-FEHB page
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

Foot care
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

See Orthopedic and prosthetic devices for information on podiatric shoe
inserts.

$10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges. 19
19 Page 20 21
2001 AmeriHealth HMO 20 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs (initial devices only) and lenses; stump hose
Worn breast prostheses – initial device only
Surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices and their replacements, such as artificial joints, pacemakers, and surgically implanted breast implant, external
and shown above, following mastectomy. Note: See 5( b) for
coverage of the surgery to insert the device.

Nothing

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics, unless for treatment of diabetes
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than 3 years after the last one we covered
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Dental prosthetics
Replacement of prosthetic devises such as artificial limbs and lenses following cataract surgery.

All charges.

Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
standard durable medical equipment prescribed by your Plan physician,
such as oxygen and dialysis equipment. Under this benefit, we also
cover:

standard hospital beds;
standard wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

Nothing

Not covered:
Motorized wheel chairs Customized durable medical equipment All charges. 20
20 Page 21 22
2001 AmeriHealth HMO 21 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family;

Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

All charges

Alternative treatments
Not covered:
Acupuncture -see Section 5( j) non-FEHB benefits available to Plan members

Naturopathic services Hypnotherapy
Biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

Diabetes self-management training and education through community-based programs certified by the American Diabetes
Association or Department of Health. Covered services may also be
provided by these contracted providers; a licensed health care
professional; or at a hospital on an outpatient basis.

Nothing

Not covered:
Smoking Cessation – see Section 5( j) non-FEHB benefits available to Plan members. 21
21 Page 22 23
2001 AmeriHealth HMO 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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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.)
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which

services require precertification and identify which surgeries require precertification.

I M
P O
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T

Benefit Description You pay
Surgical procedures

Treatment of fractures, including casting Normal pre-and post-operative care by the surgeon

Correction of amblyopia and strabismus Endoscopy procedure
Biopsy procedure Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery) Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See 5( a) (Orthopedic braces and prosthetic devices) for device coverage information.

Nothing

Surgical procedures continued on next page. 22
22 Page 23 24
2001 AmeriHealth HMO 23 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization

Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs). Insertion and removal of device covered under
medical drugs and devices covered under Rx.

Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing
$15 per office visit

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.
All charges.

Reconstructive surgery
Your physician must obtain approval from us before providing services.
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

Nothing

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

Not covered:
Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges 23
23 Page 24 25
2001 AmeriHealth HMO 24 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures require preapproval by the Plan and are,
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.

Nothing

Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures (such

as the periodontal membrane, gingiva, and alveolar bone)

All charges.

Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

Note: We cover related medical and hospital expenses of the member
donor when we cover the recipient.

Nothing

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges 24
24 Page 25 26
2001 AmeriHealth HMO 25 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient) Nothing

Professional services provided in –
Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office

Nothing 25
25 Page 26 27
2001 AmeriHealth HMO 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

I M
P O
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care or cardiac care accommodations;

general nursing care; and meals and special diets.

NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Nothing

Inpatient hospital continued on
next page 26
26 Page 27 28
2001 AmeriHealth HMO 27 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
Custodial care Non-covered facilities, such as nursing homes, extended care

facilities, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care Blood and blood derivatives not replaced by the member

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges 27
27 Page 28 29
2001 AmeriHealth HMO 28 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): Up to 180 days per calendar year when
full-time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan.

Nothing

Not covered:
Custodial care,
Rest cures,
Domicillary or convalescent care,
Personal comfort items, such as telephones and television.

All charges

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.

Nothing

Not covered:
Independent nursing,
Homemaker services
Custodial care,
Rest cures,
Domicillary or convalescent care,
Personal comfort items, such as telephones and television

All charges

Ambulance
Local professional ambulance service when medically appropriate. Preapproval is required, unless for emergency. Nothing 28
28 Page 29 30
2001 AmeriHealth HMO 29 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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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
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T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that a prudent
layperson believes endangers their 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 the 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. If you are hospitalized in non-Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital, you will be transferred when medically
feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition. To be covered by
this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of
injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day
following your admission, unless it was 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. 29
29 Page 30 31
2001 AmeriHealth HMO 30 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services (copayment waived if admitted or you
are referred to the emergency room by your PCP and services could
have been provided by your doctor)

$10 per office visit
$35 per visit

$35 per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

Emergency care at a doctor's office

Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors' services (copayment waived if admitted or you are referred
to the emergency room by your PCP and services could have been
provided by your doctor)

$10 per office visit
$35 per visit
$35 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
Professional or air ambulance service when medically appropriate.
See 5( c) Ambulance for non-emergency service.

