Pages 1--58 from AmCare Health Plans

TEXAS (AUSTIN/ SAN ANTONIO AREAS) Enrollment Code:
ZG1 Self Only ZG2 Self and Family

LOUISIANA (NEW ORLEANS AREA) Enrollment Code:
ZH1 Self Only ZH2 Self and Family

LOUISIANA (BATON ROUGE/ ALEXANDRIA/ SHREVEPORT AREAS) Enrollment Code:
ZQ1 Self Only ZQ2 Self and Family

OKLAHOMA (OKLAHOMA CITY/ TULSA AREAS)

RI 73-805
Special notice: This Plan is offered for the first time under the Federal
Employees Health Benefits Program during the 2000 Open Season.

Enrollment Code: ZX1 Self Only
ZX2 Self and Family 1
1 Page 2 3
2001 AmCare Health Plans 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………........................................................................ 4
Plain Language………………………………………………………………....................................................................... 4
Section 1. Facts about this HMO plan......................................................................................................................................... 5
How we pay providers................................................................................................................................................. 5
Who provides my health care?…………………………………………………………………………….. 5
Patients' Bill of Rights................................................................................................................................................. 5
Service Area .................................................................................................................................................................. 6
Section 2. FEHB change for 2001………………………………………............................................................................. 8
Program-wide changes................................................................................................................................................ 8

Section 3. How you get care …………....................................................................................................................................... 9
Identification cards ...................................................................................................................................................... 9
Where you get covered care ....................................................................................................................................... 9
· Plan providers ........................................................................................................................................................ 9
· Plan facilities.......................................................................................................................................................... 9
What you must do to get covered care ..................................................................................................................... 9
· Primary care ........................................................................................................................................................... 9
· Specialty care ......................................................................................................................................................... 9
· Hospital care......................................................................................................................................................... 10
Circumstances beyond our control.......................................................................................................................... 11
Services requiring our prior approval..................................................................................................................... 11
Section 4. Your costs for covered services............................................................................................................................... 12
· Copayments ......................................................................................................................................................... 12
· Deductible............................................................................................................................................................. 12
· Coinsurance ......................................................................................................................................................... 12
Yo ur out-of-pocket maximum.................................................................................................................................. 12
Section 5. Benefits…………………………………………………………....................................................................... 13
Overview...................................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ............ 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ........ 23
(c) Services provided by a hospital or other facility, and ambulance services .......................................... 28
(d) Emergency services/ accidents ..................................................................................................................... 31
(e) Mental health and substance abuse benefits.............................................................................................. 33
(f) Prescription drug benefits ............................................................................................................................. 35
(g) Special features............................................................................................................................................... 39
(h) Dental benefits ................................................................................................................................................ 40
Section 6. General exclusions --things we don't cover.......................................................................................................... 41 2
2 Page 3 4
2001 AmCare Health Plans 3 Table of Contents
Section 7. Filing a claim for covered services .......................................................................................................................... 42
Section 8. The disputed claims process..................................................................................................................................... 44
Section 9. Coordinating benefits with other coverage ............................................................................................................ 46
When you have…
·Other health coverage ........................................................................................................................................ 46
·Original Medicare ............................................................................................................................................... 46
·Medicare managed care plan............................................................................................................................. 48
TRICARE/ Workers Compensation/ Medicaid ....................................................................................................... 48
Other Government agencies...................................................................................................................................... 49
When others are responsible for injuries ................................................................................................................ 49
Section 10. Definitions of terms we use in this brochure ....................................................................................................... 50
Section 11. FEHB facts ................................................................................................................................................................ 52

Coverage information.................................................................................................................................................
· No pre-existing condition limitation...............................................................................................................
· Where you get information about enrolling in the FEHB Program..........................................................
· Types of coverage available for you and your family .................................................................................
· When benefits and premiums start .................................................................................................................
· Your medical and claims records are confidential.......................................................................................
· When you retire..................................................................................................................................................
When you lose benefits .............................................................................................................................................
· When FEHB coverage ends.............................................................................................................................
· Spouse equity coverage ...................................................................................................................................
· Temporary Continuation of Coverage (TCC)..............................................................................................
· Enrolling in TCC...............................................................................................................................................
· Converting to individual coverage.................................................................................................................
· Getting a Certificate of Group Health Plan Coverage................................................................................

Inspector General Advisory .......................................................................................................................................................... 54
Index .................................................................................................................................................................................... 55
Summary of benefits ...................................................................................................................................................................... 57
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2001 AmCare Health Plans Introduction/ Plain Language
Introduction
AmCare Health Plans
2707 North Loop West, Suite 300
Houston, Texas 77008

This brochure describes the benefits of AmCare Health Plans under our contract (CS 2864) 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. Benefits are summarized on page 59. 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 AmCare Health Plans.

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
4 Page 5 6
2001 AmCare Health Plan 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, IPA's 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. AmCare Health Plans offers members an extensive choice of primary care physicians.

Who provides my health care?
AmCare contracts with both direct physicians, Medical Groups and Independent Physician Associations (IPA). When
choosing a physician from the provider directory for your primary care needs, you should expect to receive specialty
care from providers affiliated with your primary care physician's medical group or IPA. Obstetricians/ gynecologists
must be selected from providers affiliated with your primary care physician's network. If the physician network cannot
provide the services being requested, your primary care physician will make arrangements for you to receive the care
from an appropriate provider. To find out if your primary care physician is affiliated with a medical group or IPA, check
the provider directory or call the plan before you make your selection.

