Pages 1--50 from Coventry Health Care

Serving: Wichita, Salina and Central Kansas Areas
Enrollment in this Plan is limited; see page 5 for requirements.

Enrollment codes for this Plan:
7W1 Self Only
7W2 Self and Family

RI-73-275

2001
For changes
in benefits
see page 7. 1
1 Page 2 3
2001 Coventry Health Care of Kansas, Inc. 2 Table of Contents
Table of Contents
IntroductionÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ............................................................... 4
Plain LanguageÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.............................................................. 4
Section 1. Facts about this HMO plan ........................................................................................................................ 5
How we pay providers................................................................................................................................ 5
Who provides my health care?.................................................................................................................... 5
Patients' Bill of Rights ................................................................................................................................ 6
Service Area................................................................................................................................................ 6
Section 2. How we change for 2001ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ................................................................ 7
Program-wide changes................................................................................................................................ 7
Changes to this Plan.................................................................................................................................... 7
Section 3. How you get care ÉÉÉÉ....................................................................................................................... 8
Identification cards...................................................................................................................................... 8
Where you get covered care........................................................................................................................ 8
· Plan providers........................................................................................................................................ 8
· Plan facilities.......................................................................................................................................... 8
What you must do to get covered care........................................................................................................ 8

· Primary care .......................................................................................................................................... 8
· Specialty care ........................................................................................................................................ 9
· Hospital care.......................................................................................................................................... 9
Circumstances beyond our control............................................................................................................ 10
Services requiring our prior approval ...................................................................................................... 10
Section 4. Your costs for covered services ................................................................................................................ 11
· Copayments.......................................................................................................................................... 11
· Deductible............................................................................................................................................ 11
· Coinsurance.......................................................................................................................................... 11
Your out-of-pocket maximum .................................................................................................................. 11
Section 5. BenefitsÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.............................................................. 12
Overview .................................................................................................................................................. 12
(a) Medical services and supplies provided by physicians and other health care professionals.............. 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals.......... 20
(c) Services provided by a hospital or other facility, and ambulance services ........................................ 23
(d) Emergency services/ accidents ............................................................................................................ 26
(e) Mental health and substance abuse benefits........................................................................................ 28
(f) Prescription drug benefits.................................................................................................................... 30
(g) Special features.................................................................................................................................... 33 2
2 Page 3 4
2001 Coventry Health Care of Kansas, Inc. 3 Table of Contents
(h) Dental benefits .................................................................................................................................... 34
(i) Non-FEHB benefits available to Plan members.................................................................................. 35
Section 6. General exclusions --things we don't cover ............................................................................................ 36
Section 7. Filing a claim for covered services .......................................................................................................... 37
Section 8. The disputed claims process...................................................................................................................... 38
Section 9. Coordinating benefits with other coverage .............................................................................................. 41
When you haveÉ
· Other health coverage.......................................................................................................................... 41
· Original Medicare................................................................................................................................ 41
· Medicare managed care plan .............................................................................................................. 42
TRICARE/ Workers Compensation/ Medicaid .......................................................................................... 43
Other Government agencies...................................................................................................................... 43
When others are responsible for injuries .................................................................................................. 43
Section 10. Definitions of terms we use in this brochure ........................................................................................ 44
Section 11. FEHB facts.............................................................................................................................................. 45
Coverage information................................................................................................................................ 45
· No pre-existing condition limitation.................................................................................................... 45
· Where you get information about enrolling in the FEHB Program.................................................... 45
· Types of coverage available for you and your family ........................................................................ 45
· When benefits and premiums start...................................................................................................... 46
· Your medical and claims records are confidential .............................................................................. 46
· When you retire .................................................................................................................................. 46
When you lose benefits ............................................................................................................................ 46

· When FEHB coverage ends ................................................................................................................ 46
· Spouse equity coverage ...................................................................................................................... 46
· Temporary Continuation of Coverage (TCC)...................................................................................... 46
· Converting to individual coverage .................................................................................................... 47
· Getting a Certificate of Group Health Plan Coverage ........................................................................ 47
Inspector General Advisory ...................................................................................................................... 47
Index............................................................................................................................................................................ 48
Summary of benefits .................................................................................................................................................. 49
Rates.............................................................................................................................................................. Back cover 3
3 Page 4 5
2001 Coventry Health Care of Kansas, Inc. 4 Introduction/ Plain Language
Introduction
Coventry Health Care of Kansas, Inc.
8301 E. 21st North, Suite 300
Wichita, Kansas 67206

This brochure describes the benefits of Coventry Health Care of Kansas, Inc. under our contract (CS 2108) 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 49. 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 Coventry Health Care of
Kansas, 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 Coventry Health Care of Kansas, Inc. 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 or
coinsurance.

Who provides my healthcare
Coventry Health Care provides you with a comprehensive benefit package that covers many kinds of health services for
a fixed payroll deduction and minimal copayments. As a participant of Coventry Health Care, you will select a personal
doctor for yourself and each member of your family. Depending on where you live, you will be able to choose from a
directory of more than 320 primary care doctors whose offices are located throughout the Plan's service areas.

