Pages 1--58 from Advantage Health Plan, Inc.

2002

Serving: Most of Indiana
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
6Y1 Self Only 6Y2 Self and Family

Special notice: This Plan reduced it's service area by eliminating Lake County for 2002

This Plan has New Health Plan Accreditation by NCQA from February
1, 2001 through February 1, 2004. See
the 2002 guide for more information on
accreditation.

RI 73-803

For changes in benefits
see page 8.

A Health Maintenance Organization 1
1 Page 2 3
2002 ADVANTAGE Health Plan, Inc. 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………. ................................................................................................... 4
Plain Language.............................................................................................................................................................................................................. 4
Inspector General Advisory………………………………………………………………………………………………………… …. 4
Section 1. Facts about this HMO plan ..................................................................................................................................................................... 6
How we pay providers ............................................................................................................................................................................. 6
Your Rights................................................................................................................................................................................................ 6
Service Area............................................................................................................................................................................................... 7

Section 2. How we change for 2002 ...................................................................................................................................................................... 8
Program-wide changes............................................................................................................................................................................. 8
Changes to this Plan ................................................................................................................................................................................. 8
Section 3. How you get care ..................................................................................................................................................................................... 9
Identification cards................................................................................................................................................................................... 9
Where you get covered care.................................................................................................................................................................... 9

Plan providers..................................................................................................................................................................................... 9
Plan facilities ...................................................................................................................................................................................... 9
What you must do to get covered care .................................................................................................................................................. 9

Primary care ...................................................................................................................................................................................... 10
Specialty care ................................................................................................................................................................................... 10
Hospital care ..................................................................................................................................................................................... 11
Circumstances beyond our control....................................................................................................................................................... 11
Services requiring our prior approval.................................................................................................................................................. 11
Section 4. Your costs for covered services............................................................................................................................................................ 12

Copayments ...................................................................................................................................................................................... 12
Deductible ......................................................................................................................................................................................... 12
Coinsurance...................................................................................................................................................................................... 12
Your out-of-pocket maximum.............................................................................................................................................................. 12
Section 5. Benefits -Overview................................................................................................................................................................................ 13
(a) Medical services and supplies provided by physicians and other health care professionals ......................................... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ..................................... 26
(c) Services provided by a hospital or other facility, and ambulance services....................................................................... 31
(d) Emergency services/ accidents .................................................................................................................................................. 34
(e) Mental health and substance abuse benefits........................................................................................................................... 36
(f) Prescription drug benefits.......................................................................................................................................................... 38
(g) Special features .......................................................................................................................................................................... 41

Flexible benefits option ..................................................................................................................................................... 41
Services for deaf and hearing impaired................................................................................................................................... 41 2
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2002 ADVANTAGE Health Plan, Inc. 3 Table of Contents
(h) Dental benefits............................................................................................................................................................................. 42
Section 6. General exclusions --things we don't cover....................................................................................................................................... 43
Section 7. Filing a claim for covered services ...................................................................................................................................................... 44
Section 8. The disputed claims process................................................................................................................................................................. 45
Section 9. Coordinating benefits with other coverage ....................................................................................................................................... 47
When you have…
Other health coverage ...................................................................................................................................................................... 47
Original Medicare ............................................................................................................................................................................. 47
Medicare managed care plan ......................................................................................................................................................... 49
TRICARE/ Workers' Compensation/ Medicaid ................................................................................................................................. 49
Other Government agencies.................................................................................................................................................................. 50
When others are responsible for injuries ............................................................................................................................................ 50
Section 10. Definitions of terms we use in this brochure .................................................................................................................................... 51
Section 11. FEHB facts ............................................................................................................................................................................................. 52
Coverage information........................................................................................................................................................................... 52
No pre -existing condition limitation ........................................................................................................................................ 52
Where you get information about enrolling in the FEHB Program.................................................................................... 52
Types of coverage available for you and your family ........................................................................................................... 52
When benefits and premiums start............................................................................................................................................ 52
Your medical and claims records are confidential....................................................................................................................... 53
When you retire........................................................................................................................................................................... 53
When you lose benefits........................................................................................................................................................................ 53
When FEHB coverage ends....................................................................................................................................................... 53
Spouse equity coverage ............................................................................................................................................................. 53
Temporary Continuation of Coverage (TCC)........................................................................................................................ 53
Converting to individual coverage........................................................................................................................................... 54

Getting a Certificate of Group Health Plan Coverage.......................................................................................................... 54
Long term care insurance is coming later in 2002 ................................................................................................................................................ 55
Index ................................................................................................................................................................................................................ 56
Summary of benefits .................................................................................................................................................................................................. 57
Rates............................................................................................................................................................................................................................. 58 3
3 Page 4 5
2002 ADVANTAGE Health Plan, Inc. 4 Introduction/ Plain Language
Introduction
ADVANTAGE Health Plan, Inc.
11555 North Meridian Street Suite 240

Carmel, IN 46032
This brochure describes the benefits of ADVANTAGE Health Plan, Inc. under our contract (CS 2862) 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 changes are summarized on page 57. 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 ADVANTAGE Health Plan, Inc.

