Pages 1--58 from AmeriHealth HMO

Serving: All of New Jersey
Enrollment in this Plan is limited. See page 6 for requirements. You must live or work in our geographic service area to enroll.

This Plan has received "Excellent"
accreditation from the NCQA. See
the 2002 Guide for more information
on NCQA.

RI 73-065
Enrollment codes for this Plan:
FK1 Self Only FK2 Self and Family

For changes in benefits
see page 7. 1
1 Page 2 3
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How We pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Who provides my health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Outside service area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 2. How We change for 2002. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Program-wide Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Where you get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Your out-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . 23
(c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . 27
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2002 AmeriHealth HMO 2 Table of Contents 2
2 Page 3 4
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Flexible benefits option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Services for deaf and hearing impaired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Reciprocity benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Travel benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
(h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 6. General exclusions — things we do not cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 8. The disputed claims process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
When you have . . .
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
The Original Medicare Plan (Part A or Part B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Medicare Managed Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
If you do not enroll in Medicare Part A or Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . 50
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Temporary Continuation of Coverage (TCC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Long Term Care Insurance Is Coming Later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2002 Rate Information for AmeriHealth HMO, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

2002 AmeriHealth HMO 3 Table of Contents 3
3 Page 4 5
Introduction
AmeriHealth HMO, Inc.
1901 Market Street
Philadelphia, PA 19103

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

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and are
summarized on page 56. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means AmeriHealth HMO.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also
write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900
E Street, NW Washington, DC 20415-3650.

2002 AmeriHealth HMO 4 Introduction/ Plain Language/ Advisory 4
4 Page 5 6
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800/ 877-9829
and explain the situation.

If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone
who uses an ID card if the person tries to obtain services for someone
who is not an eligible family member, or is no longer enrolled in the Plan
and tries to obtain benefits. Your agency may also take administrative
action against you.

2002 AmeriHealth HMO 5 Introduction/ Plain Language/ Advisory 5
5 Page 6 7
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 practices when
prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How We pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments.

Who provides my health care?
AmeriHealth HMO is an individual practice plan (IPP) HMO. The Plan is comprised of over 29,000 private practice
doctor sites who practice from their own private offices. Over 7,900 of these doctors are participating primary care
doctors. A wide range of specialty care is represented throughout the Plan. Inpatient services are available and can be
provided at 185 hospitals conveniently located throughout the Plan's service area.

It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before
referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only
when there has been a referral by the member's primary care doctor except for eye exams, dental care, and visits to
the OB/ GYN for preventive care, routine maternity or for problems related to gynecological conditions when
medically necessary. Non-routine care provided by Reproductive Endocrinologists/ Infertility Specialists, and
Gynecologic Oncologists continue to require a referral from the primary care physician. Treatment for mental
conditions and substance abuse may be obtained directly from Magellan Behavioral Health at 1-800-809-9954.
Magellan Behavioral Health, or any other mental health administrator for AmeriHealth HMO, manages all care related
to mental health and substance abuse services. Magellan Behavioral Health will determine what specialty care is
appropriate and which specialists will be utilized.

Your rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you.

If you want more information about us, call 1-800-877-9829, or write to AmeriHealth HMO, Inc., P. O. Box 41574,
Philadelphia, PA 19103. You may also visit our website at www. amerihealth. com.

Service Area
To enroll with us, you must live in or work in our service area. This is where our providers practice. Our service area
is the state of New Jersey.

2002 AmeriHealth HMO 6 Section 1 6
6 Page 7 8
Outside Service Area
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care. We will not pay for any other health care services; however, if you become ill
or are injured while traveling outside the Service Area, AmeriHealth will provide coverage for urgent care services
when preauthorized by us. For more on how to access these services, please contact us by calling the phone number
found on the back of your ID card.

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

Section 2. How We change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide Changes
We changed the address for sending disputed claims to OPM.

Changes to this Plan
Your share of the non-Postal premium will decrease by 57.7% for Self Only or 51.7% for Self and Family.
We added a new Section after Section 11 to discuss the Long Term Care Insurance Program that is coming in 2002.
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover routine screening for chlamydial infection. (Section 5( a))
We increased speech therapy benefits by removing the requirement that services must be required to restore
functional speech. (Section 5( a))

We now cover certain intestinal transplants. (Section 5( b))
You will now pay a $30 copay for PCP office visits, $35 copay for a specialist visit.
You will now pay a $75 copay for an emergency room visit which is waived if admitted to hospital.
You will now pay a $35 copay for gynecological care.
You will now pay a $35 copay for the initial visit for obstetrical care (pre and post natal). Subsequent visits are
covered 100%.