The first and most important decision each member must make is the selection of a primary care doctor. Your primary
care doctor will be the manager and coordinator of your health care. If you require additional care, your primary care
doctor, with your input, will select the specialist or hospital that best fits your needs. It is the responsibility of your pri-mary
care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization.

The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists),
with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are
updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service
Department at 1-800-664-9251 or 316-634-1222. You can also find out if your doctor participates by calling these
numbers.

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify
that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in the Plan,
services (except for emergency benefits) are provided through the Plan's delivery system; the continued availability
and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Should you decide to enroll, you will be asked to complete a primary care doctor selection and send it to the Plan,
indicating the name of the primary care doctor( s) selected for you and each member of your family. Members may
change their doctor selection by notifying the Plan 30 days in advance. 5
5 Page 6 7
2001 Coventry Health Care of Kansas, Inc. 6 Section 1
Facts about this HMO plan (Continued)
Patients'Bill of Rights

OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's Advisory
Commission of 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. Some of the required information is listed below.

· State Insurance Department requirements for external quality review
· Years in existence
· Profit status

If you want more information about us, call 800/ 664-9251, or write to Coventry Health Care of Kansas Inc., 8301 East
21 st North, Suite 300, Wichita, Kansas 67206. You may also contact us by fax at 316/ 634-1266 or visit our website at
www. chcwic. cvty. com.

Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is:
Butler, Harvey, McPherson, Saline, Sedgwick, and Sumner Counties.

You may also enroll with us if you live or work in the following places: Cowley, Dickinson, Greenwood, Harper,
Kingman, Lincoln, Marion, Ottawa and Reno counties.

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.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 6
6 Page 7 8
2001 Coventry Health Care of Kansas, Inc. 7 Section 2
Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it
easier for you to compare plans.

This year, the Federal Employees Health Benefits Program is implementing network mental health and substance
abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our Plan network will be the same with regard to deductibles, coinsurance, copays, and
day and visit limitations when you follow a treatment plan that we approve. Previously, we placed higher patient
cost sharing 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 us at 1-800-664-9251 or 316-634-1222, or checking our website www. chcwic. cvty. 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 tests 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 16% for Self Only or 16% for Self and Family. 7
7 Page 8 9
2001 Coventry Health Care of Kansas, Inc. 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 800-664-9251.

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

Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. Visit www. chcwic. cvty. com to
utilize our doctor search option. Our doctor search on the web is updated
monthly.

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. www. chcwic. cvty. com.

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.
The Plan's provider directory lists primary care doctors (generally family
practitioners, pediatricians, and internists), with their locations and phone
numbers, and notes whether or not the doctor is accepting new patients.
Directories are updated on a regular basis and are available at the time of
enrollment or upon request by calling the Customer Service Department at
1-800-664-9251 or 316-634-1222. You can also find out if your doctor
participates by calling these numbers.

If you are interested in receiving care from a specific provider who is listed
in the directory, call the provider to verify that he or she still participates with
the Plan and is accepting new patients.

Primary care Your primary care physician will generally 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. 8
8 Page 9 10
2001 Coventry Health Care of Kansas, Inc. 9 Section 3
How you get care (Continued)
Specialty care Your primary care physician will refer you to a specialist for needed care.
You must receive a referral from your primary care doctor before seeing or
obtaining special services, with the following exceptions:, (1) Female
members may visit a participating gynecologist without a referral from their
primary care doctor; (2) All members may visit the Plan's mental health
providers for mental conditions and substance benefits without a referral from
their primary care doctor (See "Mental Conditions /Substance Abuse
Benefits").

Referral to a participating specialist is given at the primary care doctor's
discretion; if specialists or consultants are required beyond those
participating in the Plan, the primary care doctor will make arrangements for
appropriate referrals.

When you receive a referral from your primary care doctor, you must return
to the primary care doctor after the consultation. All follow-up care must be
provided or arranged by the primary care doctor. On referrals, the primary
care doctor will give specific instructions to the consultant as to what services
are authorized. If the consultant suggests additional services or visits, you
must first check with your primary care doctor. Do not go to the specialist
unless your primary care doctor has arranged for and the Plan has issued an
authorization for the referral in advance.

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 work with
the specialist to 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 9
9 Page 10 11
2001 Coventry Health Care of Kansas, Inc. 10 Section 3
How you get care (Continued)
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 1-800-664-9251 or
316-634-1222. If you are new to the FEHB Program, we will arrange for you
to receive care.

If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the hospital benefits of the hospitalized
person.

C i rcumstances beyond our c o n t ro l Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that
case, we will make all reasonable efforts to provide you with the necessary
care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us.

Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician
must obtain, for example, prior authorization from the Plan for outpatient
surgeries or inpatient hospitalization. You may call customer service at
1-800-664-9251 to find out if a specific procedure treatment requires prior
authorization. 10
10 Page 11 12
2001 Coventry Health Care of Kansas, Inc. 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

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

Example: When you see your primary care physician you pay a copayment
of $10 per office visit and when you go in the hospital, you pay nothing.

Deductible A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for them. We have no
deductible.

NOTE: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective date
of your new plan. If you change plans at another time during the year, you
must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your
old option to any deductible of your new option.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care.

Example: In our Plan, you pay 50% of our allowance for infertility services
and 20% for covered durable medical equipment.