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 at 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.

Inspector General Advisory
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 317/ 580-8474-xxxx 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

Stop health care fraud! 4
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2002 ADVANTAGE Health Plan, Inc. 5 Introduction/ Plain Language
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. 5
5 Page 6 7
2002 ADVANTAGE Health Plan, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services.

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

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. ADVANTAGE Health
Plan pays almost all of its contracting medical groups and other physician networks on a capitation basis. Capitation is a method of payment in which an HMO pays a provider or provider network an agreed upon monthly fee for each member assigned to that
provider or provider network.
Under capitation payment arrangements, the provider network is responsible for paying the physicians, hospitals and ancillary providers who provide the covered services to members. In some cases, the provider network pays the primary care physicians and
specialty physicians on either a capitation basis or on a fee-for-services basis. "Fee-for-service" payment means that the physician bills the provider network for each service he/ she provides, and the provider network pays an agreed upon rate for each service. Some
hospital and ancillary providers are paid on a capitation payment basis, and others are paid on a fee-for-service basis. The provider
networks may pay bonuses to, or withhold funds from, their contracted physicians based on how appropriately the physician has managed the utilization and costs of care for all his/ her members.

If a member believes that his/ her physician is refusing to authorize care when needed, or if it is taking too long to get approvals for
specialty care or hospitalization, the member should contact Member Services at 1-800-553-8933 to discuss the concern. A Member Service Representative will assist in the evaluation of the concern and action.

ADVANTAGE Health Plan members may also contact a Member Service Representative to obtain additional information about provider payment arrangements and incentives.
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. Some of the required information is listed below.

ADVANTAGE HMO, Inc. received its Certificate of Authority to operate a prepaid health care delivery system in Indiana on April 27, 2000 and meets the State's financial solvency requirements as of that date.
The Plan was incorporated in November 1999 and began operations as a new health plan on May 1, 2000.
The Plan is incorporated in Indiana as a For-profit company
The Plan has no ownership or interest in any health care facilities
The Plan and its contracted providers use nationally recognized clinical protocols, practice guidelines and utilization review standards published by Milliman and Robertson, Inc. and InterQual, to direct a patient's care.

ADVANTAGE HMO, Inc. is a privately held Indiana corporation owned by four Catholic health care systems: Ascension Health, Sisters of St. Francis Health Services, Inc., Saint Joseph's Regional Medical Center, Inc. and Ancilla Systems, Inc. ADVANTAGE 6
6 Page 7 8
2002 ADVANTAGE Health Plan, Inc. 7 Section 1
HMO, Inc. is a managed care company licensed to operate a prepaid health plan under a Certificate of Authority issued by the State of
Indiana on April 27, 2000. The managed care benefit plans are marketed as "ADVANTAGE Health Plan".

As a Catholic owned organization, ADVANTAGE HMO, Inc. supports the Ethical and Religious Directives for Catholic Health Care
Services (Directives). Our organization encourages individuals to apply their values in reaching a decision of conscience in matters of health.

ADVANTAGE Health Plan includes primary care physicians, specialists, hospitals and other health care providers. Each provider is affiliated with a Provider Network (PN) or Physician Hospital Organization (PHO). All care is coordinated by your selected primary
care physician (PCP), and to the extent possible, services are arranged and provided within your PCP's affiliated network.
The first and most important decision each member must make is the selection of a PCP. The PCP you choose will be your primary health care provider. Your PCP is the key to the HMO Network because he/ she is responsible for coordinating all of your health care
needs. The PCP is committed to providing you with the most appropriate care to meet your medical needs. Your PCP should always be contacted first for your health care needs. Your PCP will arrange for you to be referred to a specialist when medically necessary.
When your PCP authorizes your referral to a specialist, he/ she will obtain a referral authorization number for you. The PCP will also
arrange for any hospital stays which may be required.

Specialty providers are generally limited to those participating within your PCP's network. The Provider Directory lists specialists by
type of practice and by affiliated network.