Nothing 30
30 Page 31 32
2001 AmeriHealth HMO 31 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

Parity
Beginning in 2001, all FEHBP plans' mental health and substance abuse benefits
will achieve "parity" with other benefits. This means that we will provide mental
health and substance abuse benefits differently than in the past.

When you get our approval for services and follow a treatment plan we approve,
cost-sharing and limitations for Plan mental health and substance abuse benefits will
be no less than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

Benefit Description You pay
After the calendar year
deductible…

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. 31
31 Page 32 33
2001 AmeriHealth HMO 32 Section 5( e)
Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social
workers.

Medication management

$10 per office visit

Services provided by a hospital or other facility
Diagnostic tests

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order us
to pay or provide one clinically appropriate treatment plan in favor of
another.

All charges 32
32 Page 33 34
2001 AmeriHealth HMO 33 Section 5( e)
Network out-of-pocket maximums After your copayments total $1,000 per person or $2,000 per family
enrollment in any calendar year, you do not have to pay any more for
covered services. 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.

Preauthorization To be eligible to receive these mental health and substance abuse benefits you must follow your treatment plan and all of our network
authorization processes. These include:
Treatment for mental conditions and substance abuse is coordinated
directly by Magellan Behavioral Health 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
including referrals to mental health and substance abuse specialists.
Questions about related benefits and pre-certification should be
addressed to Magellan Behavioral Health at 1-800-809-9954.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued
coverage with your provider for up to 90 days under the following
condition:

If your mental health or substance abuse professional provider with
whom you are currently in treatment leaves the plan at our request for
other than cause.

If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.

Network limitation We may limit your benefits if you do not follow your treatment plan. 33
33 Page 34 35
2001 AmeriHealth HMO 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
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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.
We do not have a deductible.
Be sure to read Section 4. Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

I M
P O
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A N
T

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed dentist must write the prescription.

Where you can obtain them. You may fill the prescription at a Plan pharmacy, a non-network pharmacy, or by mail. We pay a higher level of benefits when you use a network
pharmacy.
We use a formulary. The Amerihealth Formulary is a list of generic and brand name drugs that physicians use when prescribing medications for you, the patient. A committee of

physicians, the Plan's Pharmacy and Therapeutics Committee, regularly reviews the drugs
that appear on the formulary list to ensure the formulary promotes rational therapeutic
alternatives, the appropriate use of generics, and discourages the unnecessary use of high-cost
alternatives. They consider the effectiveness of the drug before reviewing the cost.

There are the dispensing limitations. You pay the pharmacy copay per prescription for up to a 34 day supply or a 120 unit supply. If you select a brand name drug when generic

equivalents are available, you pay the price difference between the brand and generic in
addition to your copayment.

When you have a claim. Prescription drugs obtained from a non-Plan pharmacy, for an out-of-area emergency will be reimbursed. You must submit acceptable proof-of-payment

with a direct reimbursement form. All claims for payment must be received within ninety
(90) days of the date of proof-of-purchase. Direct reimbursement forms may be obtained by
calling 1-800-877-9829.

Prescription Drug benefits— Continued on the next page. 34
34 Page 35 36
2001 AmeriHealth HMO 35 Section 5( f)
Section 5 (f). Prescription drug benefits
Covered medications and supplies You pay
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

Drugs for which a prescription is required by Federal law of the United States

Oral and Injectable contraceptive drugs – up to a three-cycle supply for a single copay
Contraceptive diaphragms and IUDs
Implanted time-release medications, such as Norplant
Insulin, with copay charges applied to each vial
Diabetic supplies, including disposable insulin needles and syringes, diabetic blood testing strips, lancets and glucometers obtained through a
Participating Pharmacy

Disposable needles and syringes needed to inject covered prescribed medications

Prenatal and Pediatric Vitamins
Non-injectable fertility drugs
Drugs to treat sexual dysfunction may be subject to dosage limitations. Contact the Plan for dose limits