Your out-of-pocket maximum After your copayments and coinsurance total $ 1,000 per person or $ 3,000 per family enrollment in any calendar year, you do not have to pay any more
for covered services. However, copayments for prescription drugs do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for prescription drugs.

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 11
11 Page 12 13
2001 Coventry Health Care of Kansas, Inc. 12 Section 5 (Overview)
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 49 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. To obtain claims forms, claims filing advice, or more information about our benefits,
contact us at 800-664-9251 or at our website at www. chcwic. cvty. com.

(a) Medical services and supplies provided by physicians and other health care professionals.............................. 13-19
Diagnostic and treatment services Hearing services (testing, treatment, and
Lab, X-ray, and other diagnostic tests supplies)
Preventive care, adult Vision services (testing, treatment, and
Preventive care, children supplies)
Maternity care Foot care
Family planning Orthopedic and prosthetic devices
Infertility services Durable medical equipment (DME)
Allergy care Home health services
Treatment therapies Alternative treatments
Rehabilitative therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals .......................... 20-22
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ........................................................ 23-25
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory surgical facility benefits
center Hospice care

Ambulance

(d) Emergency services/ accidents.............................................................................................................................. 26-27
Medical emergency Ambulance

(e) Mental health and substance abuse benefits........................................................................................................ 28-29
(f) Prescription drug benefits.................................................................................................................................... 30-32
(g) Special features.......................................................................................................................................................... 33
Vision Discount Program

(h) Dental benefits .......................................................................................................................................................... 34
(i) Non-FEHB benefits available to Plan members ...................................................................................................... 35
Summary of benefits.......................................................................................................................................................... 49 12
12 Page 13 14
2001 Coventry Health Care of Kansas, Inc. 13 Section 5 (a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

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.
We have no calendar year 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.

Benefit Description You Pay
Diagnostic and treatment services
Professional services of physicians $10 per visit
In physician's office

Professional services of physicians $10 per office visit
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

Office medical consultations
Second surgical opinion

At home $25 per office visit
Lab, X-ray and other diagnostic tests
Tests, such as: Nothing if you receive these
Blood tests services during your office visit;
Urinalysis
otherwise, $10 per office visit

Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
C. A. T. Scans/ MRI
Ultrasound
Electrocardiogram and EEG

I M
P O
R T
A N
T

I M
P O
R T
A N
T 13
13 Page 14 15
2001 Coventry Health Care of Kansas, Inc. 14 Section 5 (a)
Preventive care, adult You Pay
Routine screenings, such as: $10 per office visit
Blood lead level Ð One annually
Total Blood Cholesterol Ð once every three years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening Ð every five years starting at age 50 $10 per office visit

Prostate Specific Antigen (PSAtest) Ð one annually for men age 40 and older $10 per office visit

Routine pap test $10 per office visit
Note: The office visit is covered if pap test is received on the same day;
see Diagnostic and Treatment, above.

Routine mammogram Ðcovered for women age 35 and older, as follows: $10 per office visit
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

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

Routine Immunizations, limited to: $10 per office visit
Tetanus-diphtheria (Td) booster Ð once every 10 years, ages 19 and
over (except as provided for under Childhood Immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

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

Examinations, such as: $10 per office visit
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) 14
14 Page 15 16
2001 Coventry Health Care of Kansas, Inc. 15 Section 5 (a)
Maternity care You pay
Complete maternity (obstetrical) care, such as: $10 for initial office visit to
Prenatal care confirm pregnancy.
Delivery
All other copayments for

Postnatal care
prenatal visits during the course

Note: Here are some things to keep in mind:
of pregnancy are waived.

You do not need to precertify your normal delivery; see page xx for
other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.

We cover routine nursery care of the newborn child during the covered
portion of the mother 's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
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).

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
Voluntary sterilization $100 per sterilization procedure
Surgically implanted contraceptives (implant only; not removal) $10 for office visit applies to
implanted contraceptive devices.
Intrauterine devices (IUDs Ð implant only, not removal) Benefit does NOT cover
removal of devices.

Injectable contraceptive drugs $10 office visit copay applies to
the injectable contraceptive drugs.

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as: 50% of charges up to a $1,000
Artificial insemination: annual out-of-pocket maximum
intravaginal insemination (IVI)
for an individual and $3,000 out of

intracervical insemination (ICI)
pocket maximum for family. The

intrauterine insemination (IUI)
Plan pays remaining charges. 15
15 Page 16 17
2001 Coventry Health Care of Kansas, Inc. 16 Section 5 (a)
Infertility services (Continued) You pay
Not covered: All charges.
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

Fertility Drugs

Allergy care
Testing and treatment 50% of cost of testing; you pay
$10 copayment for treatment
Allergy injection visits, including allergy serum.

Allergy serum Nothing

Not covered: provocative food testing and sublingual allergy desensitization All charges.
Treatment therapies
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone $25 per office visit for
marrow transplants are limited to those transplants listed under Respiratory Therapy
Organ/ Tissue Transplants on page 22.