If you want more information about us, call 1-800-553-8933, or write to ADVANTAGE Health Plan Member Services, P. O. Box 876, Carmel, IN 46082. You may also contact us by fax at 317-573-2839 or visit our web site at www. advantageplan. com

Service Area
To enroll with us, you must live in or work in our service area. Members must select a Primary Care Provider within a 30 mile radius
of their residence. This is where our providers practice. Our service area includes the following counties: Allen, Boone, Clinton, DeKalb, Delaware, Elkhart, Gibson, Hamilton, Hancock, Hendricks, Henry, Howard, Huntington, Johnson, Kosciusko, Marion,

Marshall, Morgan, Noble, Porter, Posey, Putnam, Shelby, St. Joseph, Vanderburgh, Wabash, Warrick, Wells and Whitley.
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 benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
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.

National Committee for Quality Assurance (NCQA) Accreditation
Effective February 1, 2001 ADVANTAGE Health Plan, Inc. has been granted New Health Plan Accreditation by The National Committee for Quality Assurance. This accreditation status will be in effect until February 1, 2004 and is posted on the NCQA Web
Site, www. NCQA. org. NCQA's New Health Plan Accreditation Program applies to health plans that are less than two years old. The program is distinct from NCQA's MCO Accreditation Program.

. 7
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2002 ADVANTAGE Health Plan, Inc. 8 Section 2
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 increased speech therapy benefits by removing the requirement that services must be required to restore functional speech.
(Section 5( a))

Changes to this Plan
Your share of the non-Postal premium will increase by 15.5% for Self Only or 15.5% for Self and Family.
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 now cover certain intestinal transplants. (Section 5( b))
We increased the specialists copay (excluding Obstetricians/ Gynecologists) to $15. (Section 5( a))
We now require a Maternity Care $10 copayment for the first visit only. (Section 5( a))
The Family Planning copayment for office visits and outpatient facility visits is now 50% of actual charges. (Section 5( a))
We increased the Inpatient Hospital copayment to $200 per admission. (Section 5( c))
We require you now to pay $200 per admission for Extended care benefits/ Skilled Nursing Facility care . (Section 5( c))
You now pay 20% of actual charges for ambulance service. (Section 5( c))
We increased the Emergency care copay to $50 for treatment you receive at an urgent care center (Section 5( d))
We increased the Emergency care copay to $75 for treatment you receive as an outpatient at a hospital.. (Section 5( d))
We increased the Prescription drug benefit copayments to $20 for Name Brand and to $45 for Non-formulary and 50% coinsurance for lifestyle drugs. (Section 5( f))

We increased the "professional services" benefit copay under mental health and substance abuse to $15 per office visit. (Section 5 (e))
We increased the mental health and substance abuse copay for services provided by a hospital or other inpatient facility to $200 per admission. (Section (5( e)). 8
8 Page 9 10
2002 ADVANTAGE Health Plan, Inc. 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-553-8933.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards. The Plan's Primary Care Physicians (PCPs)
specialize in Family Practice, General Practice, Internal Medicine, and Pediatrics. The Plan's Specialists are practitioners who have furthered their training in specific areas of

health care such as cardiology, surgery, dermatology, and oncology. The Plan arranges
access to a broad range of participating providers through contracting with provider networks who directly contract with PCPs, specialists, hospitals and other facilities

making up that provider network's delivery system.
We list all Plan providers in the provider directory, which we update periodically. This list is also available on our website. You may contact a Member Service Representative
to obtain additional information about participating providers such as: method of compensation, ownership or interest in health care facilities, professional education,
medical school and residency training, current board certification status, number of years
in practice, and member satisfaction rates.

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. When you select a PCP, you agree
to utilize the physician's affiliated hospital or hospital services. When your physician authorizes inpatient or outpatient hospital services, you may contact us to obtain more

information about the hospital, such as: hospital accreditation status, experience/ volume
in performing certain procedures, and comparable measures of quality and consumer satisfaction.

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. At the time of enrollment, you are
given a Provider Directory to select your PCP.

The ADVANTAGE Health Plan's Provider Directory lists primary care doctors with
their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of

enrollment or upon request by calling the ADVANTAGE Health Plan Member Services
Department at 1-800-553-8933. Yo u can also find out if your doctor participates with the ADVANTAGE Health Plan by calling this number. If you are interested in receiving

care from a specific provider who is listed in the directory, call the provider to verify that
he or she still partic ipates and is accepting new patients under this Plan. NOTE: When you enroll in the ADVANTAGE Health Plan, services (except for emergencies) are

What you must do
to get covered care 9
9 Page 10 11
2002 ADVANTAGE Health Plan, Inc. 10 Section 3
provided through the Plan's delivery system; the continued availability and/ or
participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Primary care Your primary care physician can be a Family Practice, General Practice, Internal
Medicine or Pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialis t 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 an
Obstetrician/ Gynecologist, midwife or nurse practitioner affiliated with your PCP provider network for the woman's annual routine examination without a referral. All

other specialty care must be referred and arranged by your PCP in advance. Your PCP
will coordinate your total care and work directly with your specialist. When your PCP authorizes your referral to a specialist, he/ she will obtain a referral authorization number

for you. Please do not schedule an appointment with a specialist until you have been
properly authorized to do so.