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

If you want more information about us, call us at: Texas: (800) 782-8373; Oklahoma: (800) 772-2993; Louisiana (800)
772-2995., or write to AmCare Health Plans 2707 N. Loop West, Suite 300, Houston, Texas 77008. You may also
contact us by fax at (713) 864-9393 or visit our website at www. amcarehealthplans. com 5
5 Page 6 7
2001 AmCare Health Plans 6 Section 1
Service Area
To enroll in this Plan, you must live, reside in or work in our Service Area. This is where our providers practice and
where we are licensed to provide services. Where we are licensed only in certain zip codes of a parish or county
covered zip codes have been listed. Our service area is:

TEXAS (HOUSTON/ EL PASO AREAS) Enrollment Code:
2V1 Self Only 2V2 Self and Family

Full County
EL PASO FORT BEND GALVESTON HARRIS HUDSPETH MONTGOMERY

Partial County by zip code
AUSTIN -BELLVILLE 77418, KENNEY 77452, SAN FELIPE 77473, SEALY 77474, WALLIS 77485
BRAZORIA -ALVIN 77511, 77512, ANGLETON 77515, 77516, CLUTE 77531, DAMON 77430, DANBURY
77534, DANCIGER 77431, FREEPORT 77541, 77542, LAKE JACKSON 77566, LIVERPOOL 77577, MANVEL
77578, OLD OCEAN 77463, PEARLAND 77581, 77584, ROSHARON 77583, WEST COLUMBIA 77486
CHAMBERS -BAYTOWN 77520
COLORADO -CAT SPRING 78933
LIBERTY -CLEVELAND 77327, DAYTON 77535

TEXAS (AUSTIN/ SAN ANTONIO AREAS) Enrollment Code:
ZG1 Self Only ZG2 Self and Family

Full County ATASCOSA BANDERA BASTROP BELL BEXAR BLANCO
BURNET CALDWELL COMAL GUADALUPE HAYS KENDALL
KERR LEE MEDINA MILAM TRAVIS WALLER
WILLIAMSON WILSON

OKLAHOMA (OKLAHOMA CITY/ TULSA AREAS) Enrollment Code:
ZX1 Self Only ZX2 Self and Family

Full County
ALFALFA CANADIAN CHEROKEE CLEVELAND COMANCHE COTTON
CREEK GARFIELD GRANT HUGHES JACKSON KINGFISHER
KIOWA LOGAN LINCOLN MAYES MCCLAIN OKFUSKEE
OKLAHOMA OKMULGEE PAWNEE POTTAWATOMIE ROGERS
SEMINOLE TILLMAN TULSA WAGONER WOODS

Partial County by zip code
BLAINE -HITCHCOCK 73744, OKEENE 73763, WATONGA 73772
CADDO -ALBERT 73001, CEMENT 73017, CYRIL 73029
GRADY -AMBER 73004, MINCO 73059, POCASSET 73079, TUTTLE 73089
GREER -GRANITE 73547, MANGUM 73554, WILLOW 73673
HARMON -GOULD 73544
MAJOR -AMES 73718, ISABELLA 73747, MENO 73760, RINGWOOD 73768
MUSKOGEE -BOYNTON 74422, HASKELL 74436, PORUM 74455, TAFT 74463, WARNER 74469
NOWATA -NOWATA 74048 6
6 Page 7 8
2001 AmCare Health Plans 7 Section 1
OSAGE -AVANT 74001, BARNSDALL 74002, HOMINY 74035, OSAGE 74054, PAWHUSKA 74056, PRUE
74060, SKIATOOK 74070, WYNONA 74084
STEPHENS -DUNCAN 73533, 73534, MARLOW 73055
WASHINGTON -OCHELATA 74051, RAMONA 74061, VERA 74082
WASHITA -BESSIE 73622, BURNS FLAT 73624, CORDELL 73632, DILL CITY 73641, ROCKY 73661,
SENTINEL 73664

LOUISIANA (BATON ROUGE/ ALEXANDRIA/ SHREVEPORT AREAS) Enrollment Code:
ZQ1 Self Only ZQ2 Self and Family

Full Parish
ASCENSION ASSUMPTION BIENVILLE BOSSIER CADDO CLAIBORNE
CONCORDIA DE SOTO EAST BATON ROUGE EAST FELICIANA
GRANT IBERVILLE LA SALLE LIVINGSTON NATCHITOCHES
POINTE COUPEE RED RIVER SABINE ST. HELENA WEBSTER WEST BATON
ROUGE WEST FELICIANA WINN

LOUISIANA (NEW ORLEANS AREA) Enrollment Code:
ZH1 Self Only ZH2 Self and Family

Full Parish
JEFFERSON ORLEANS PLAQUEMINES ST. CHARLES ST. JAMES
ST. JOHN THE BAPTIST ST. BERNARD ST. TAMMANY TANGIPAHOA WASHINGTON

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care. 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 office or retirement office. 7
7 Page 8 9
2001 AmCare Health Plans 8 Section 2
Section 2. FEHB changes 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.

· 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: Texas: (800) 782-8373; Oklahoma: (800) 772-2993; Louisiana (800) 772-2995, or
checking our website, www. amcarehealthplans. com. You can find out more about patient safety on the OPM
website, www. opm. gov/ insure. To improve your healthcare, take these five steps:

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

language referenced only women. 8
8 Page 9 10
2001 AmCare Health Plans 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at Texas: (800)
782-8373; Oklahoma: (800) 772-2993; Louisiana (800) 772-2995.

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

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

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since
your primary care physician provides or arranges for most of your health
care. If you need assistance in choosing a primary care physician please
call us at Texas: (800) 782-8373; Oklahoma: (800) 772-2993; Louisiana
(800) 772-2995.

· · Primary care Your primary care physician can be a general practitioner, family practitioner, internist for members over age 16 or a pediatrician for
children up to age 18. Your primary care physician will provide most of
your health care, or give you a referral to see a specialist, when
appropriate.