You will now pay a $35 copay for approved physical, occupational, speech and hand therapies.
You will now pay a $30 copay for vision and hearing screeing when performed at a participating plan PCP office.
You will now pay a $35 copay for vision care including eye exams and refractions.
You will now pay a $35 copay for approved diagnostic testing procedures and x-rays.
You will now pay a $30 copay for allergy care (testing and treatment) and allergy injections at PCP office or a
$35 copay when treated at specialist office.

You will now pay a $30 copay for routine immunizations.
The out of pocket maximum will now be $1,500 per person or $3,000 per family annually.

2002 AmeriHealth HMO 7 Section 2 7
7 Page 8 9
You will now pay a $15 copay per prescription order or refill for formulary generic drugs; a $25 copay per
prescription order or refill for formulary brand name drugs; and a $35 copay per prescription order or refill for
non-formulary drugs. The above copays refer to a 30-day supply. The plan includes oral contraceptives
coverage, and you will pay 3 copays for retail dispensing up to 90 days; 2 copays for each 90-day supply through
the mail order program.

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

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

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

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

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

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

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

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

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

2002 AmeriHealth HMO 8 Section 3 8
8 Page 9 10
Specialty care Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or authorize
all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see a
participating physician for eye exams, dental care, and visits to the
OB/ GYN for preventive care, routine maternity or for problems related to
gynecological conditions when medically necessary. You may also visit a
participating facility for all mammograms. Non-routine care provided by
Reproductive Endocrinologists/ Infertility Specialists, and Gynecologic
Oncologists continues to require a referral from the primary care
physician. Treatment for mental conditions and substance abuse may be
obtained directly from Magellan Behavioral Health at 1-800-809-9954.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval
beforehand).

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

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

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

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

— reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 4 months
after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.

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

2002 AmeriHealth HMO 9 Section 3 9
9 Page 10 11
Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-877-9829. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd 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 Your primary care physician has authority to refer you for most services. prior approval 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 practices.

We call this review and approval process preauthorization. Your
physician must obtain preauthorization for services such as:

All Non-Emergency Hospital Admissions
All Same Day Surgery/ Short Procedure Unit Admissions
Outpatient Therapies: Speech, Cardiac, Pulmonary, Respiratory,
Home Infusion
Other Facility Services: Skilled Nursing, Home Health, Hospice,
Birthing Center
Rental/ Purchase of Durable Medical Equipment and Prosthesis
(purchase over $100.00 and all rentals)
Non-Emergency Ambulance Services
Spinal Manipulation Services
Inpatient Psychiatric Care
Inpatient Alcohol and Substance Abuse Treatment
Some Medications that have specific uses and are administered in
Outpatient Settings or Physician Offices

2002 AmeriHealth HMO 10 Section 3 10
10 Page 11 12
Your physician must get our approval before sending you to a hospital, referring you to a specialist, or
recommending follow-up care. Before giving approval, we determine if the service is medically necessary,
and if it follows generally accepted medical practices. Members are not responsible for payment of services
if the provider does not obtain preauthorization for services rendered.

Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when
you receive services.

Example: When you see your primary care physician you pay a
copayment of $30 per office visit or a copayment of $35 per office visit to
a specialist.

Deductible We do not have a deductible.
Coinsurance We do not have a coinsurance.
Your out-of-pocket maximum After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for these services:

Prescription drugs
Dental services

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

2002 AmeriHealth HMO 11 Section 4 11
11 Page 12 13
Section 5. Benefits — OVERVIEW
(See page 7 for how our benefits changed this year and page 56 for a benefits summary.)

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

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . 12-21
— Diagnostic and treatment services — Hearing services (testing, treatment, and
— Lab, X-ray, and other diagnostic tests supplies)
— Preventive care, adult — Vision services (testing, treatment, and
— Preventive care, children supplies)
— Maternity care — Foot care
— Family planning — Orthopedic and prosthetic devices
— Infertility services — Durable medical equipment (DME)
— Allergy care — Home health services
— Treatment therapies — Chiropractic
— Physicial and occupational therapies — Alternative treatments
— Speech therapy — Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . 22-26
— Surgical procedures — Oral and maxillofacial surgery
— Reconstructive surgery — Organ/ tissue transplants
— Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-29
— Inpatient hospital — Extended care benefits/ skilled nursing care
— Outpatient hospital or ambulatory surgical facility benefits
center — Hospice care
— Ambulance

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

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

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-40
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41-42
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2002 AmeriHealth HMO 12 Section 5 12
12 Page 13 14
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits:
— Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

— Plan physicians must provide or arrange your care.
— 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.