If your PCP determines that you require treatment for a covered health service that is not
available in your PCP's network, he/ she will refer you to an appropriate provider outside of the network. An out-of-network provider will only be allowed to collect from you the

copayment amount listed in your benefit plan that you would be responsible to pay if the
services had been provided by an in-network provider.

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, 10
10 Page 11 12
2002 ADVANTAGE Health Plan, Inc. 11 Section 3
you may be able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at xxx. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the 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.
Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally
accepted medical practice.

We call this review and approval process Precertification Review. Your
physician must obtain Precertification for the following services. These services include but are not limited to:

Diagnostic procedures such as CAT Scans and MRIs
Elective hospital admissions
Transplants
Outpatient surgical procedures

The Precertification Review process is initiated by a physician referral to the appropriate medical management department (most of the Plan's provider networks are delegated
medical management and Precertification Review). A Registered Nurse applying nationally accepted clinical guidelines and criteria performs the review. Any referral not
meeting medical necessity guidelines is referred to a physician consultant. Only a
licensed physician will render a denial of the referral and only after consultation with the requesting physician. All denial letters include the principal reason for denial, specific

details regarding your appeal rights, and how to obtain a copy of the actual clinical
guidelines used during the review process. Precertification Review determinations are made within 2 business days of receiving all necessary information unless the request is

urgent. Urgent precertification requests are completed within one business day of receipt.
If procedures requiring Precertification are not appropriately reviewed, the services may be denied for coverage and may result in nonpayment by the Plan.

Services requiring our
prior approval 11
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2002 ADVANTAGE Health Plan, Inc. 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy,
etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per
office visit and when you go in the hospital, you pay $200 per admission.

Deductible . We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. Coinsurance doesn't begin until you meet your deductible. We do not have coinsurance.

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

Your catastrophic protection We do not have an out-of-pocket maximum. out-of-pocket maximum 12
12 Page 13 14
2002 ADVANTAGE Health Plan, Inc. 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 68 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 800-553-8933 or at our website at www. ADVANTAGEplan. com.
(a) Medical services and supplies provided by physicians and other health care professionals ............................................................... 16-27

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

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................................................... 28-33

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services......................................................................................... 34-36
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance

(d) Emergency services/ accidents .................................................................................................................................................................... 37-38
Medical emergency Ambulance

(e) Mental health and substance abuse benefits............................................................................................................................................. 39-40
(f) Prescription drug benefits............................................................................................................................................................................ 41-44
(g) Special features .................................................................................................................................................................................................. 45
Flexible benefits option
Services for deaf and hearing impaired
(h) Dental benefits..................................................................................................................................................................................................... 46

Summary of benefits .................................................................................................................................................................................................. 64 13
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2002 ADVANTAGE Health Plan, Inc. 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible…
Diagnostic and treatment services
Professional services of physicians
In physician's office

$10 per visit to your primary care physician
$15 per visit to a specialist

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

Nothing

At home (within the service area) $25 per visit
Diagnostic and treatment services --continued on next page 14
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2002 ADVANTAGE Health Plan, Inc. 15 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per
office visit with PCP or $15 per office visit with
Specialist

Preventive care, adult
Routine screenings, such as:
Routine physical exam
Total Blood Cholesterol –,
Colorectal Cancer Screening, including

-Fecal occult blood test -Sigmoidoscopy, screening – every five years starting at age 50

$10 per office visit

Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$10 per office visit

Preventive Care -Adult --continued on next page 15
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2002 ADVANTAGE Health Plan, Inc. 16 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 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

$10 per o ffice visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit

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

Well-child care charges for routine examinations, immunizations and care ( up to age 22)
Examinations, such as:
-Eye exams through age 17 to determine the need for vision correction.