Respiratory and inhalation therapy
Dialysis Ð Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Ð Home IV and antibiotic therapy
Growth hormone therapy (GHT)( covered under the medical benefit.)
Note: Ð We will only cover GHT when the treatment is prior authorized
by your Primary Care Physician. It is a good idea to call us at
1-800-664-9251 to confirm that prior authorization has been done before
starting 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 authorization in Section 3. 16
16 Page 17 18
2001 Coventry Health Care of Kansas, Inc. 17 Section 5 (a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy, speech therapy and cardiac 20% of charges for each outpatient
rehabilitation. --session.

60 days per condition 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 60 days per
condition.

Not covered: All charges.
Long-term rehabilitative therapy
Exercise programs

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury $10 per office visit
Hearing testing for children through age 17 (see Preventive care,
children)

Not covered: All charges.
all other hearing testing

hearing aids, testing and examinations for them

Vision services (testing, treatment, and supplies)
Eye refraction every two years $10
One pair of eyeglasses or contact lenses to correct an impairment directly $10 per office visit
caused by accidental ocular injury or intraocular surgery (such as for
cataracts)

Eye exam to determine the need for vision correction for children $10 per office visit
through age 17 (see preventive care)

Not covered: All charges.
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery 17
17 Page 18 19
2001 Coventry Health Care of Kansas, Inc. 18 Section 5 (a)
Foot care You Pay
Routine foot care when you are under active treatment for a metabolic $10 per office visit
or peripheral vascular disease, such as diabetes.

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

Not covered: All charges.
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)

Orthopedic and prosthetic devices
Orthopedic devices such as braces 20% of charges; limited to a
Artificial limbs and eyes maximum Plan benefit of $1,000
Externally worn breast prostheses and surgical bras, including necessary
per member per calendar year.

replacements, following a mastectomy. External prosthetic devices, except
those associated with reconstructive surgery after a mastectomy, are limited
to one per member per lifetime.

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

Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

Not covered: All charges.
orthopedic and corrective shoes
arch supports
foot orthotics
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 18
18 Page 19 20
2001 Coventry Health Care of Kansas, Inc. 19 Section 5 (a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of 20% of charges; $1,000 benefit
durable medical equipment prescribed by your Plan physician, such as per member per calendar year
oxygen and dialysis equipment. Under this benefit, we also cover: limitation.

hospital beds;
wheelchairs;
crutches;
walkers;
insulin pumps;
insulin pumps; and
blood glucose monitors. Blood glucose monitors are
Note: Call us at 1-800-664-9251 as soon as your Plan physician prescribes covered 100% for those with
this equipment. We will arrange with a contracting health care provider to diabetes.
provide you with the necessary equipment, according to the benefit.

Not covered: Motorized wheel chairs All charges.

Home health services
Home health care ordered by a Plan physician and provided by a Nothing.
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.

Not Covered: All charges
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.

Alternative treatments
Not covered All charges.

Educational classes and programs
Coverage is limited to: Nothing
Diabetes Self-Management educational classes, as referred by your
Plan physician

Prenatal education classes 19
19 Page 20 21
2001 Coventry Health Care of Kansas, Inc. 20 Section 5 (b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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.
· We have no calendar year 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.
· 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.)

Benefit Descriptions You Pay
Surgical procedures
· Treatment of fractures, including casting $10 for office visit;
· Normal pre-and post-operative care by the surgeon Nothing for hospital visit
· 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) Ð Orthopedic braces and prosthetic devices for device coverage information.

Treatment of burns
· Voluntary sterilization $100 copayment per procedure
· Norplant (a surgically implanted contraceptive) and intrauterine for voluntary sterilization devices (IUDs) Note: Devices are covered under 5( a).

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

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2001 Coventry Health Care of Kansas, Inc. 21 Section 5 (b)
Reconstructive surgery You Pay
· Surgery to correct a functional defect $10 per office visit;
· Surgery to correct a condition caused by injury or illness if: Nothing for hospital visit.
·· 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.

· All stages of breast reconstruction surgery following a mastectomy, $10 for office visit such as: Nothing for hospital visit.

·· 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: All charges
· Cosmetic surgery Ð 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.
Oral and maxillofacial surgery

Oral surgical procedures, limited to: $10 per office visit;
· Reduction of fractures of the jaws or facial bones; Nothing if performed in the hospital
· 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.

Not covered: All charges.
· Oral implants and transplants
· Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) 21
21 Page 22 23
2001 Coventry Health Care of Kansas, Inc. 22 Section 5 (b)
Organ/ tissue transplants You Pay
Limited to: Nothing
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single ÐDouble
· 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

· National Transplant Program (NTP) -URN
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

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

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

· Implants of artificial organs
· Transplants not listed as covered

Anesthesia
Professional services provided in Ð You pay nothing. When
· Hospital (inpatient) performed in the physician office,
· Hospital outpatient department the $10 office copayment will apply.
· Skilled nursing facility
· Ambulatory surgical center
· Office 22
22 Page 23 24
2001 Coventry Health Care of Kansas, Inc. 23 Section 5 (c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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.
· We have no calendar year 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.
· 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).