2002 AmeriHealth HMO 13 Section 5( a)
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
— In physician's office

— Office medical consultations
— Second surgical opinion

Professional services of physicians $30 per office visit
— In an urgent care center
— During a hospital stay
— In a skilled nursing facility

At home. $35 per home visit
Not covered: All charges.
— Charges for missed appointments
— Charges for completion of insurance forms

$30 per office visit to your
primary care physician

$30 per office visit to your
primary care physician

$35 per office visit to a specialist 13
13 Page 14 15
2002 AmeriHealth HMO 14 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
— Non-routine pap tests
— Pathology
— X-rays
— Non-routine Mammograms
— Cat Scans/ MRI
— Ultrasound
— Electrocardiogram and EEG

Preventive care, adult
Routine screenings, based on medical necessity and risk such as: $30 per office visit
— Total Blood Cholesterol – once every three years
— Colorectal Cancer Screening, including
— Fecal occult blood test
— Sigmoidoscopy, screening – every five years starting at age 50

Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $30 per office visit
Routine pap test $35 per office visit
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

Nothing if you receive these
services during your office visit;
otherwise, $35 per visit 14
14 Page 15 16
2002 AmeriHealth HMO 15 Section 5( a)
Preventive care, adult (Continued) You pay
Routine mammogram – covered for women age 35 and older, as follows:
— From age 35 through 39, one during this five year period
— From age 40 and older, one every calendar year

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

Routine Adult immunizations limited to: $30 per office visit
— Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

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

Preventive care, children
— Childhood immunizations recommended by the American Academy $30 per office visit
of Pediatrics

— Examinations, such as: $30 per office visit
— Eye exams through age 17 to determine the need for
vision correction

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

— Examinations done on the day of immunizations
(through age 22)

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

Nothing if you receive these
services during your office visit;
otherwise, $35 per visit 15
15 Page 16 17
Maternity care You pay
Complete maternity (obstetrical) care, such as:
— Prenatal care
— Delivery
— Postnatal care
Note: Here are some things to keep in mind:
— You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.

— We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.

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

Not covered: Routine sonograms to determine fetal age, size or sex All charges.

Family planning
Voluntary family planning services and infertility services. A broad range
of voluntary family planning covered services. Covered services also
include artificial insemination, infertility, diagnosis and counseling.

— Voluntary sterilization $35 per office visit
— Surgically implanted contraceptives (such as Norplant). Insertion and
removal covered under Medical – Drug covered under Rx

— Injectable contraceptive drugs (such as Depo Provera) –
Covered under Rx

— Intrauterine devices (IUDs) and Diaphragms – Device covered under Rx
Note: We cover oral contraceptives under the prescription drug benefit.

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

$35 copayment applies to first
visit only

2002 AmeriHealth HMO 16 Section 5( a) 16
16 Page 17 18
2002 AmeriHealth HMO 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as: $35 per office visit
— Artificial insemination:
— intravaginal insemination (IVI)
— intracervical insemination (ICI)
— intrauterine insemination (IUI)
— Oral Fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.

Not covered: All charges.
— Assisted reproductive technology (ART) procedures, such as:
— in vitro fertilization
— embryo transfer, gamete GIFT and zygote ZIFT
— zygote transfer
— Services and supplies related to excluded ART procedures
— Cost of donor sperm
— Cost of donor egg
— Injectable fertility drugs

Allergy care
Testing and treatment If treated at PCP office, $30 per office
visit. At specialist office, $35 per
office visit.

Allergy injection

Allergy serum Nothing
Not covered: All charges.
— Provocative food testing
— Sublingual allergy desensitization 17
17 Page 18 19
Treatment therapies You pay
— Chemotherapy and radiation therapy Nothing
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.

— Respiratory and inhalation therapy
— Dialysis – Hemodialysis and peritoneal dialysis
— Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
— Growth hormone therapy (GHT)
Note: We will only cover GHT when we preauthorize the treatment. If we
determine GHT is not medically necessary, we will not cover the GHT or
related services and supplies. See Services requiring our prior approval
in Section 3.

Not covered: See Section 6 General Exclusions All charges.

2002 AmeriHealth HMO 18 Section 5( a) 18
18 Page 19 20
2002 AmeriHealth HMO 19 Section 5( a)
Physical and occupational therapies You pay
— 60 consecutive days per condition if significant improvement can $35 per visit
be expected in the two month period for the services of each of
the following:

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

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

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

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

Speech therapy
60 consecutive days per condition $35 per visit

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 $30 per office visit
(see Preventive care, children)

Not covered: All charges.
All other hearing testing
Hearing aids, testing and examinations for them 19
19 Page 20 21
Vision services (testing, treatment, and supplies) You pay
One eye refraction every two calendar years. $35 per office visit

One pair of eyeglasses or contact lenses to correct an impairment Nothing
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)

Eye exam to determine the need for vision correction for children $30 per office visit
through age 17 (see preventive care)

Not covered: All charges.
Eyeglasses or contact lenses; but see non-FEHB page
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic $35 per office visit
or peripheral vascular disease, such as diabetes.