-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations (up to age 22)

$10 per office visit 16
16 Page 17 18
2002 ADVANTAGE Health Plan, Inc. 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

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

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

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

$10 for first visit only

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

50% of actual charges

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges. 17
17 Page 18 19
2002 ADVANTAGE Health Plan, Inc. 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI) -intracervical insemination (ICI)

-intrauterine insemination (IUI)

50% of actual charges for each procedure

Not covered:
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization -embryo transfer, gamete GIFT and zygote ZIFT

Services and supplies related to excluded ART procedures
Injectable or oral fertility drugs
Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 18
18 Page 19 20
2002 ADVANTAGE Health Plan, Inc. 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 29.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: – We will only cover GHT when we preauthorize the treatment. Call your Plan physician for preauthorization. GHT must be medically

necessary, and authorized by your Plan physician before you begin
treatment. If you do not obtain authorization or if we determine GHT is not medically necessary, we will not cover the GHT or related services

and supplies. See Services requiring our prior approval in Section 3.

$10 per office visit

Not covered: All charges. 19
19 Page 20 21
2002 ADVANTAGE Health Plan, Inc. 20 Section 5( a)
Physical and occupational therapies
Up to two (2) consecutive months per condition for the services of each of the following:

-qualified physical therapists and -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 a three (3) month period.

$10 per office visit
Nothing per visit during covered inpatient admission

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
Up to three (3) months per condition for the services of the following:

-Speech therapists

50% of actual charges

Not covered:
Services and supplies that would be covered at no cost if the Covered
Person did not have coverage under this plan.

All charges. 20
20 Page 21 22
2002 ADVANTAGE Health Plan, Inc. 21 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental
injury

Hearing testing for children through age 17 (see Preventive care, children)

$10 per office visit

Not covered:
all other hearing testing
hearing aids, testing and examinations for them

All charges.

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

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)
Annual eye refractions
Note: See Preventive care, children for eye exams for children.

$10 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges. 21
21 Page 22 23
2002 ADVANTAGE Health Plan, Inc. 22 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

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

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

treatment is by open cutting surgery)

All charges.

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: See 5( b) for coverage of the surgery to insert the device.

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

Nothing

50% of charges
Orthopedic and prosthetic devices-Continued on next page 22
22 Page 23 24
2002 ADVANTAGE Health Plan, Inc. 23 Section 5( a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements provided less than two (2) years after the last one we covered

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call your Plan physician who will prescribe this equipment and
direct you to a contracted supplier.

50% of charges

Not covered:
Motorized wheel chairs
Swimming pools and spas
Exercise equipment
Repair of DME when malfunction is directly a result of misuse or neglect

All charges. 23
23 Page 24 25
2002 ADVANTAGE Health Plan, Inc. 24 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.
Transparenteral Therapy (TPN)
Sleep Apnea Studies
Ventillator Management
Wound Care

$15 per office visit

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

home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic or
rehabilitative.

All charges.

Chiropractic
Manipulation of the spine and extremities
Up to two (2) consecutive months per condition for the services of
each of the following:

-Chiropractors

$15 per office visit

Not covered:
Labs, x-rays, diagnostic testing

All charges

Alternative treatments You pay
No Benefits All Charges

Educational classes and programs
Coverage is limited to:

Smoking Cessation if enrolled in an approved smoking cessation program. Approved prescription drugs are subject to the prescription
copay.

Diabetes disease management
Asthma disease management
Note: You may call our health education department for a list of approved
classes.

Nothing 24
24 Page 25 26
2002 ADVANTAGE Health Plan, Inc. 25 Section 5( a)
Not Covered:
Over the counter smoking cessations aids
More than one (1) smoking cessation class per calendar year and no more than three (3) classes per lifetime.

All Charges 25
25 Page 26 27
2002 ADVANTAGE Health Plan, Inc. 26 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, f or 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.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and

identify which surgeries require precertification

I M
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T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
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)

$15 per office visit 26
26 Page 27 28
2002 ADVANTAGE Health Plan, Inc. 27 Section 5( b)
Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; has a body mass

index (BMI) over 40 kilograms/ meter2; or has a BMI over 35
kilograms/ meter2 and a high risk co-morbid condition. In addition the eligible members must be age 18 or over, has failed to lose a

significant amount of weight or has regained weight despite
compliance with a medically supervised, mutlidisciplinary, n on-surgical program including low calorie or very low calorie diet,

supervised exercise, behavioral modification and support and
treatment of co-morbid condition; does not have a correctable cause for obesity; and is being treated in a surgical program with

experience in obesity surgery including but not only surgeons, but
also a multidisciplinary team including all of the following: -Preoperative medical consultation and approval

-Preoperative psychiatric consultation and approval
-Nutritional counseling
-Exercise counseling
-Psychological counseling
-Support group meetings

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

Voluntary sterilization
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.

$15 per office visit

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

All charges.