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

· · Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see an obstetrician/ gynecologist without a referral.

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 your specialist to develop a treatment plan that allows you to see
your specialist for a certain number of visits, up to a 12 month referral
for certain types of medical conditions which require on-going 9
9 Page 10 11
2001 AmCare Health Plan s 10 Section 3
treatment of referring diagnosis, 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). In certain situations with chronic, disabling or
life threatening illnesses you may be eligible to have your specialist act
as your primary care physician. This process requires the prior approval
of the AmCare Health Plans Senior Medical Director and must meet
certain criteria set forth by AmCare Health Plans.

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

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

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

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

·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us at Texas: (800) 782-
8373; Oklahoma: (800) 772-2993; Louisiana (800) 772-2995 for more
information; or, if we drop out of the Program, contact your new health
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 Texas: (800) 782-8373;
Oklahoma: (800) 772-2993; Louisiana (800) 772-2995. 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 10
10 Page 11 12
2001 AmCare Health Plans 11 Section 3
· The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
prior 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 Referral Notification/ Prior
Authorization.

There are certain services which only require Referral Notification to
AmCare by your physician: Specialist consultations; referrals to ER;
Dialysis; Colonoscopy/ Endoscopy; Cystoscopy; CT Scans; Home Uterine
Monitoring; Hyperbaric treatment; Lithotripsy; Outpatient Chemotherapy;
Outpatient Radiation; Outpatient Nuclear Imaging; ; Pre-natal care; and
DME items such as: nebulizers, canes, crutches, walkers, commode chairs,
and cervical traction units.

Your physician must obtain prior authorization for the following services:
Inpatient admissions; Outpatient Surgery; Twenty-three hour observation
(in a hospital); Angiography; CT Myelogram; MRA; MRI; DME, except
as listed above; Home Health and Hospice services; Home IV therapy;
Infertility Services; Nutritional Therapy and Dietician services;
Occupational, speech, cardiac and physical therapy;
Orthotics/ Prosthetics/ Braces; Psychological testing; Growth Hormones;
Morbid Obesity Treatment; Requests for services by out-of-network
providers; and Transplant Services. 11
11 Page 12 13
2001 AmCare Health Plans 12 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 or specialist
physician you pay a copayment of $10 per office visit and when you go in
the hospital, you pay nothing per admission.

· · Deductible We do not have a 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 if the new plan has a
deductible.

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. Coinsurance doesn't begin until you meet your deductible.

Example: In our Plan, you pay 50% of our allowance for infertility
services and 50% of the cost of prescription drug medications not listed in
the AmCare Preferred Plan Guide (see Prescription Drug benefits in
section 5 for more information.)

Your out-of-pocket maximum for coinsurance, and copayments After your copayments and/ or coinsurance total $650 per person or $1500

per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, copayments and/ or coinsurance for
the following services do not count toward your out-of-pocket maximum,
and you must continue to pay copayments and/ or coinsurance for these
services:

· Durable Medical Equipment ·
Prosthetic Devices
· Prescription Drugs
· Infertility Services Be sure to keep accurate records of your copayments and/ or coinsurance

since you are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 AmCare Health Plans 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 57 for a benefits summary.)

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

Texas: (800) 782-8373 Oklahoma: (800) 772-2993 Louisiana: (800) 772-2995
(a) Medical services and supplies provided by physicians and other health care professionals .......................................... 14-22

·Diagnostic and treatment services
·Lab, X-ray, and other diagnostic tests ·Preventive
care, adult
·Preventive care, children
·Maternity care ·Family
planning
·Infertility services
·Allergy care ·Treatment
therapies
·Rehabilitative therapies

·Hearing services (testing, treatment, and
supplies)
·Vision services (testing, treatment, and supplies)

·Foot care ·Orthopedic
and prosthetic devices
·Durable medical equipment (DME)
·Home health services ·Alternative
treatments
·Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals .......................... 23-27
·Surgical procedures ·Reconstructive
surgery
·Oral and maxillofacial surgery ·Organ/
tissue transplants
·Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ............................................................ 28-30
·Inpatient hospital ·Outpatient
hospital or ambulatory surgical
center

·Skilled nursing care facility benefits ·Hospice
care
·Ambulance

(d) Emergency services/ accidents ............................................................................................................................... 31-32
·Medical emergency ·Ambulance

(e) Mental health and substance abuse benefits........................................................................................................ 33-34
(f) Prescription drug benefits ............................................................................................................................................... 35-38
(g) Special features....................................................................................................................................................................... 39
· Flexible benefits option
· AmCare Arrivals

· Services for deaf and hearing impaired
· Travel benefit
(h) Dental benefits ........................................................................................................................................................................ 40
Summary of benefits...................................................................................................................................................................... 57 13
13 Page 14 15
2001 AmCare Health Plans 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

· Plan physicians must provide or arrange your care.
· The calendar year deductible is: 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.