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

Not covered: All charges.
Cutting, trimming or removal of corns, calluses, or the free edge of
toenails, and similar routine treatment of conditions of the foot,
except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)

2002 AmeriHealth HMO 20 Section 5( a) 20
20 Page 21 22
2002 AmeriHealth HMO 21 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs (initial devices only); stump hose Nothing
Artificial lenses following cataract surgery
Externally worn breast prostheses – initial device only
Surgical bras, including necessary replacements, following a
mastectomy

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

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

Prosthetic replacements provided less than three years after the last
one we covered

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

Dental prosthetics

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of Nothing
standard durable medical equipment prescribed by your Plan physician,
such as oxygen and dialysis equipment. Under this benefit, we also
cover:

standard hospital beds
standard wheelchairs
crutches
walkers
blood glucose monitors
insulin pumps

Not covered: All charges.
Motorized wheelchairs
Customized durable medical equipment 21
21 Page 22 23
Home health services You pay
Home health care ordered by a Plan physician and provided by a Nothing
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

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

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

Chiropractic
Spinal manipulation will be provided for up to 60 consecutive days $35 per visit
per condition if significant improvement can be expected in the two
month period.

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

Naturopathic services
Hypnotherapy
Biofeedback

Educational classes and programs
Coverage is limited to: Nothing
Diabetes self-management training and education through
community-based programs certified by the American Diabetes
Association or Department of Health. Covered services may also be
provided by these contracted providers; a licensed health care
professional; or at a hospital on an outpatient basis.

Not covered:
Smoking Cessation – see Section 5( j) non-FEHB benefits available to
Plan members.

2002 AmeriHealth HMO 22 Section 5( a) 22
22 Page 23 24
I M
P O
R T
A N
T

2002 AmeriHealth HMO 23 Section 5( b)

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See Section 5( a) –
(Orthopedic and prosthetic devices) for device coverage information.

Surgical procedures continued on next page.

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care
professional for your surgical care. Look in Section 5( c) for charges associated with the
facility (i. e., hospital, surgical center, etc.)

YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES.
Please refer to the precertification information shown in Section 3 to be sure which
services require precertification and identify which surgeries require precertification. 23
23 Page 24 25
2002 AmeriHealth HMO 24 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Nothing
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.

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

Reconstructive surgery
Your physician must obtain approval from us before providing service. Nothing
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.

All stages of breast reconstruction surgery following a mastectomy,
such as:

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

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

Not covered: All charges.
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 24
24 Page 25 26
2002 AmeriHealth HMO 25 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures require preapproval by the Plan, and are limited to: Nothing
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.

Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)

Organ/ tissue transplants
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single – Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors

— Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach
and pancreas.

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

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

Implants of artificial organs
Transplants not listed as covered 25
25 Page 26 27
2002 AmeriHealth HMO 26 Section 5( b)
Anesthesia You pay
Professional services provided in – Nothing
Hospital (inpatient)

Professional services provided in – Nothing
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 26
26 Page 27 28
2002 AmeriHealth HMO 27 Section 5( c)
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5 (c). Services provided by a hospital or other facility, and ambulance services
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

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

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

The amounts listed below are for the charges billed by the facility (i. e., hospital or
surgical center) or ambulance service for your surgery or care. Any costs associated
with the professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).

Benefit Description You pay
Inpatient hospital
Room and board, such as Nothing
ward, semiprivate, or intensive care or cardiac care accommodations;
general nursing care; and
meals and special diets.

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

Inpatient hospital continued on next page. 27
27 Page 28 29
2002 AmeriHealth HMO 28 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
— Administration of blood and blood products
— Blood or blood plasma
— Dressings, splints, casts, and sterile tray services
— Medical supplies and equipment, including oxygen
— Anesthetics, including nurse anesthetist services
— Take-home items
— Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Not covered: All charges.
— Custodial care
— Non-covered facilities, such as nursing home and schools
— Personal comfort items, such as telephone, television, barber services,
guest meals and beds

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

Outpatient hospital or ambulatory surgical center
— Operating, recovery, and other treatment rooms Nothing
— Prescribed drugs and medicines
— Diagnostic laboratory tests, X-rays, and pathology services
— Administration of blood, blood plasma, and other biologicals
— Blood and blood plasma, if not donated or replaced
— Pre-surgical testing
— Dressings, casts, and sterile tray services
— Medical supplies, including oxygen
— Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Not covered: blood and blood derivatives not replaced by the member All charges. 28
28 Page 29 30
2002 AmeriHealth HMO 29 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): Up to 180 days per calendar year when Nothing
full-time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan.