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

-the condition produced a major effect on the member's appearance and

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

$15 per office visit

Reconstructive surgery --continued on next page 27
27 Page 28 29
2002 ADVANTAGE Health Plan, Inc. 28 Section 5( b)
Reconstructive surgery (continued) You pay
All stages of breast reconstruction surgery following a mastectomy,
such as:

-surgery to produce a symmetrical appearance on the other breast;

-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy , you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

See above.

Not covered:
Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation
Surgical procedures for body fat reduction, such as liposuction.

All charges.

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their
supporting structures.

Treatment of TMJ, including surgical and non-surgical intervention,
corrective orthopedic appliances and physical therapy

$15 per office visit

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

Dental work related to TMJ

All charges. 28
28 Page 29 30
2002 ADVANTAGE Health Plan, Inc. 29 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian

cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
National Transplant Program (NTP) -Limited Benefits -Treatment for breast cancer, multiple myeloma, and

epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Nothing

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

Implants of artificial organs
Transplants not listed as covered

Experimental or investigational transplants

All charges. 29
29 Page 30 31
2002 ADVANTAGE Health Plan, Inc. 30 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing

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

$15 per office visit 30
30 Page 31 32
2002 ADVANTAGE Health Plan, Inc. 31 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

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

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
No calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

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

I M
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T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.
When your Plan physician determines it is medically necessary, the
physician may prescribe private accommodations or private duty nursing care.

$200 per admission; limited to two (2) copayments per member per calendar
year.

Inpatient hospital continued on next page. 31
31 Page 32 33
2002 ADVANTAGE Health Plan, Inc. 32 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

Nothing

Not covered:
Custodial care
Non-covered facilities, such as nursing homes and schools
Personal comfort items, such as telephone, television, barber
services, guest meals and beds
Private nursing care
Take-home prescriptions drugs
Hospitalization for dental procedures

All charges.

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

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

$100 per admission

Not covered: blood and blood derivatives not replaced by the member All charges. 32
32 Page 33 34
2002 ADVANTAGE Health Plan, Inc. 33 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: Up to 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing

facility is medically appropriate and determined by you Plan physician
and approved by the Plan

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

$200 per admission

Not covered:
custodial care, rest cures, domiciliary or convalescent care or homemaker services.

Personal comfort items, such as telephone or television

All charges.

Hospice care
Provided for a terminally ill member in accordance with a treatment
plan developed before admis sion to the Hospice Care Program. The treatment plan must be approved by ADVANTAGE Health Plan or its

designated agent.
Note: Limited to services provided under the direction of a Plan physician who certifies the patient is in the terminal stage of illness,

with a life expectancy of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance

Local professional ambulance service when medically appropriate 20% of actual charges 33
33 Page 34 35
2002 ADVANTAGE Health Plan, Inc. 34 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing
works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
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T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care physician. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911
telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours, unless it is not
reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

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

To be covered by this Plan, any follo w-up care recommended by non-Plan physician must be approved by your Plan physician with a prior referral.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan physician believes care can be
better provided in a Plan facility, 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 an emergency room physician must be approved by the
Plan or provided by a Plan physician.

If you are required to pay for services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card. Payment will be sent to you (or the provider if you did not
pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the
denial and the provisions of the contract on which denial was based. If you disagree with the Plan's decision, you may request reconsideration in accordance with the disputed claims procedure described on pages 40-41. 34
34 Page 35 36
2002 ADVANTAGE Health Plan, Inc. 35 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office

Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$10 per office visit
$50 per visit

$75 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$10 per office visit
$50 per visit
$75 per visit

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

All charges.

Ambulance
Professional ambulance service when medically appropriate. Includes
air ambulance services when medically appropriate.

See 5( c) for non-emergency service.

20% of actual charges 35
35 Page 36 37
2002 ADVANTAGE Health Plan, Inc. 36 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

I M
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T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

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

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

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

Medication management

$15 per visit

Mental health and substance abuse benefits -continued on next page 36
36 Page 37 38
2002 ADVANTAGE Health Plan, Inc. 37 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests $15 per office visit

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

$200 per admission

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

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
Mental Health and Substance Abuse services do not require an authorization from your primary care physician and may be obtained on self-referral basis. However,
the contracting ADVANTAGE providers available to you will depend on the primary care physician you have selected. The Mental Health and Substance
Abuse Service access phone number is listed on the bottom of your
ADVANTAGE Health Plan Member ID Card. Inpatient and Outpatient treatment plans require authorization from a Mental Health and Substance Abuse Plan

physician.
If you would like more information about your Mental Health and Substance Abuse benefits, please contact an ADVANTAGE Health Plan Member Service

Representative for assistance.