Benefit Descriptions You Pay
Inpatient hospital
Room and board, such as Nothing
· ward, semiprivate, or intensive care accommodations;
· general nursing care; and
· meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
· Operating, recovery, maternity, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests and X-rays
· Administration of blood and blood products
· Blood or blood plasma, if not donated or replaced
· Dressings, splints, casts, and sterile tray services
· Medical supplies and equipment, including oxygen
· Anesthetics, including nurse anesthetist services
· Take-home items
· Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

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2001 Coventry Health Care of Kansas, Inc. 24 Section 5 (c)
Inpatient hospital (Continued) You pay
Not covered: All charges.
· 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
Outpatient hospital or ambulatory surgical center
· Operating, recovery, and other treatment rooms Nothing
· 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: Ð 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.

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
A comprehensive range of benefits with no dollar or day limit when Nothing
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. All necessary services are covered, including:

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

doctor.

Not covered: custodial care All charges 24
24 Page 25 26
2001 Coventry Health Care of Kansas, Inc. 25 Section 5 (c)
Hospice care You Pay
Supportive and Palliative care for a terminally ill member is covered in the Nothing
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.

Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when medically appropriate $25 per trip
Benefits for transportation by air ambulance are reimbursed at the cost of
ground ambulance transportation. 25
25 Page 26 27
Section 5 (d). Emergency services/ accidents
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.

· We have no calendar year 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.

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are
emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are
medical emergencies Ð what they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor, for First Help, the Plan's 24-hour advice line at 1-800/ 622-9528. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system (e. g., the 911-telephone system) or go to the nearest hospital
emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the
Plan. You or a family member must notify the Plan within 48 hours. It is your responsibility to ensure that the Plan
has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it is not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges are 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.
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers. You pay $50 per hospital emergency room visit or $25 per urgent care center visits
for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the
emergency care copay is waived.

Emergencies outside 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 not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can
be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges
covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers.

2001 Coventry Health Care of Kansas, Inc. 26 Section 5 (d)

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2001 Coventry Health Care of Kansas, Inc. 27 Section 5 (d)
Benefit Descriptions You Pay
Emergency within our service area
· Emergency care at a doctor's office $10 per office visit
· Emergency care at an urgent care center $25 per office visit
· Emergency care as an outpatient or inpatient at a hospital, including $50 per office visit; doctors' services waived if admitted to hospital

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
· Emergency care at a doctor's office $10 per office visit
· Emergency care at an urgent care center $25 per office visit
· Emergency care as an outpatient or inpatient at a hospital, including $50 per ER visit; waived doctors' services if admitted to hospital

Not covered: All charges.
· 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 .

Ambulance
Professional ambulance service when medically appropriate. $25 per trip
See 5( c) for non-emergency service. 27
27 Page 28 29
2001 Coventry Health Care of Kansas, Inc. 28 Section 5 (e)
Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve
"parity" with other benefits. This means that we will provide mental health and substance
abuse benefits differently than in the past.

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

Here are some important things to keep in mind about these benefits:
· All benefits are subject to the definitions, limitations, and exclusions in this brochure.
· We have no calendar year 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.
· YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

· Professional services, including individual or group therapy by $10 per office visit providers such as psychiatrists, psychologists, or clinical social
workers
· Medication management

· Diagnostic tests Nothing
· Services provided by a hospital or other facility Nothing
· Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day

hospitalization, facility based intensive outpatient treatment

Not covered: Services we have not approved. All charges.
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.

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Your cost sharing responsibilities are no
greater than for other illness or conditions. 28
28 Page 29 30
2001 Coventry Health Care of Kansas, Inc. 29 Section 5 (e)
Mental health and substance abuse benefits (Continued)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

Call 1-800-752-7242. When you call, be prepared to give your name and
member I. D. number. You will be asked some general questions about why
you are seeking services, and you will be referred to a provider for
treatment..

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

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

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

Limitation We may limit your benefits if you do not follow your treatment plan. 29
29 Page 30 31
2001 Coventry Health Care of Kansas, Inc. 30 Section 5 (f)
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Section 5 (f). Prescription drug benefits
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 have no calendar year deductible. Some drugs require prior authorization. Your
physician will obtain any prior authorizations needed.

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.

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 must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication.

We use a formulary. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan
pharmacy will be dispensed for up to a 31-day supply or 100-unit dosage, whichever is less. You pay a
$5 copay per prescription unit or refill for formulary generic drugs or an $10 copay for formulary name
brand drugs or a $20 copay for non-formulary prescription drugs requested by the prescribing doctor.
When generic substitution is permissible (i. e., a generic drug is available and the prescribing doctor does
not require the use of a mane brand drug), but you request the name brand drug, you pay the price
difference between the average wholesale prices of the generic and name brand drug as well as the
$10 copay per prescription unit or refill.

You can obtain covered "maintenance" prescription drugs use to treat chronic or long-term health
conditions such as high blood pressure or diabetes) for a 93-day supply. You pay $10 copay per
prescription unit or refill for formulary generic drugs, a $20 copay for formulary name brand drugs
or a $40 copay for non-formulary prescription drugs requested by the prescribing doctor.

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The
Plan's formulary is based on effectiveness and cost of drugs. Nonformulary drugs will be covered when
prescribed by a Plan doctor.