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

Hospice care
Supportive and palliative care for a terminally ill member is covered in Nothing
the home or hospice facility. Services include inpatient and outpatient care,
and family counseling; these services are provided under the direction of a
Plan doctor who certifies that the patient is in the terminal stages of illness,
with a life expectancy of approximately six months or less.

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

Ambulance
Local professional ambulance service when medically appropriate. Nothing
Preapproval is required, unless for emergency. 29
29 Page 30 31
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.

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

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

What to do in case of emergency:
Emergencies within the service area:
If you are in an emergency situation, contact the local emergency system (e. g., the 911 telephone system)
or go to the nearest hospital emergency room. If you are hospitalized in non-Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any
ambulance charges covered in full.

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

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

If you need to be hospitalized, you or a family member must notify the Plan within 48 hours or on the first
working day following your admission, unless it was not reasonably possible to notify the Plan within that time.
If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically
feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow up care recommended by non-Plan providers must be approved by the
Plan or provided by Plan providers.

2002 AmeriHealth HMO 30 Section 5( d) 30
30 Page 31 32
2002 AmeriHealth HMO 31 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $30 per office visit
Emergency care at an urgent care center $30 per visit
Emergency care as an outpatient or inpatient at a hospital, including $75 per visit
doctors' services (copayment waived if admitted or you are referred to
the emergency room by your PCP and services could have been
provided by your doctor)

Not covered: Elective care or non-emergency care All charges.

Emergency outside our service area
Emergency care at a doctor's office $30 per office visit
Emergency care at an urgent care center $30 per visit
Emergency care as an outpatient or inpatient at a hospital, including $75 per visit
doctors' services (copayment waived if admitted or you are referred to
the emergency room by your PCP and services could have been
provided by your doctor)

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

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

Ambulance
Professional or air ambulance service when medically appropriate. Nothing
See Section 5( c) Ambulance for non-emergency service. 31
31 Page 32 33
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5 (e). Mental health and substance abuse benefits
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 illness and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

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

Benefit Description You pay
After the calendar year
deductible . . .

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

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

Professional services, including individual or group therapy by $35 per office visit
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

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

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

Mental health and substance abuse benefits continued on next page.

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

2002 AmeriHealth HMO 32 Section 5( e) 32
32 Page 33 34
Network out-of-pocket maximums After your copayments total $1,500 per person or $3,000 per family
enrollment in any calendar year, you do not have to pay any more for
covered services. This is called a catastrophic limit. However,
copayments for your prescription drugs and dental services do not count
toward these limits and you must continue to make these payments.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:

Treatment for mental conditions and substance abuse is coordinated
directly by Magellan Behavioral Health or other behavioral health
administrator designated by the Plan. Magellan Behavioral Health, acting
as behavioral health administrator for AmeriHealth HMO, Inc., manages
all care related to mental health and substance abuse services including
referrals to mental health and substance abuse specialists. Questions
about related benefits and pre-certification should be addressed to
Magellan Behavioral Health at 1-800-809-9954.

Limitation We may limit your benefits if you do not follow your treatment plan.

2002 AmeriHealth HMO 33 Section 5( e) 33
33 Page 34 35
I M
P O
R T
A N
T

Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the
next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and
are payable only when we determine they are medically necessary.

We do not have a deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy, a non-network
pharmacy, or by mail. We pay a higher level of benefits when you use a network pharmacy.

We use a formulary. The AmeriHealth formulary is a defined list of medications that includes
treatments for all therapeutic categories and has been screened for medical effectiveness, positive
results and value.

These are the dispensing limitations. You pay the pharmacy copay per prescription for up to a
30-day supply. Maintenance medications may be obtained through the Mail Order program for up to a
90-day supply.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent
to more expensive brand-name drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original brand-name product. Generics cost less than the
equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for
generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name
drugs. You can save money by using generic drugs. However, you and your physician have
the option to request a name-brand if a generic option is available. Using the most cost-effective
medication saves money.

When you have a claim. Prescription drugs obtained from a non-Plan pharmacy, for an out-of-area
emergency will be reimbursed. You must submit acceptable proof-of-payment with a direct
reimbursement form. All claims for payment must be received within ninety (90) days of the date of
proof-of-purchase. Direct reimbursement forms may be obtained by calling 1-800-877-9829.

Prescription drug benefits continued on next page.