Limitation We may limit your benefits if you do not obtain a treatment plan. 37
37 Page 38 39
2002 ADVANTAGE Health Plan, Inc. 38 Section 5( e)
Section 5 (f). Prescription drug benefits
I M

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T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

I M
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T

7

There are important features you should be aware of. These include:
Who can write your prescription. A licensed prescriber must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication

We use a formulary. A formulary is a list of generic and brand-name prescription medications that have been
approved by the Food and Drug Administration (FDA). ADVANTAGE Health Plan has a team of physicians and pharmacists that meets regularly throughout the year to review and update that list. It includes medications for most

conditions treated outside the hospital. Your physician can use the list to select medications that are appropriate to
meet your healthcare needs, while helping you maximize your prescription drug benefit.

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

1-800-553-8933.
Your health plan/ employer has chosen a prescription drug program that has three different co-pay levels. This program allows you to pay a lower copay for covered drugs that are on the formulary. We cover non-formulary drugs prescribed
by a Plan doctor, but at a higher copay.
If a prescription for a non-formulary medication is written, the pharmacist will receive an on-line message at the
pharmacy. The pharmacist should contact the physician to request a change to a formulary product. If the physician is unwilling to change, or is unavailable, the pharmacist will dispense the prescription as written. Patients will be

required to pay a higher copay when a non-formulary product is dispensed. This policy will reflect the patient's
prescription drug benefit.

These are the dispensing limitations. Prescription drugs prescribed by a plan or referral doctor and obtained at a plan
pharmacy will be dispensed up to a 30-day supply; or one commercially prepared unit (i. e. one inhaler, one vial ophthalmic medication or insulin). You pay a $5 copay per prescription unit or refill for generic drugs or a $20 copay

per prescription unit or refill for name brand drugs when generic substitution is not available. You pay a $45 copay for
non-formulary drugs. When generic substitution is available, but you request the name brand drug or non-formulary drug, you pay the price difference and the required copay per prescription unit or refill as written. You will always pay

the appropriate copayment or the actual cost of the drug, whichever is less.
If your physician orders more than a 30 day supply of covered drugs, up to a 90 day supply, mail service is available. Initially you request your prescription information by completing a Pharmacare Mailer and enclosing your original
written prescription. If you are currently taking a medication, you must call your physician's office and request a new prescription for the maximum day supply. You pay a $10 copay per generic, a $40 copay per name brand (when
generic is not available), and $90 for non-formulary for up to a 90 day supply. When generic substitution is available,
but you request the name brand or non-formulary drug, you pay the price difference and the required copay. 38
38 Page 39 40
2002 ADVANTAGE Health Plan, Inc. 39 Section 5( e)
Pharmacare's system incorporates on-line drug reviews at the point of dispensing medications. Elements reviewed include, Drug-Drug Interaction, Refill Too Soon, Therapeutic Duplication, Duplication of Therapy, Over Dosage
and Under Dosage.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not

specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name
brand drug and the generic.

Why use generic drugs? Generic drugs are lower-priced rugs 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 to file a claim. You will not be required to file claims with this plan.

Benefit Description You pay
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:

Covered medications and supplies:
Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except those listed as Not covered

Insulin
Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction are limited. Contact the Plan for dose
limitations, such as, Viagra quantity limited to 6 tabs/ month
Oral and injectable contraceptive drugs and devices

Growth hormone

$ 5 per generic
$ 20 per name brand
$ 45 per non-formulary
50% coinsurance for lifestyle drugs
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.

Covered medications and supplies --continued on next page 39
39 Page 40 41
2002 ADVANTAGE Health Plan, Inc. 40 Section 5( e)
Covered medications and supplies (continued) You pay
Not covered medications and supplies:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines

All charges. 40
40 Page 41 42
2002 ADVANTAGE Health Plan, Inc. 41 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 hearing impaired Toll Free 1-800-743-3333 41
41 Page 42 43
2002 ADVANTAGE Health Plan, Inc. 42 Section 6
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

Plan dentists must provide or arrange your care.
We have no calendar year deductible.
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.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must result from an accidental injury.
$ 15 per office visit

Dental benefits
We have no other dental benefits. 42
42 Page 43 44
2002 ADVANTAGE Health Plan, Inc. 43 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services and supplies that would have been covered at no cost if the Covered Person did not have Coverage under this plan. 43
43 Page 44 45
2002 ADVANTAGE Health Plan, Inc. 44 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

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

Medical, hospital and drug 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 1-800-553-8933.
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: ADVANTAGE Health Plan, Inc. ATTN: HMO Claims
P. O. Box 876
Carmel, IN 46082