I M
P O
R T
A N
T

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

· After-hour physician visits in physician's office

$10 per office visit
$35 per office visit

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

· Office medical consultations
· Second surgical opinion

Nothing
Nothing
Nothing
Nothing
$10 per office visit
Nothing

At home $10 per office visit

Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2001 AmCare Health Plans 15 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Lab, X-ray and other diagnostic tests
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap tests
· Pathology
· X-rays
· Non-routine Mammograms
· CAT Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG

Nothing

Preventive care, adult
Routine screenings, such as:
· Routine Physical Examinations
· Blood lead level – One annually
· Total Blood Cholesterol – as clinically indicated
· Colorectal Cancer Screening, including
··Fecal occult blood test

Nothing

··Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing
Routine pap test
Note: Included as part of the annual well-woman examination
Nothing

Routine mammogram –covered for women age 35 and older, as
follows:

· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age 65 and older, one every two consecutive calendar years

· For those women with other risk factors

Nothing

Not covered: Physical exams or immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or
travel.
All charges. 15
15 Page 16 17
2001 AmCare Health Plans 16 Section 5( a)
Preventive care, adult (Continued) You pay
Routine Adult Immunizations, such as:
· Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

· Influenza/ Pneumococcal vaccines,
· Hepatitis A & B
· Varicella
(Prescribed as clinically indicated or in accordance with AmCare
Preventive Care Guidelines for Adults)

Nothing

Preventive care, children You pay
· Childhood immunizations recommended by the American Academy
of Pediatrics
Nothing

· Examinations, such as:
··Eye exams through age 17 to determine the need for vision
correction.

··Ear exams through age 17 to determine the need for hearing correction

··Examinations done on the day of immunizations ( through age 22)
· Well-child care charges for routine examinations, immunizations and
care (through age 22)

Nothing

Maternity care You pay
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery

· Postnatal care
Note: Here are some things to keep in mind:
· You do need to precertify your normal delivery; see page 11 for
other circumstances, such as extended stays for you or your baby.

· You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
· We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

· We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

$10 per office visit for initial visit
only

Nothing

Nothing, after initial visit
copayment noted above 16
16 Page 17 18
2001 AmCare Health Plans 17 Section 5( a)
· Routine Obstetrical care includes medically necessary diagnostic
procedures such as ultrasounds as determined by your Physician

Family planning You pay
· Voluntary sterilization
· Counseling
· Surgically implanted contraceptives
· Injectable contraceptive drugs
· Intrauterine devices insertion/ removal (IUDs)

$25 per office visit
$10 per office visit
50% of charges
$10 per office visit
$25 per office visit

Not covered: reversal of voluntary surgical sterilization, subsequent resterilization; and genetic counseling, All charges.

Infertility services You pay
Diagnosis and treatment of infertility, such as:
· Diagnostic Testing

· Artificial insemination Services:
· Intravaginal insemination (IVI)
· Intracervical insemination (ICI)

$10 per office visit
50% of charges per procedure

Not covered:
· Assisted reproductive technology (ART) procedures, such as:
··in vitro fertilization
··embryo transfer and GIFT
··ZIFT procedures
··Intra-uterine insemination

· Services and supplies related to excluded ART procedures
· Cost of donor sperm
· Surrogate Parenting
· Fertility drugs (We do not cover fertility drugs under either medical or prescription drug benefits.)

All charges. 17
17 Page 18 19
2001 AmCare Health Plans 18 Section 5( a)
Allergy care
Testing and treatment

Allergy injection
$25 per office visit

$10 per office visit
Allergy serum (Covered in full) Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges.

Treatment therapies You pay
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page xx.

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

· Growth hormone therapy (GHT)
Note: – We will only cover GHT when we prior authorize the
treatment. Call Texas: (800) 585-7290; Oklahoma: (800) 977-1775;
Louisiana (800) 772-2995 for prior authorization. We will ask you to
submit information that establishes that the GHT is medically necessary
and meets the plan's medical criteria. Ask us to authorize GHT before
you begin treatment; otherwise, we will only cover GHT services from
the date you receive prior authorization. If you do not ask or if we
determine GHT is not medically necessary, we will not cover the GHT
or related services and supplies. See Services requiring our prior
approval in Section 3.

$10 per office visit

Not covered: All charges. 18
18 Page 19 20
2001 AmCare Health Plans 19 Section 5( a)
Rehabilitative therapies You pay
Unlimited (Medically Necessary) Physical therapy, occupational
therapy, speech therapy, and cardiac therapy which meets the
following requirements–

· For a physically disabled person, is designed to restore maximum
function, maintenance of functioning or prevention of or slowing of
deterioration

· Is authorized by your Primary Care Physician and approved by Us
· Includes a written treatment plan with specific goals and objectives
· Services can be expected to meet or exceed treatment goals and objectives in written treatment plan

· Can be provided in an inpatient or outpatient setting

$10 per office visit

Not covered:
· For cardiac rehabilitation, supervised exercise that is not EKG monitored
All charges.

Hearing services (testing, treatment, and supplies)
· Hearing testing for children through age 17 (see Preventive care, children)

· Hearing aids for children (up to 13 years of age)
$10 per office visit
$10 per office visit

Not covered:
· all other hearing testing · hearing aids, testing and examinations for them
All charges.

Vision services (testing, treatment, and supplies) You pay
· Eye exam to determine the need for vision correction for children through age 17 (see preventive care)

· Annual eye refractions for children through age 17 (see preventive
care)

$10 per office visit

Not covered:
· Eyeglasses or contact lenses
· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery

All charges. 19
19 Page 20 21
2001 AmCare Health Plans 20 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe
inserts relating to the treatment of diabetes.

$10 per office visit

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

except as stated above
· Braces and splints

All charges.

Orthopedic and prosthetic devices You pay
· Artificial limbs and eyes
· Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

· Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5 (c) for payment information. 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.

Nothing

Not covered:
· 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

All charges. 20
20 Page 21 22
2001 AmCare Health Plans 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including replacement and
adjustment of rented items, of durable medical equipment prescribed by
your Plan physician, such as oxygen and dialysis equipment. Under this
benefit, we also cover:

· hospital beds;
· standard wheelchairs;
· crutches;
· walkers;
· Orthopedic tractions
· Bedside commodes
· Suction machines
· blood glucose monitors; and
· insulin pumps.