2002 AmeriHealth HMO 34 Section 5( f)

I M
P O
R T
A N
T 34
34 Page 35 36
2002 AmeriHealth HMO 35 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a
Plan physician and obtained from a Plan pharmacy or through our mail
order program:

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

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

Disposable needles and syringes needed to inject covered prescribed
medications

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

Maintenance medications obtained through the Mail Order program
for up to a 90-day supply for two copays

Maintenance drugs obtained at a Participating Pharmacy for up to a
90-day supply for three copays

$15 per prescription order or
refill for generic formulary
drugs; $25 per prescription order
or refill for brand name
formulary drugs; $35 per
prescription or refill for non-formulary
drugs for a 30-day
supply

Two copays for each 90-day
supply

Three copays for retail
dispensing 35
35 Page 36 37
2002 AmeriHealth HMO 36 Section 5( f)
Covered medications and supplies (Continued) You pay
Here are some things to keep in mind about our prescription drug program:
We have a formulary. A formulary is a defined list of medications that
includes treatments for all therapeutic categories and has been screened
for medical effectiveness, positive results and value. You will receive
increased benefits by using formulary drugs.

Not covered: All charges.
Drugs available without a prescription or for which there is a
nonprescription equivalent available

Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies

Vitamins and nutritional substances that can be purchased without
a prescription

Medical supplies such as dressings and antiseptics
Injectable fertility drugs
Contraceptive devices (except diaphragms and IUDs)
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation
The cost of a prescription drug when the usual and customary charge
is less than the member's prescription drug copayment 36
36 Page 37 38
2002 AmeriHealth HMO 37 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.

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

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

Travel benefit Ordinarily, you must get your care from providers who contract with us. However, emergency (described in Section 5( d)) and urgent care provided
outside the service area will be covered. Urgent care includes covered services
provided in order to treat an unexpected medical or psychiatric illness or
injury that is not life-threatening and requires care by a provider within 24
hours. The services must be required in order to prevent a serious deterioration
in your or your covered family member's health, if treatment were delayed.

If you become ill or are injured while traveling outside the service area,
AmeriHealth will provide coverage for urgent care services when preauthorized
by us. For more information on how to access these services, please contact us
by calling the phone number found on the back of your I. D. card.

Your prescription drug card works in more than 50,000 pharmacies
nationwide.

No coverage will be provided for urgent care that has not been preauthorized
or for routine or elective services rendered outside the service area. 37
37 Page 38 39
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental 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.

Benefit Description You pay
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair $35 per office visit
(but not replace) sound natural teeth when provided by Plan dentists.
The need for these services must result from an accidental injury and be
treated within six (6) months or as other medical conditions permit after
the accident.

Dental benefits are continued on next page.

2002 AmeriHealth HMO 38 Section 5( h) 38
38 Page 39 40
Dental Benefits
2002 AmeriHealth HMO 39 Section 5( h)
Service You Pay
Preventive Services:
Oral examination and diagnosis (limited to once in 6 months); $5 copay per office visit
prophylaxis/ teeth cleaning to include scaling and polishing
(limited to once in six months); topical fluoride (includes child
and adult); oral hygiene instruction.

Diagnostic Services:
Complete series x-rays; intraoral occlusal film; bitewings
(limited to once in 6 months); emergency examinations;
panaramic film; cephalometric film.

Restorative Services:
Amalgam (silver) restoration to primary and permanent teeth;
anterior and posterior composite restoration to primary and
permanent teeth; pin restoration; sedative restoration (per tooth);
emergency treatment (palliative).

Out-of-Area Dental Services:
The program will reimburse member for dental services in
connection with dental emergencies requiring palliative treatment
(relieve pain) when the member is 50 miles or more from the
member's Primary Dental Office, up to a maximum of $50 for
each occurrence less the $5 copay.

To receive payment for Out-of-Area dental services, the member
must submit a receipt to AmeriHealth HMO Member Services.
The receipt must itemize charges and dental services performed.

CARE MUST BE RECEIVED FROM OR ARRANGED BY
PLAN DOCTORS 39
39 Page 40 41
2002 AmeriHealth HMO 40 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket expenses.

Weight Management Reimbursement– AmeriHealth HMO's Weight Management Reimbursement program gives you the option of participating in any weight management program offered by an AmeriHealth network hospital or Weight
Watchers. 100% reimbursement of all program fees (up to $200).
New Fitness Reimbursement Program – To give members added incentive to maintain an active lifestyle, we will reimburse members up to $150 of their annual fitness club fees. Members can now enjoy the flexibility of joining any
approved fitness club and working out at multiple fitness clubs. Visits can be recorded by swipe-card, computer printout,
telephone or logbook.

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

Vision Care – Up to a $35 allowance for eyeglasses or contact lenses every two (2) calendar years, members maximize their benefit by using participating providers.