Maintenance medications obtained through the Mail Order program for up to a 90-day supply
Maintenance drugs obtained at a Participating Pharmacy for up to a 90-day supply

$5 copay per prescription order or
refill, for up to a 34 day supply or
120 unit dosage

$5 copay per prescription order or
refill

$15 copay per prescription order or
refill 35
35 Page 36 37
2001 AmeriHealth HMO 36 Section 5( f)
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as Written
for the name brand drug, you have to pay the difference in cost
between the name brand drug and the generic.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call 800-922-1557.

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
Medical 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
The cost of a prescription drug when the usual and customary charge is less than the member's prescription drug copayment

All Charges 36
36 Page 37 38
2001 AmeriHealth HMO 37 Section 5( g)
Section 5 (g). Special Features
Feature Description

Services for deaf and hearing impaired TDD 1-888-857-4816

Reciprocity benefit 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.

Travel benefit 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 outside the service area, 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. 37
37 Page 38 39
2001 AmeriHealth HMO 38 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including Medicare.

I M
P O
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A N
T

Accidental injury benefit You Pay
We cover restorative services and supplies necessary
to promptly repair (but not replace) sound natural
teeth when provided by Plan dentists. The need for
these services must result from an accidental injury
and be treated within six (6) months or as other
medical conditions permit after the accident.

$15 per office visit 38
38 Page 39 40
2001 AmeriHealth HMO 39 Section 5( h)
Service You pay
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);
emergency examinations; panaramic film;
cephalometric film.

Restorative Services:
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 Dental Services:
The program will reimburse member for dental
services in connection with dental emergencies
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

$5 copay per office visit 39
39 Page 40 41
2001 AmeriHealth HMO 40 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
expenses.

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 any fitness 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 two (2) calendar years, members maximize their benefit by using participating providers.

BabyFootSteps 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 two (2) home care visits. If member opts for a 3 day stay for a cesarean delivery, the
mother will receive one (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%
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. 40
40 Page 41 42
2001 AmeriHealth HMO 41 Section 6
Section 6. General Exclusions --Things We Do Not 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; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 41
41 Page 42 43
2001 AmeriHealth HMO 42 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process.

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians
must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 800-877-9829.

When you must file a claim – such as for out-of-area care – submit
It on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number; Name and address of physician or facility that provided the service
or supply;
Dates you received the services or supplies; Diagnosis;

Type of each service or supply; The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer – such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
AmeriHealth HMO, Inc.
P. O. Box 41574
Philadelphia, PA 19101

Prescription drugs Submit your claims to:
Paid Prescriptions, Inc.
P. O. Box 727
Parsippany, NJ 07054-0727

Other supplies or services Submit your claims to:
AmeriHealth HMO, Inc.
P. O. Box 41574
Philadelphia, PA 19101

Deadline for filing your claim Send us all of the documents for your claim as soon as possible.
You must submit the claim by December 31 of the year after the
Year you received the service, unless timely filing was prevented by
Administrative operations of Government or legal incapacity, provided
The claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may
delay processing or deny your claim if you do not respond. 42
42 Page 43 44
2001 AmeriHealth HMO 43 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description

Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 8000 Midlantic Drive, Mt. Laurel, NJ 08054; 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.

 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy
of our request— go to step 3.

 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.
We will write to you with our decision.

 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III,
P. O. Box 436, Washington, D. C. 20044-0436.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim. 43
43 Page 44 45
2001 AmeriHealth HMO 44 Section 8
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must provide a copy of your specific written consent with the
review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.

 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support 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
800-877-9829 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 III at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 44
44 Page 45 46
2001 AmeriHealth HMO 45 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 disablilities, under 65 years of age People with End-Stage Renal Disease (permanent kidney failure

requiring dialysis or a transplant).
Medicare has two parts:

Part A (Hospital Insurance). Most people do not have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare 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 The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B benefits.
You may go to any doctor, specialist, or hospital that accepts Medicare.
Medicare pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.

When you are enrolled in this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. Your care
must continue to be authorized by your Plan PCP. We will not waive
any of our copayments.