Note: If AmCare elects to purchase an item of DME for a Member the
member is the owner of the equipment and responsible for its repair,
replacement, and maintenance.

Nothing

Not covered:
· Motorized and special lightweight wheel chairs and beds, comfort items, bedboards, bathtub lifts, overbed tables, air purifiers,

disposable supplies, elastic stockings, sauna baths, exercise
equipment, stethoscopes, sphygmomanometers, orthopedic shoes, arch supports, and dentures

· Repair, replacement or maintenance of DME purchased by AmCare for a Member

All charges.

Home health services
· Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.
· Services include oxygen therapy, intravenous therapy and medications, physical, speech and hearing, and occupational

therapy.

$10 per office visit

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

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

All charges. 21
21 Page 22 23

22 Page 23 24
2001 AmCare Health Plans 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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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.
· The calendar year deductible is: 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© for charges associated with the facility (i. e. hospital, surgical

center, etc.) .
· YOU MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require prior

authorization and identify which surgeries require prior authorization.

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Benefit Description You pay
Surgical procedures
· Treatment of fractures, including casting
· Normal pre-and post-operative care by the surgeon ·
Correction of amblyopia and strabismus
· Endoscopy procedure ·
Biopsy procedure
· Removal of tumors and cysts ·
Correction of congenital anomalies (see reconstructive surgery)
· Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over

· Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces and prosthetic devices for device coverage information.

Nothing

Surgical procedures continued on next page. 23
23 Page 24 25
2001 AmCare Health Plans 24 Section 5( b)
Surgical procedures (Continued) You pay
· Voluntary sterilization ·
Norplant (a surgically implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered under 5( a).
· Treatment of burns

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

Nothing

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

Reconstructive surgery
Surgery to correct a functional defect
· Surgery to correct a condition caused by injury or illness if:
··the condition produced a major effect on the member's appearance and

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

Nothing

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

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

See above.

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

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

All charges 24
24 Page 25 26
2001 AmCare Health Plans 25 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
· Reduction of fractures of the jaws or facial bones; ·
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts;
· Excision of leukoplakia or malignancies; ·
Excision of cysts and incision of abscesses when done as independent
procedures; and
· Other surgical procedures that do not involve the teeth or their supporting structures.

· Surgical and non-surgical intervention for the treatment of TMJ,
including corrective orthopedic appliances and physical therapy

· Note: Orthognathic surgery would be covered when the member's health is affected but not when the doctor determines it is to improve
the appearance of a functioning structure.

Nothing

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

as the periodontal membrane, gingiva, and alveolar bone)

All charges. 25
25 Page 26 27
2001 AmCare Health Plans 26 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
· Kidney;

· Cornea;
· Liver;
· Heart;
· Lung/ Heart-Lung;
· 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.

· Limited Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a 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 and medical criteria.

Medical and hospital expenses of the donor are covered when we cover the
recipient.

$10 per office visit
Nothing for Inpatient services

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

· Donor's transportation and lodging costs · Implants of artificial organs

· Transplants not listed as covered

All charges 26
26 Page 27 28
2001 AmCare Health Plans 27 Section 5( b)
Anesthesia You pay
Professional services provided in –

· Hospital (inpatient)
Nothing

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

Nothing 27
27 Page 28 29
2001 AmCare Health Plans 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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.

· Calendar Year Deductible – We have no 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).

· YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as:
· ward, semiprivate, or intensive care accommodations;
· general nursing care; and
· meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Nothing

Other hospital services and supplies, such as:
· Operating, recovery, maternity, and other treatment rooms
· Prescribed drugs and medicines ·
Diagnostic laboratory tests and X-rays
· Administration of blood and blood products
· Blood or blood plasma, 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 bill by a hospital for use at home

Nothing

Inpatient hospital continued on next page. 28
28 Page 29 30
2001 AmCare Health Plans 29 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered:
· Custodial care · Non-covered facilities, such as nursing homes, extended care

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

· Private nursing care, unless medically necessary

All charges.

Outpatient hospital or ambulatory surgical center You pay
· Operating, recovery, and other treatment rooms ·
Prescribed drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services ·
Administration of blood, blood plasma, and other biologicals
· Blood and blood plasma, if not donated or replaced ·
Pre-surgical testing
· Dressings, casts, and sterile tray services ·
Medical supplies, including oxygen
· Anesthetics and anesthesia service

NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges
Skilled Nursing Care facility benefits You pay
The following services and supplies are covered on a short-term basis
limited to sixty (60) consecutive days when full-time skilled nursing
care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved
by the Plan.

· Use of a semi-private room ·
Meals and services of a dietician;
· General nursing care; ·
Routine laboratory examinations and tests;
· Oxygen; ·
Biologicals, drugs and medications furnished and administered by
the SNF; and
· Services and supplies for the administration of blood, blood products, or blood plasma.

$25 per day not to exceed a total
member copayment of $300.

Not covered: custodial care All charges 29
29 Page 30 31
2001 AmCare Health Plans 30 Section 5( c)
Hospice care You pay
The following services and supplies for a participating Hospice will be
covered when medically necessary and appropriate including:

· Dietary and nutritional guidance;
· 24-hour home care for periods of crisis;
· Bereavement counseling for family members;
· Pain and symptom management;
· Services of registered nurses, home health aides and medical and social workers.

Note: Such services will continue only while the member is under the
direct and active medial supervision of a participating physician for a
condition necessitating hospice care. The member must be diagnosed
with a terminal illness with a life expectancy of six months or less and
all services must be requested by and authorized by member's Primary
Care Physician

$25 per day

Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
Local professional ambulance service when it is not medically appropriate
to transport the member by ordinary public or private vehicle.