These are the dispensing limitations. Covered "maintenance" prescription drugs use to treat chronic or
long-term health conditions such as high blood pressure or diabetes) for a 93-day supply. Prescription
drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up
to a 31-day supply or 100-unit dosage, whichever is less. If a 90 day supply is prescribed, you will be
able to pick up a 31 day supply at the pharmacy. The balance of the script will be dispensed on a 31-day
basis..

Prescription drug benefits begin on the next page. 30
30 Page 31 32
2001 Coventry Health Care of Kansas, Inc. 31 Section 5 (f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail
order program:

· Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded below.

· Insulin
· Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution, or equivalent, and

acetone test tablets are each available for the $10 copay.
· Disposable needles and syringes for the administration of covered medications

· Drugs for sexual dysfunction (see Prior authorization below)
· Contraceptive drugs and devices

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
1-800-664-9251.

Retail Pharmacy
$ 5 per generic formulary drug
$ 10 per brand name formulary
drug

$20 per non formulary drug
Mail Order (93-day supply)
$10 generic formulary
$20 brand name formulary
$40 non-formulary drug

Note: If there is no generic
equivalent available, you will
still have to pay the brand name
c o p a y. If there is a generic
equivalent and you choose the
brand name drug, you will pay
the brand name copay plus the
d i fference in the average whole-sale
price between the generic
and the brand name drug. T h i s
applies to both the formulary and
non-formulary drugs. 31
31 Page 32 33
2001 Coventry Health Care of Kansas, Inc. 32 Section 5 (f)
Covered medications and supplies (Continued) You Pay
Not covered: All charges
· Drugs available without a prescription or for which a non-prescription equivalent is available.

· Drugs and supplies for cosmetic purposes
· Vitamins, nutrients and food supplements even if a physician prescribes or administers them

· Nonprescription medicines
· Drugs obtained at a non-plan pharmacy except out-of-area emergencies
· Medical supplies such as dressings and antiseptics
· Drugs to enhance athletic performance
· Drugs to aid in smoking cessation, including nicotine patches

· Fertility drugs
· Appetite suppressants and other drugs to assist in weight control (except for the treatment of morbid obesity when authorized by the

Plan and your primary care physician). 32
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2001 Coventry Health Care of Kansas, Inc. 33 Section 5 (g)
Section 5 (g). Special Features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

· We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.
· Alternative benefits are subject to our ongoing review.
· By approving an alternative benefit, we cannot guarantee you will get it in the future.

· The decision to offer an alternative benefit is solely ours, and we may with draw it at any time and resume regular contract benefits.
· Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

High risk pregnancies Members enrolled in our prenatal program who are identified as being in a high risk category will be followed by an RN and placed into case
management. This program offers special services for moms with special
needs. Contact us at 1-800-664-9251 for more information. 33
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2001 Coventry Health Care of Kansas, Inc. 34 Section 5 (h)
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Section 5 (h). Dental benefits
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 have no calendar year deductible.
· 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 with Medicare.

Accidental injury benefit You pay
We cover restorative services and supplies necessary to $10 per office visit
promptly repair (but not replace) sound natural teeth.
The need for these services must result from an
accidental injury.

Dental Benefits
We have no other dental benefits. 34
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2001 Coventry Health Care of Kansas, Inc. 35 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
maximums.

Vision Discount Program: In addition to the other vision benefit, when a Coventry Health
Care member has an office visit with a participating optometrist who dispenses glasses and
non-disposable contact lenses, that eyewear can be purchased with a 15% discount. Ask
your participating optometrist for details. 35
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2001 Coventry Health Care of Kansas, Inc. 36 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.

We do not cover the following:
· Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
· Services, drugs, or supplies you receive while you are not enrolled in this Plan;
· Services, drugs, or supplies that are not medically necessary;
· Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

· Experimental or investigational procedures, treatments, drugs or devices;
· Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest ;

· Services, drugs, or supplies related to sex transformations;
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 36
36 Page 37 38
2001 Coventry Health Care of Kansas, Inc. 37 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, Hospital and Drug
B e n e f i t s In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.

Facilities will file on the UB-92 form. For claims questions and assistance,
call us at 1-800-664-9251.

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 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: Coventry Health Care of Kansas
8301 E. 21 st North, Suite 300
Wichita, Kansas 67206

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. 37
37 Page 38 39
2001 Coventry Health Care of Kansas, Inc. 38 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 Ð including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. Write to us at: Coventry Health Care of Kansas, Inc, 8301 E 21 st North, Suite 300, Wichita, KS 67206

You must:
(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: Coventry Health Care of Kansas, Inc.; 8301 E. 21 st North, Suite 300;
Wichita, KS 67206

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy
of our requestÑ go to step 3.

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

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within: · 90 days after the date of our letter upholding our initial decision; or

· 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 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. 38
38 Page 39 40
2001 Coventry Health Care of Kansas, Inc. 39 Section 8
The disputed claims process (Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as
your representative, such as medical providers, must provide a copy of your specific written consent with the
review request.

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

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies. 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
1-800-664-9251 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/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 39
39 Page 40 41
2001 Coventry Health Care of Kansas, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under
coverage another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance Commissioners'
guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance.

· What is Medicare? Medicare is a Health Insurance Program for:
·· People 65 years of age and older.
·· Some people with disabilities, under 65 years of age.
·· People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
·· Part A (Hospital Insurance). Most people do not have to pay for Part A.
·· Part B (Medical Insurance). Most people pay monthly for Part B.