(Primary payer chart begins on next page.) 45
45 Page 46 47
2001 AmeriHealth HMO 46 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a familymember are eligible for Medicare solelybecause of a disability),

2) Are an annuitant,

3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB

b) The position is not excluded from FEHB
Ask your employing office which of these applies to you.

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status,
(for Part B
services)

(for other
services)

6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

(except for claims
related to Workers'
Compensation.)

B. When you --or a covered family member --have Medicare
based on end stage renal disease (ESRD) and…

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) And are an active employee

46
46 Page 47 48
2001 AmeriHealth HMO 47 Section 9
Claims Process You probably will never have to file a claim form when you have both our Plan and Medicare.
When we are the primary payor, we process the claim first.
When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claims will be
coordinated automatically and we will pay the balance of
covered charges. You will not need to do anything. To find out
if you need to do something about filing your claims, call us at
800-877-9829.

Medicare Managed Care Plan If you are eligible for Medicare, you may choose to enroll in a Medicare managed care plan. 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 our Medicare Managed Care Plan: You may enroll in
our Medicare managed plan and also remain enrolled in our FEHB plan.
In this case, we do not waive any of our copayments for your FEHB
coverage.

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.

Suspended FEHB coverage and a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare managed
care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open
season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for eligible dependents, military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or 47
47 Page 48 49
2001 AmeriHealth HMO 48 Section 9
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
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 for When you receive money to compensate you for medical or hospital care 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. 48
48 Page 49 50
2001 AmeriHealth HMO 49 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 57.

Covered services Care we provide benefits for, as described in this brochure.
Experimental or Investigational services To establish if a biological, medical device, drug or procedure is
experimental/ investigative or not, a technology assessment is performed.
The results of the assessment provide the basis for the determination of
the service's status (e. g., medically effective, experimental, etc.).
Technology assessment is the review and evaluation of available data
from multiple sources using industry standard criteria to assess the
medical effectiveness of the service. Sources of data used in technology
assessment 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 by
government agencies, as well as regional and national experts and/ or
panels and, if applicable, literature supplied by the manufacturer.

Us/ We Us and we refer to AmeriHealth HMO, Inc.
You You refers to the enrollee and each covered family member. 49
49 Page 50 51
2001 AmeriHealth HMO 50 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. 50
50 Page 51 52
2001 AmeriHealth HMO 51 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when

coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for
other forms of coverage, such as temporary continuation of coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you

may be eligible for your own FEHB coverage under the spouse equity
law. If you are recently divorced or are anticipating a divorce, contact
your ex-spouse's employing or retirement office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or
retirement office or from www. opm. gov/ insure. 51
51 Page 52 53
2001 AmeriHealth HMO 52 Section 11
Converting to You may convert to a non-FEHB individual policy if: individual coverage Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot
convert;

You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no
longer eligible for coverage.

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

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled with us. You
can use this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods, limitations, or exclusions
for health related conditions based on the information in the certificate, as long as
you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

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

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800-877-9829
and explain the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE— 202-418-3300 or write to: The United States Office of

Personnel Management, Office of the Inspector General Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate
anyone who uses an ID card if the person tries to obtain services for
someone who is not an eligible family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 52
52 Page 53 54
2001 AmeriHealth HMO 53 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 23,38 Allergy tests 11,16
Alternative treatment 11,21,40 Ambulance 9,11,26,28,29,30
Autologous bone marrow transplant 17,24
Biopsies 22 Birthing centers 9
Blood and blood plasma 27 Casts 27
Catastrophic protection 33 Changes for 2001 6
Chemotherapy 17 Childbirth 40
Cholesterol tests 13 Claims 34,42,43-44,47,51
Coinsurance 10 Colorectal cancer screening 13
Congenital anomalies 22, 23 Contraceptive devices and drugs 36
Crutches 20
Deductible 10,34,40,42 Definitions 49

Dental care 5,7,38 Diagnostic services 11,12, 13,
27,31,32,39 Disputed claims review 43-44
Donor expenses (transplants) 24 Dressings 27,36
Durable medical equipment (DME) 9,11,20
Educational classes and programs 11,21
Effective date of enrollment 7, 49 Emergency 5,6,29
Experimental or investigational 41,49
Eyeglasses 19,40 Family planning 11,15
Fecal occult blood test 13 General Exclusions 41
Hearing services 9,11,18 Home health services 9,11,21
Hospice care 9,11,21