Local professional ambulance service when medically necessary to transfer
a member from a participating facility to another participating facility
provided each trip is requested by the member's Primary Care Physician
and receives prior authorization.

Nothing 30
30 Page 31 32
2001 AmCare Health Plans 31 Section 5( d)
Section 5 (d). Emergency services/ accidents
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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.

· The calendar year deductible is: 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.

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

What to do in case of emergency: 1. If time and circumstance permit, call your Primary Care Physician before seeking emergency care.
2. If possible, go to a participating emergency facility.
3. Call local emergency service or dial 911 and go to the emergency room
4. Show or have a family member show your AmCare ID card to the emergency room staff. It provides
information they may need to verify your coverage.

Emergencies within our service area: Member must obtain the services immediately after the emergency condition occurs, or as soon as
possible afterward.
As soon as possible after the emergency occurs the member must contact his or her Primary Care
Physician for advice and instruction. In any event, the member or a family member must notify the Plan
within 48 hours, unless it was not reasonably possible to do so.

The Member must be transferred to the care of health care providers that participate in the Plan as soon as
this can be done without harming your condition .

Emergencies outside our service area: If a Member requires Emergency Care outside the service area when a Participating provider is not available all benefits as described in this brochure will be

covered subject to the copayments and limitation set forth in this brochure. Such coverage is extended until
such time as it is medically appropriate for the member to return to the care of a participating provider
within the service area. Non-participating provider may require the member to make immediate and full
payment for services rendered. AmCare will reimburse the member for any services and supplies covered
under the Plan, less any copayments due for the services and supplies. 31
31 Page 32 33
2001 AmCare Health Plans 32 Section 5( d)
Benefit Description You pay
Emergency within our service area

· Emergency Care at an Urgent Care Center
· Emergency Care at a hospital emergency room
· Emergency care as an outpatient at a hospital or urgent care center, includes doctors' services

Note: Hospital emergency room copayments are waived if member is
admitted

$35 per urgent care visit
$75 per emergency visit

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

· Emergency Care at an Urgent Care Center

· Emergency care at a hospital emergency room
· Emergency care as an outpatient at a hospital or urgent care center, includes doctors' services

Note: Hospital emergency room copayments are waived if member is
admitted

$35 per urgent care visit
$75 per emergency visit

Not covered:
· Elective care or non-emergency care
· Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

· Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

Ambulance You pay
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing 32
32 Page 33 34
2001 AmCare Health Plans 33 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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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.
· The calendar year deductible is: 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.

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

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

Your cost sharing
responsibilities are no
greater than for other illness
or conditions.

· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

· Medication management

$10 per office visit
$10 per office visit

Mental health and substance abuse benefits -Continued on next page 33
33 Page 34 35
2001 AmCare Health Plans 34 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
· Diagnostic tests Nothing

· Services provided by a hospital or other facility
· Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

order us to pay or provide one clinically appropriate treatment plan in
favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
In Texas and Oklahoma AmCare Health Plans has contracted with
Magellan Behavioral Health Services (Magellan) to provide mental
health/ substance abuse benefits. AmCare members may self-refer into
the Magellan provider network. Case managers may also consult with
the Primary Care Physician concerning hospitalization to ensure
continuity of care. In the event of a crisis situation please contact
Magellan at the numbers below to be directed to the appropriate
provider or facility. Prior authorization for any mental health condition
and/ or crisis intervention must be obtained through Magellan.

Texas: (800) 324-8911
Oklahoma: (800) 729-2422

In Louisiana AmCare Health Plans has contracted with Family
Managed Care (FMC) to provide mental health/ substance abuse
benefits. AmCare members may self-refer into the FMC provider
network. Case managers may also consult with the Primary Care
Physician concerning hospitalization to ensure continuity of care. In the
event of a crisis situation please contact FMC at the number below to be
directed to the appropriate provider or facility. Prior authorization for
any mental health condition and/ or crisis intervention must be obtained
through FMC.

Louisiana: (800) 572-6983

Limitation We may limit your benefits if you do not follow your treatment plan. 34
34 Page 35 36
2001 AmCare Health Plans 35 Section 5( f)
Section 5 (f). Prescription drug benefits
I
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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.

· The calendar year deductible is: We have no Calendar Year Deductible
· Certain medications are eligible for coverage only after a patient-specific approval has been authorized. Physicians and pharmacists must contact MedImpact Healthcare

Services, Inc. prior authorization requests are accepted by fax only from the physician.
Please fax to (800) 578-9732.

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

coverage, including with Medicare.

I
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There are important features you should be aware of. These include:
· Who can write your prescription. A licensed physician in the state where the services are rendered must write the prescription.

· Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail through the Plan's mail order drug benefit for a maintenance medication.
· We use a Preferred Plan Drug List. The Preferred Plan Drug List is a listing of medications
available at your generic, and preferred brand copay levels. As your plan is for a three tiered or open
formulary, the medications not listed in the Generic or Preferred Brand categories are also available
to you but at a higher copayment. There may also be medications not covered so see the Exclusions
section for details.

· These are the dispensing limitations. The amount of covered medication will be limited to a 30-day supply. However, covered medications that are maintenance medications obtained through the mail

under AmCare participating Mail Order program are limited to a 90-day supply. Prescription mail
order and an explanation of how to use this program can be obtained from AmCare's Customer
Service Department.

· When you have to file a claim. If you have to pay for covered medications on a medical emergency
basis when temporarily outside the service area, submit a copy of the paid bill to AmCare for
reimbursement. All claims should be submitted to AmCare at: AmCare Health Plans, Attention: Claims Department, 2707 N. Loop West, Suite 300, Houston, Texas 77008
within 60 calendar
days from the date expenses are incurred, beyond which no coverage is available. Please include the
following information on a separate sheet of paper: a statement that you are an AmCare member;
patient's name, address, and the id number and group number from the member's identification card;
name , address, and phone number of the pharmacy ( if not on the bill); name, address and phone
number of the prescribing physician; detailed statement of the circumstances requiring the emergency
care (i. e. describe "who, what, when, where, why, and how" it happened).