BabyFootSteps Program – AmeriHealth HMO members can receive educational materials and free gifts for you and your baby in our prenatal program. Plus, you can receive a 100% reimbursement (up to $50) of the cost of a childbirth class.
Mother's Option – AmeriHealth HMO pregnant mothers have the option of a 24 or 48 hour length of stay for a normal delivery and a 3 or 4 day length of stay for a cesarean delivery. If member opts for a 24 hour stay for a normal delivery, the
mother will receive two (2) home care visits. If member opts for a 3 day stay for a cesarean delivery, the mother will receive
one (1) home care visit.

Child Safety – Offers tips on how to reduce children's risk for household accidents such as burns, injuries from firearms, choking, and accidental poisonings. Our newly enhanced Family Health Portfolio includes a child identification record, "Mr.
Yuk" stickers to place on poisonous substances, coupons for free bottle of Syrup of Ipecac, tips for safe bicycling and more.
Reimbursement up to $25 for bike helmet.

American Red Cross CPR and First Aid Course Reimbursements – AmeriHealth HMO members can receive up to $25 reimbursement on any course offered by the American Red Cross.

Alternative Health Discounts – In response to our members' interest in alternative health services, we developed our Alternative Health Directory, which includes a list of practitioners who offer members up to 40% discounts on acupuncture,
massage therapy, and nutritional counseling.
Medicare Prepaid Plan Enrollment – This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 18, annuitants and former spouses with FEHB coverage and Medicare Part B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area. They may than
later re-enroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A may
join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium. Before
you join the plan, ask whether the plan covers hospital benefits and, if so, what you will have to pay. Contact your retirement
system for information on changing your FEHB enrollment. Contact us at 1-800-898-3492 for information on Plan benefits
under the Medicare plan and the cost of that enrollment. If you are Medicare eligible and are interested in enrolling in a
Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan, call 1-800-898-3492 for
information on the benefits available under the Medicare HMO. 40
40 Page 41 42
Section 6. General exclusions — things we do not cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.

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

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

2002 AmeriHealth HMO 41 Section 6 41
41 Page 42 43
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

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

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

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

Covered member's name and ID number;
Name and address of the physician or facility that provided the
service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any
primary payer – such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.

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

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

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

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

2002 AmeriHealth HMO 42 Section 7 42
42 Page 43 44
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 1901 Market Street, Philadelphia, PA 19103; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street NW, Washington, DC 20415-3630.

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.

2002 AmeriHealth HMO 43 Section 8 43
43 Page 44 45
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.

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

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of
benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorized/ prior approval, then call us at
1-800/ 227-3114 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your
claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time.

2002 AmeriHealth HMO 44 Section 8 44
44 Page 45 46
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you are covered or a family member is covered under health coverage another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance

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

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our

regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for
People 65 years of age and older
Some people with disablilities, under 65 years of age
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered

employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983
or since automatically qualifies.) Otherwise, if you are age 65 or older,
you may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare managed care plan is the term used to describe the

various health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original Medicare) is a Medicare+ Choice
(Part A or Part B) plan that is available everywhere in the United States. It is the way
everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits. You may go to any doctor,

specialist, or hospital that accepts Medicare. The original Medicare plan pays its share and you pay your share. Some things are not covered under
Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to

be authorized by your Plan PCP. We will not waive any of our copayments.
(Primary payer chart begins on next page.)

2002 AmeriHealth HMO 45 Section 9 45
45 Page 46 47
2002 AmeriHealth HMO 46 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart

A. When either you– or your covered spouse – are age 65 or over and … Then the primary payer is… Original Medicare This Plan

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

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you . . .)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C.
(or if your covered spouse is this type of judge),

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

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

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

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

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

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

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee or
c) Are a former spouse of an annuitant or
d) Are a former spouse of an active employee 46
46 Page 47 48
Claims Process when you have the Original Medicare Plan – You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.

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 800-877-9829.

Medicare Managed Care Plan If you are eligible for Medicare, you may choose to enroll in and get
your Medicare benefits from another type of Medicare+ Choice plan – a
Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans,
you can only go to doctors, specialists, or hospitals that are part of the
plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4277) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options
are available to you:

This Plan and our Medicare Managed Care Plan: You may enroll
in our Medicare managed care plan and also remain enrolled in our
FEHB plan. In this case, we do/ do not waive any of our copayments
for your FEHB coverage.

This Plan and another plan's Medicare managed care plan: You
may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you
are in the Original Medicare Plan or in a Medicare managed care plan so
we can correctly coordinate benefits with Medicare.

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

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be
Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can't get premium-free Part A, we will not
ask you to enroll in it.

2002 AmeriHealth HMO 47 Section 9 47
47 Page 48 49
TRICARE TRICARE is the health care program for eligible dependents, military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

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

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

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

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

When others are responsible When you receive money to compensate you for medical or hospital care for injuries for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.