If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.

· The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B benefits. You
may go to any doctor, specialist, or hospital that accepts Medicare. Medicare
pays its share and you pay your share. Some things are not covered under
Original Medicare, like prescription drugs

When you are enrolled in this Plan and Original Medicare, you still need to
follow the rules in this brochure for us to cover your care. Your care must
continue to be authorized by your Plan PCP, or precertified as required.

We will waive some copayments, coinsurance, and deductibles, as follows:
When Original Medicare is the primary payor, we will waive your out of
pocket costs including copayments and coinsurance. 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.

(Primary payer chart begins on next page.) 40
40 Page 41 42
2001 Coventry Health Care of Kansas, Inc. 41 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
A. When either you --or your covered spouse --are age 65 or over and É Then the primary payer isÉ

Original Medicare This Plan
1) Are an active employee with the Federal government (including when
you or a family member are eligible for Medicare solely because of a 3
disability),

2) Are an annuitant, 3
3) Are a re-employed annuitant with the Federal government when ............
a) The position is excluded from FEHB, or............................................ 3

b) The position is not excluded from FEHB .......................................... 3
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 3
covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, 3 3
(for Part B (for other
services) services)

6) Are a former Federal employee receiving Workers'Compensation and 3
the Office of Workers'Compensation Programs has determined that (except for claims
you are unable to return to duty, related to Workers'
Compensation.)

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

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, 3

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, 3

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

C. When you or a covered family member have FEHB andÉ

1) Are eligible for Medicare based on disability, and
a) Are an annuitant ................................................................................ 3
b) Are an active employee .................................................................... 3

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 41
41 Page 42 43
2001 Coventry Health Care of Kansas, Inc. 42 Section 9
Coordinating benefits with other coverage (Continued)
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 payer, we process the claim first.
· When Original Medicare is the primary payer, 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 1-800-664-9251 or visit
us at www. chcwic. cvty. com.

We waive some costs when you have Medicare --When Medicare is the
primary payer, we will waive some out-of-pocket costs, as follows:

· Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare Part B, we will waive

your out-of-pocket costs including copayments and coinsurance. 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.

· Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare
managed care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans cover all Medicare Part A
and B benefits. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you
enroll in a Medicare managed care plan, the following options are available
to you:

This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary and we will waive your out-of
pocket costs like copayments and coinsurance, up to our allowed amount.

Suspended FEHB coverage and a Medicare managed care plan: If you
are an annuitant or former spouse, you can suspend your FEHB coverage
and enroll in a Medicare managed care plan. For information on suspending
your FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the
Medicare+ Choice 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. 42
42 Page 43 44
2001 Coventry Health Care of Kansas, Inc. 43 Section 9
Coordinating benefits with other coverage (Continued)
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS

program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

Workers' Compensation We do not cover services that:
· you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or
State agency determines they must provide; or

· OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under
OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment,
we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care for
for injuries 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. 43
43 Page 44 45
2001 Coventry Health Care of Kansas, Inc. 44 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 cal-endar 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 13.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Non-medical services that do not attempt to cure, are provided during periods when the medical condition of a patient is not changing, and do not require
the continual services of medical personnel.

Deductible A deductible is a fixed amount of covered expenses you must incur for cer-tain covered services and supplies before we start paying benefits for those
services. We have no deductible.

Experimental or
investigational services Any treatment, procedure, facility, equipment, drug or drug usage, device, or supply that is not accepted as standard medical practice by Coventy Health

Care or the general medical community, or does not have federal government
agency approval for its use or application.

Medical necessity Any service or supply for the prevention, diagnosis, or treatment that is (1) consistent with illness, injury or condition of the Member; (2) in accordance
with the approved and generally accepted medical or surgical practice
prevailing in the geographical locality where, and at the time when, the
service or supply is ordered. Determination of "generally accepted practice"
is the discretion of the Medical Director or Medical Director's designee.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. We base our allowance on the allowed
covered charges Providers in the network accept from the Plan. Allowances,
which are generally lower than a provider's billed charges, serve as
maximum allowed amounts in computing coinsurances. Providers in the
network accept the Plan allowance as payment in full for all covered
services.