Prescription drug benefits begin on the next page. 35
35 Page 36 37
2001 AmCare Health Plans 36 Section 5( f)
Benefit Description You pay
Covered medications and supplies

Retail Participating Pharmacy and Mail Order
Preferred Generic Prescription Drugs – A prescription drug which is
therapeutically equivalent to a Brand name prescription drug, as
published in the most current edition of the FDA "Orange Book". Those
Preferred Generic medications on the AmCare Preferred Plan Drug List
are included in the first tier of your prescription drug benefit.

Preferred Brand Name Prescription Drugs – A prescription drug that
has been given a brand or trade name by it's manufacturer and is
advertised and sold under that name. Those Preferred Brand Name
medications on the AmCare Preferred Plan Drug List are included in the
second tier of your prescription drug benefit..

Other Covered Prescription Drugs – A Brand Name prescription drug
which is covered under the third tier

.
Mail Order Maintenance Drugs are covered for up to a 90-day
supply per prescription unit or refill.

Maintenance Medications prescription drugs intended for use in a
chronic disease state or in the treatment of a disease or illness , the
course of which is expected to continue for a period in excess of ninety
(90) days.

We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

· AmCare Preferred Plan Drug List prescription drugs, which may be
revised periodically, and Other prescription Drugs except as indicated
under the exclusions section.
· Compounded medications of which at least one ingredient is a
prescription Drug and which is prescribed for an FDA approved
indication
· Prescription inhalers that are medically necessary
· Prescription vitamins, including prenatal vitamins ·
Nutritional formulas necessary for the treatment of PKU or other
heritable diseases upon the written orders of a Participating Physician
· Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as excluded below.
· Insulin ·
Disposable needles and syringes for the administration of covered
medications

Retail Pharmacy
$5 per prescription or refill

$15 per prescription or refill
50% of covered charges per
prescription or refill

Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.

Mail Order
Preferred Generic -$10 per 90-day
supply

Preferred Brand -$30 per 90-day
supply

Other Covered Drugs – 50% of
charges for a 90-day supply 36
36 Page 37 38
2001 AmCare Health P lans 37 Section 5( f)
Covered medications and supplies (continued)
You pay

· Drugs for sexual dysfunction (see Note below) ·
Contraceptive drugs and devices
· Appetite suppressants as medically necessary in cases of morbid
obesity
· Prescription Drugs for smoking cessation up to $185, limited to one course of treatment in a lifetime.

Note: Prescriptions Drugs for the treatment of Sexual Dysfunction require
Prior authorization and may be limited to a specified number of pills per
month. (i. e. Viagra is limited to 6 pills per 30 day period)

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 third (3 rd ) tier
copayment of 50%.

· We administer a three tier 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 Preferred
Plan Drug List. This list of generic and brand name 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 AmCare
Customer Service. 37
37 Page 38 39
2001 AmCare Health Plans 38 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
· Drugs and supplies for cosmetic purposes
· Nutrients and food supplements even if a physician prescribes or administers them

· Nonprescription medicines
· Covered medications not obtained at a Participating pharmacy, except in the cases of an emergency

· Blood or urine testing devices
· Medication that is not medically necessary for the treatment of the condition for which it is prescribed

· Medical supplies such as dressing and antiseptics
· Drugs to enhance athletic performance
· Fertility Drugs
· Appetite suppressants, except as used in the treatment of morbid obesity

All Charges 38
38 Page 39 40
2001 AmCare Health Plans 39 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 withdraw it at any time and resume regular contract benefits.

· Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

AmCare Arrivals A Program for
Mothers To Be

Pregnant AmCare members are eligible to participate in AmCare's
pre-natal care program "AmCare Arrival", a special program designed
to assist the pregnant member with the various benefits related to her
pregnancy. Features of the program include:

· Early verification of coverage and benefits
· Verification that the selected hospital for delivery is a participating AmCare facility

· Assistance in selecting a Pediatrician for the newborn
· Assistance in coordinating care and benefits for any special needs
which may arise during a member's pregnancy

· Resource support for any member pre-natal education
· Discharge planning, including home nursing visits if needed to
assist the member in transitioning from hospital to home

Services for deaf and hearing impaired AmCare provides the hearing impaired with a Telephone Device for the Deaf (TDD) number to access for member information needs.
TDD number (800) 772-4669

Travel benefit When traveling in Louisiana, Texas or Oklahoma, you can receive non emergency care from our Plan in these respective States.
Member is required to contact our Customer Service Department
prior to traveling to obtain access to this Travel benefit. 39
39 Page 40 41
2001 AmCare Health Plans 40 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

· Plan dentists must provide or arrange your care.
· The calendar year deductible is: 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.

I M
P O
R T
A N
T

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

$10 for professional services and
nothing for hospitalization

Dental benefits
We have no other dental benefits. 40
40 Page 41 42
2001 AmCare Health Plans 41 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 elective abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape

or incest ;
· Services, drugs, or supplies related to sex transformations; or
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program 41
41 Page 42 43
2001 AmCare Health Plans 42 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at Texas: (800) 782-8373; Oklahoma: (800) 772-2993;
Louisiana (800) 772-2995.