2002 AmeriHealth HMO 48 Section 9 48
48 Page 49 50
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 56.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Care provided primarily for maintenance of the patient or care designed (Domiciliary Care) essentially to assist the patient in meeting his activities of daily living
and which is not primarily provided for its therapeutic value in the
treatment of an illness, disease, bodily injury, or condition. Custodial
Care includes, but is not limited to, help in walking, bathing, dressing,
feeding, preparation of special diets and supervision of self-administration
of medications which do not require the technical skills
or professional training of medical or nursing personnel in order to be
performed safely and effectively.

Experimental or To establish if a biological, medical device, drug or procedure is Investigational services experimental/ investigative or not, a technology assessment is performed.
The results of the assessment provide the basis for the determination of
the service's status (e. g., medically effective, experimental, etc.).
Technology assessment is the review and evaluation of available data
from multiple sources using industry standard criteria to assess the
medical effectiveness of the service. Sources of data used in technology
assessment include but are not limited to clinical trials, position papers
or articles published by local and/ or nationally accepted medical
organizations or peer-reviewed journals, information supplied by
government agencies, as well as regional and national experts and/ or
panels and, if applicable, literature supplied by the manufacturer.

Us/ We Us and we refer to AmeriHealth HMO, Inc.
You You refers to the enrollee and each covered family member.

2002 AmeriHealth HMO 49 Section 10 49
49 Page 50 51
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.

2002 AmeriHealth HMO 50 Section 11 50
50 Page 51 52
When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this Plan during Open Season, your coverage begins on the first day
of your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any other
time during the year, your employing office will tell you the effective
date of coverage.

Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

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

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

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

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

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

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

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

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not
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.

2002 AmeriHealth HMO 51 Section 11 51
51 Page 52 53
Temporary Continuation If you leave Federal service, or if you lose coverage because you no
of Coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

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

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law ends.

(If you canceled your coverage or did not pay your premium,
you cannot convert);

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

You are not eligible for coverage under TCC or the spouse equity law.

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

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

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled
with us. You can use this certificate when getting health insurance or
other health care coverage. Your new plan must reduce or eliminate
waiting periods, limitations, or exclusions for health related conditions
based on the information in the certificate, as long as you enroll within
63 days of losing coverage under this Plan. If you have been enrolled
with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked question. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and information about Federal and State
agencies you can contact for more information.

2002 AmeriHealth HMO 52 Section 11 52
52 Page 53 54
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October
2002. As part of its educational effort, OPM asks you to consider these questions:

What is long term care It's insurance to help pay for long term care services you may need if you can't (LTC) insurance? take care of yourself because of an extended illness or injury, or an age-related
disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care, care
in an assisted living facility, care in your home, adult day care, hospice care, and
more. It can supplement care provided by family members, reducing the burden
you place on them.

I'm healthy. I won't need Welcome to the club! long term care. Or, will I? 76% of Americans believe they will never need long term care, but the facts are
that about half them will. And it's not just the old folks. About 40% of people
needing long term care are under age 65. They may need chronic care due to a
serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their financial and retirement planing.

Is long term care expensive? Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before inflation!
Long term care can easily exhaust your savings. Long term care insurance can
protect your savings.

But won't my FEHB plan, Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your Medicare or Medicaid cover FEHB brochure. Health plans don't cover custodial care or a stay in an assisted
my long term care? living facility or a continuing need for a home health aide to help you get in and out of bed and with other activities of daily living. Limited stays in skilled
nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and preserve
your independence.

When will I get more information Employees will get more information from their agencies during the LTC open on how to apply for this new enrollment period in the late summer/ early fall of 2002.
insurance coverage? Retirees will receive information at home.
How can I find out more about Our toll-free teleservice center will begin in mid-2002. In the meantime, you the program NOW? can learn more about the program on our web site at www. opm. gov/ insure/ ltc.

Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG!

How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

2002 AmeriHealth HMO 53 Long Term Care Insurance 53
53 Page 54 55
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 23,38
Allergy tests 11,16
Allogeneic (Donor) Bone Marrow
Transplant
Alternative treatment 11,21,40
Ambulance
9,11,26,28,29,30
Autologous bone marrow
transplant 17,24
Biopsies 22
Birthing centers 9
Blood and blood plasma 27
Casts 27
Catastrophic protection 33
Changes for 2002 6
Chemotherapy 17
Childbirth 40
Chiropractic 22
Cholesterol tests 13
Claims 34,42,43-44,47,51
Coinsurance 10
Colorectal cancer screening 13
Congenital anomalies 22,23
Contraceptive devices and drugs 36
Crutches 20
Deductible 10,34,40,42
Definitions 49
Dental care 5,7,38
Diagnostic services 11,12,13,
27,31,32,39
Disputed claims review 43-44
Do