Us/ We Us and we refer to Coventry Health Care of Kansas
You You refers to the enrollee and each covered family member. 44
44 Page 45 46
2001 Coventry Health Care of Kansas, Inc. 45 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. 45
45 Page 46 47
2001 Coventry Health Care of Kansas, Inc. 46 Section 11
FEHB Facts (Continued)
When benefits and The benefits in this brochure are effective on January 1. If you are new to this
premiums start Plan, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. A n n u i t a n t s ' 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
c o v e r a g e 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 F e d e r a l
e x -s p o u s e 's employing or retirement office to get RI 70-5, the Guide to
Employees Health Benefits Plans for Te m p o r a ry Continuation of Coverage
and Former Spouse Enro l l e e s , 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. 46
46 Page 47 48
2001 Coventry Health Care of Kansas, Inc. 47 Section 11
FEHB Facts (Continued)
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 n o t 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;
h o w e v e r, 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/ 664-9251 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. 47
47 Page 48 49
2001 Coventry Health Care of Kansas, Inc. 48 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Fecal occult blood test .................. 14
General Exclusions........................ 36
Hearing services ............................ 17
Home health services .................... 19
Hospice care .................................. 25
Home nursing care ........................ 19
Hospital.......................................... 23
Immunizations .............................. 14
Infertility........................................ 15
Inhospital physician care .............. 13
Inpatient Hospital Benefits............ 23
Insulin............................................ 30
Laboratory and pathological
services .................................. 13
Machine diagnostic tests................ 13
Magnetic Resonance Imagings
(MRIs).................................... 13
Mail Order Prescription Drugs...... 30
Mammograms................................ 14
Maternity Benefits ........................ 15
Medicaid........................................ 43
Medically necessary ...................... 44
Medicare........................................ 40
Mental Conditions/ Substance
Abuse Benefits ...................... 28
Newborn care ................................ 13
Non-FEHB Benefits ...................... 35
Obstetrical care.............................. 15
Occupational therapy .................... 17
Ocular injury.................................. 17
Office visits.................................... 11
Oral and maxillofacial surgery...... 21
Orthopedic devices........................ 18
Ostomy and catheter supplies........ 19
Out-of-pocket expenses ................ 11
Outpatient facility care.................. 24
Oxygen .......................................... 19
Pap test .......................................... 23
Physical examination .................... 14
Physical therapy ............................ 17

Physician.......................................... 8
Pre-admission testing .................... 24
Precertification .............................. 10
Preventive care, adult.................... 14
Preventive care, children .............. 14
Prescription drugs.......................... 31
Preventive services........................ 14
Prior approval................................ 10
Prostate cancer screening .............. 14
Prosthetic devices.......................... 18
Psychologist .................................. 28
Psychotherapy................................ 28
Radiation therapy .......................... 24
Rehabilitation therapies ................ 17
Renal dialysis ................................ 23
Room and board ............................ 23
Second surgical opinion ................ 13
Skilled nursing facility care .......... 24
Smoking cessation ........................ 32
Speech therapy .............................. 17
Splints............................................ 23
Sterilization procedures ................ 20
Subrogation.................................... 43
Substance abuse ............................ 29
Surgery .......................................... 20
Anesthesia...................................... 22
Oral................................................ 21
Outpatient ...................................... 24
Reconstructive .............................. 21
Syringes ........................................ 31
Temporary continuation of
coverage.................................. 46
Transplants .................................... 22
Treatment therapies ...................... 16
Vision services .............................. 17
Well child care .............................. 14
Wheelchairs .................................. 19
Workers'compensation ................ 43
X-rays ............................................ 13

Accidental injury .......................... 26
Allergy tests .................................. 16
Alternative treatment .................... 18
Ambulance .................................... 24
Anesthesia...................................... 22
Autologous bone marrow
transplant................................ 22
Biopsies ........................................ 20
Birthing centers.............................. 15
Blood and blood plasma................ 23
Breast cancer screening ................ 13
Casts .............................................. 23
Catastrophic protection.................. 26
Changes for 2001 ............................ 7
Chemotherapy................................ 16
Childbirth ...................................... 15
Cholesterol tests ............................ 14
Claims............................................ 37
Coinsurance .................................. 11
Colorectal cancer screening .......... 14
Congenital anomalies .................... 20
Contraceptive devices and drugs .. 15
Coordination of benefits................ 42
Covered charges ............................ 44
Covered providers............................ 7
Crutches ........................................ 19
Definitions .................................... 44
Dental care .................................... 34
Diagnostic services........................ 13
Disputed claims review ................ 38
Donor expenses (transplants) ........ 22
Dressings ...................................... 20
Durable medical equipment
(DME) .................................... 19
Educational classes and programs .. 19
Effective date of enrollment............ 8
Emergency .................................... 26
Experimental or investigational .... 36
Eyeglasses...................................... 17
Family planning ............................ 15 48
48 Page 49 50
2001 Coventry Health Care of Kansas, Inc. 49 Summary
Summary of benefits for Coventry Health Care of Kansas -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 primary 13 care; $10 specialist

Services provided by a hospital:
· Inpatient.................................................................................................... Nothing 23
· Outpatient..................................................................................................

Emergency benefits:
· In-area ...................................................................................................... $50 per Emergency Room visit; 26 $25 per Urgent Care visit

· Out-of-area................................................................................................

Mental health and substance abuse treatment................................................ Regular cost sharing 28
Prescription drugs .......................................................................................... $5 for generic formulatory 30
$10 for brand name formulary
$20 for generic/ brand name
non-formulatory drug

Dental Care .................................................................................................... No benefit. 34

Vision Care .................................................................................................... $10 per office visit 17
Special features: Comprehensive Prenatal program including educational packets and coupons for free 33
prenatal classes.

Protection against catastrophic costs ............................................................ Nothing after $1,000/ Self Only or
(your out-of-pocket maximum) $3,000/ Family enrollment per year

Prescription drug costs do not
11

count toward this protection. 49
49 Page 50
2001 Rate Information for
Coventry Health Care of Kansas, Inc. (formerly Principal Health Care of Kansas City)

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