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: AmCare Health Plans
2707 N. Loop West, Suite 300
Houston, Texas 77008

Prescription drugs If you have to pay for covered medications on an emergency basis when temporarily outside the service area, submit a copy of the paid bill to
AmCare for reimbursement. Include all of the following on a separate
sheet of paper:

· A statement that you are a member of AmCare Health Plans;
· The patient's name, address and the identification number and group
number from the member's identification card;

· Name, address, and phone number of the pharmacy (if not on the bill); 42
42 Page 43 44
2001 AmCare Health Plans 43 Section 7
· Name, address, and phone number of the physician; and
· A detailed statement of the circumstances or event requiring emergency care, the symptoms at the time of emergency, and the
type of emergency care received (i. e. in general describe "who, what,
where, when and how" it happened).

Submit your claims to: AmCare Health Plans
2707 N. Loop West, Suite 300
Houston, Texas 77008

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. 43
43 Page 44 45
2001 AmCare Health Plans 44 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. Write to us at: AmCare Health Plans, 2707 North Loop West, Suite 300, Houston, TX 77008.
You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: AmCare Health Plans, 2707 North Loop West, Suite 300, Houston,
Texas 77008; and

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

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III,
P. O. Box 436, Washington, D. C. 20044-0436. 44
44 Page 45 46
2001 AmCare Health Plans 45 Section 8
The Disputed Claims process (continued)
Send OPM the following information:
· A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

Note: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must 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
Texas: (800) 782-8373; Oklahoma: (800) 772-2993; Louisiana (800) 772-2995 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. 45
45 Page 46 47
2001 AmCare Health Plans 46 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We,
like other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

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

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

Medicare has two parts:
·· Part A (Hospital Insurance). Most people do not have to pay for Part A.
·· 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 not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.) 46
46 Page 47 48
2001 AmCare Health Plans 47 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.

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

Original Medicare This Plan
1) Areanactiveemployee withtheFederalgovernment (includingwhenyouor
a family member are eligible for Medicare solely because of a disability), ü

2) Are an annuitant, ü
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or………………………… ü

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

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

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

ü
(for other
services)

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

ü
(except for claims
related to Workers'
Compensation.)

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

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

ü

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

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

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

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare 47
47 Page 48 49
2001 AmCare Health Plans 48 Section 9
Claims process --You probably will never have to file a claim form when you have both our Plan and Medicare.
· When we are the primary 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 Texas: (800) 782-
8373; Oklahoma: (800) 772-2993; Louisiana (800) 772-2995., or
write to AmCare Health Plans 2707 N. Loop West, Suite 300,
Houston, Texas 77008. You may also visit our website at
www. amcarehealthplans. com

· When you have Medicare --When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows: "In this case we
do not waive any out-of-pocket costs"

· · 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, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments, coinsurance, or
deductibles. In this case we do not waive any out-of-pocket costs.

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

TRICARE TRICARE is the health care progra m for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS 48
48 Page 49 50
2001 AmCare Health Plans 49 Section 9
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
for injuries medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will

cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 49
49 Page 50 51
2001 AmCare Health Plans 50 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided primarily for the maintenance of a patient in meeting his or her activities of daily living and, which is not primarily provided for
its therapeutic value in the treatment of a sickness or injury. Activities of
daily living include bathing, feeding, dressing, walking, and taking oral
medicine.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 12.

Experimental or investigational services A drug, biological product, device, medical treatment, or procedure is
determined to be experimental or investigational if reliable evidence
shows it meets one of the following criteria:
· When applied to the circumstances of a particular patient is the
subject of ongoing phase I, II, or III clinical trials, or
· When applied to the circumstances of a particular patient is under study with written protocol to determine maximum tolerated dose,

toxicity, safety, efficacy, or efficacy in comparison to conventional
alternatives, or
· Is being delivered or should be delivered subject to the approval and supervision of an Institutional review Board as required and defined

by the USFDA or Department of Health and Human Services; and
· Is not generally accepted by the medical community.

Reliable evidence means, but is not limited to, published reports and
articles in authoritative medical scientific literature or regulations and
other official actions and publications issued by the USFDA or the
Department of Health and Human Services.

Group health coverage An employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 to the extent that the plan provides medical
cart including items and services paid for as medical care to employees
or their dependents, as defined under the terms of the Plan, directly or
through insurance, reimbursement, or otherwise.

Medical necessity Means covered health care services which meet the following criteria:
· it is required for the diagnosis, treatment or prevention of an illness or injury, or a medical condition such as pregnancy, 50
50 Page 51 52
2001 AmCare Health Plans 51 Section 10
· it could not be omitted without adversely affecting the Member's
condition;

· it is not primarily for the convenience of the Member or the treating provider;

· it is generally accepted as safe and effective treatment under standard medical practice in the community where the service is
rendered and;
· it is provided in the most cost-efficient manner that is consistent with an appropriate level of care.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their
allowances in different ways. We determine our allowance as follows:
For a capitated provider the discounted fee for service equivalent of the
provider's capitated rate is used to determine the allowable. For a
provider reimbursed on a fee for service basis the allowable is the fee for
service rate the provider would be entitled to under his contract with
AmCare Health Plans.

Us/ We Us and we refer to AmCare Health Plans
You You refers to the enrollee and each covered family member. 51
51 Page 52 53
2001 AmCare Health Plans 52 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. 52
52 Page 53 54
2001 AmCare Health Plans 53 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

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

· Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;

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

· OPM, when reviewing a disputed claim or defending litigation about a claim.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for
other forms of coverage, such as Temporary Continuation of Coverage (TCC).

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

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

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

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

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

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

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or
retirement office or from www. opm. gov/ insure. 53
53 Page 54 55
2001 AmCare Health Plans 54 Section 11
· · Converting to You may convert to a non-FEHB individual policy if: individual coverage ··
Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot
convert;

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

·· You are not eligibl