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. 44
44 Page 45 46
2002 ADVANTAGE Health Plan, Inc 45 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: ADVANTAGE Health Plan, Inc., Appeals and Grievance Coordinator or Appeals Committee, 11555 North Meridian Street, Suite 240, Carmel, IN 46032; 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. 45
45 Page 46 47
2002 ADVANTAGE Health Plan, Inc 46 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and
explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must 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 preauthorization/ prior approval, then call us at 1-800-553-8933 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/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 46
46 Page 47 48
2002 ADVANTAGE Health Plan, Inc. 47 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard
to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. 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 + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) 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 now. 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 along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be authorized by your Plan PCP, or precertified as required. We will not waive any of our

copayments and coninsurance.
(Primary payer chart begins on next page.)

The Original Medicare Plan
(Part A or Part B) 47
47 Page 48 49
2002 ADVANTAGE Health Plan, Inc. 48 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
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability),

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 TaxCourt
judge who retired under Section 7447 of title 26, U. S. C. (or if your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, (for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and
the Office of Workers' Compensation Programs has determined that you are unable to return to duty,

(except for claims
related to Workers' Compensation.)

B. When you --or a covered family member --have Me dicare 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

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 48
48 Page 49 50
2002 ADVANTAGE Health Plan, Inc. 49 Section 9
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 1-800-553-8933.

We do not waive any costs when you have Medicare.

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-

633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this case, we do not
waive any of our copayments or coinsurance 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 or coinsurance. 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 have one or both Parts of Medicare, you can still be 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.

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

If you do not enroll in
Medicare Part A or Part B 49
49 Page 50 51
2002 ADVANTAGE Health Plan, Inc. 50 Section 9
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 for injuries medical or hospital care for injuries or illness caused by another person, you must
reimburse us for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures. 50
50 Page 51 52
2002 ADVANTAGE Health Plan, Inc. 51 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 14.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.
Covered services Care we provide benefits for, as described in this brochure.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 14.

ADVANTAGE Health Plan has available participating specialists, sub-
investigational services specialists, and a referral center to assist with the review and determination of experimental treatment, procedures, drugs or devices. Your PCP must request an

approval, before the service date, regarding the recommended treatment or services that is to be reviewed. A review with Technology Evaluation Center (TEC) is done to
determine the feasibility of the recommended treatment. If a review of new technology is made on your behalf by your PCP, ADVANTAGE Health Plan will notify you of the
determination for coverage within one business day following the determination. Review
for urgent and emergent determinations will be communicated within 72 hours. For further information about the Medical Technology Assessment, please contact a Member

Service Representative at 1-800-553-8933.

Medical necessity Medical necessity means health services or supplies that are skilled care; are required for the treatment of illness or injury; are consistent with your symptoms or diagnosis; are
appropriate treatments with regard to standards of accepted medical practice; are not primarily for your convenience, your family's convenience or the convenience of any
health care provider; are not experimental, investigational or unproven; and do not
exceed the level of care which is needed to provide a safe, adequate, and appropriate diagnosis of treatment.

A health service does not meet medical necessity if your symptoms or condition indicates that it would be safe to provide the service or supply in a less comprehensive setting. The
fact that a physician or other health care provider has furnished, ordered, or approved a
service or supply does not, alone, make that service or supply a medical necessity.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our
allowance as follows: We determine our allowance based on the lesser of the fee arrangement between ADVANTAGE Health Plan and the provider, or the billed charge.
When covered services are provided by a Plan provider you are not responsible for charges above the allowance.

Us/ We Us and we refer to ADVANTAGE Health Plan, Inc. You You refers to the enrollee and each covered family member.

Experimental or
investigational services 51
51 Page 52 53
2002 ADVANTAGE Health Plan, Inc. 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or about enrolling in the retirement office can answer your questions, and give you a Guide to Federal

FEHB Program Employees 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.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start 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. 52
52 Page 53 54
2002 ADVANTAGE Health Plan, Inc. 53 Section 11
Your medical and claims We will keep your medical and claims information confidential. Only the records are confidential following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating

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

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

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

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

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

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you may
be eligible for your own FEHB coverage under the spouse equity law. If you are
recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees

Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other information about your coverage choices.

Temporary continuation If you leave Federal service, or if you lose coverage because you no longer
of coverage (TCC) 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. 53
53 Page 54 55
2002 ADVANTAGE Health Plan, Inc. 54 Section 11
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled
your coverage or did not pay your premium, you cannot convert);

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

You are not 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 wit