Hospital 5,6,7,8,9,11,12,15,20,21,22,
23, 24,25,26-28,29,30,32,40,42,45,48,52
Immunizations 5, 14 Infertility 5, 7, 11, 16
Insulin 20,35 Laboratory and pathological
services 27 Magnetic Resonance Imagings
(MRIs) 13 Mail Order Prescription Drugs 35
Mammograms 13,14 Maternity Benefits 5,7,11,15,27
Medicaid 48 Medically necessary
5,7,9,12,15,17,22,26,29,34, 38,41
Medicare 12,22,26, 29,31,34,38,40,45,46-47
Mental Conditions/ Substance Abuse Benefits 5,7,31-33
Newborn care 12,15 Non-FEHB Benefits 40
Nurse 21,27
Obstetrical care 9,15 Occupational therapy 18

Ocular injury 19 Office visits 5
Oral and maxillofacial surgery 11,24
Orthopedic devices 11,19,20,22
Out-of-pocket expenses 10,33,40
Outpatient facility care 11,21,25,27,28,30,32
Oxygen 20,21,27 Pap test 13
Physical examination 5,14 Physical therapy 18
Physician 5,6,7,8,9,10,11, 12,20,21,22,23,26,34,35,
36,37,42,43,44,52

Preauthorization 7,9,31,33,43,44
Preventive care, adult 11,13,14
Preventive care, children 11,14
Prescription drugs 10,33, 34-36,42,45
Prosthetic devices 11,19,20,22,23
Psychologist 32 Radiation therapy 17
Rehabilitation therapies 18
Renal dialysis 45 Room and board 26

Second surgical opinion 12 Skilled nursing facility care
12,25,28 Smoking cessation
21,36,40 Speech therapy 18
Splints 27 Sterilization procedures
15,23 Subrogation 48
Substance abuse 5,6,7,9,11,31-33
Surgery 6,9,15,18,19,20,23,24,
26 Oral 11,24
Reconstructive 11,23 Syringes 35
Temporary continuation of coverage 51,52
Transplants 11,17,24 Treatment therapies 11,17
Vision services 11,19 Wheelchairs 20
Workers' compensation 46,47,51
X-rays 11,13,27,39 53
53 Page 54 55
2001 AmeriHealth HMO 54
NOTES: 54
54 Page 55 56
2001 AmeriHealth HMO 55 Summary
Summary of benefits for the AmeriHealth HMO -2001
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 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

12-21

Services provided by a hospital:
Inpatient............................................................................................

Outpatient .........................................................................................

Comprehensive range of medical
and surgical services without dollar
or day limit. Includes in-hospital
doctor care, room and board,
general nursing care, private room
and private nursing care if
medically necessary, diagnostic
tests, drugs and medical supplies,
use of operating room, intensive
care and complete maternity care.
You pay nothing.

Comprehensive range of services
such as diagnosis and treatment of
illness or injury, including
specialist's care; preventive care,
including well-baby care, periodic
check-ups and routine
immunizations; laboratory tests
and X-rays; complete maternity
care. You pay a $10 copay per
office visit to a primary care
doctor or a $15 copay per office
visit for specialty care; $15 per
house call by a doctor.

26-27
27

Emergency benefits:
In-area..............................................................................................
Out-of-area ......................................................................................

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, waived if
admitted

29-30
30

Mental health and substance abuse treatment...................................... Regular cost sharing. 31-33 55
55 Page 56 57
2001 AmeriHealth HMO 56 Summary
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
pay a $5 copay per 90 day supply.

34-36

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.

38-39

Vision Care ....................................................................................... Refractions once every two years.
You pay a $15 copay per visit. 19

Protection against catastrophic costs
(your 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.

10 56
56 Page 57
2001 Rate Information for
AmeriHealth HMO, 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 and Tool & Die employees
(see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of
any postal employee organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

AmeriHealth HMO NJ
Self Only FK1 $86.59 $74.89 $187.61 $162.26 $102.22 $59.26

Self and Family FK2 $195.82 $162.53 $424.28 $352.15 $231.17 $127.18 57

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