HMO Health Ohio

Pages 1--66 from HMO Health Ohio

Serving: Northeast Ohio
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 9 for requirements.

Enrollment code:
L41 Self Only
L42 Self and Family

Federal Employees Health Benefits Program
RI 73-157

2004
For changes
in benefits
see page

10.

This Plan has a excellent accredita-tion
from the NCQA. See the 2004
Guide for more information on
accreditation. 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits ( FEHB) Program plan brochure. The brochure
describes the benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your
plan s brochure every Open Season especially Section 2, , which explains how the plan changed.

It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our
FEHB Guide, and our web-based resources, make it easier than ever to get information about plans, to compare
benefits and to read customer service satisfaction ratings for the national and local plans that may be of interest. Just
click on www. opm. gov/ insure!

The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector
competition to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in
1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any
healthcare program in the country.

I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health
benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies
and departments to pay the full FEHB health benefit premium for their employees called to active duty in the Reserve
and National Guard so they can continue FEHB coverage for themselves and their families. Our carriers have also
responded to my request to help our members to be prepared by making additional supplies of medications available
for emergencies as well as call-up situations and you can help by getting an Emergency Preparedness Guide at
www. opm. gov. OPM s HealthierFeds campaign is another way the carriers are working with us to ensure Federal
employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain
healthcare costs and keep premiums down by living a healthy life style.

Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare
needs. Use this brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if
you know someone interested in Federal employment, refer them to www. usajobs. opm. gov.

Sincerely,

Kay Coles James
Director

OFFICE OF THE DIRECTOR
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
WASHINGTON, DC 20415-0001 2.
2 Page 3 4
Notice of the Office of Personnel Management s
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

By law, the United States Office of Personnel Management ( OPM) , which administers the Federal Employees Health
Benefits ( FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also
required to give you this notice to tell you how OPM may use and give out ( disclose ) your personal medical
information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you ( your personal representative) , To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For
example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government health care oversight activities ( such as fraud and abuse investigations) , For research studies that meet all privacy law requirements ( such as for medical research or education) , and

To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an authorization ) to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back ( revoke ) your written permission
at any time, except if OPM has already acted based on your permission.

By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if

information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any 3.
3 Page 4 5
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place ( for example, by sending materials to a P. O. Box instead of your home address) .
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the Web. You
may also call 202-606-0191 and ask for OPM s FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:

Privacy Complaints
United States Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the
Secretary of the United States Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your
personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice are effective April 14, 2003. 4.
4 Page 5 6
2004 HMO Health Ohio Table Of Contents 2
Table of Contents
Introduction .......................................................................................................................................................................... 5
Plain Language ...................................................................................................................................................................... 5
Stop Health Care Fraud ......................................................................................................................................................... 5
Preventing medical mistakes................................................................................................................................................. 6
Section 1. Facts about this HMO plan ................................................................................................................................. 8
How we pay providers ........................................................................................................................................ 8
Your Rights ......................................................................................................................................................... 8
Service Area........................................................................................................................................................ 9
Section 2. How we change for 2004 .................................................................................................................................. 10
Program-wide changes...................................................................................................................................... 10
Changes to this Plan......................................................................................................................................... .10
Section 3. How you get care............................................................................................................................................... 11
Identification cards............................................................................................................................................ 11
Where you get covered care ............................................................................................................................. 11
Plan providers............................................................................................................................................. 11
Plan facilities .............................................................................................................................................. 11
What you must do to get covered care ............................................................................................................. 11
Primary care................................................................................................................................................ 11
Specialty care.............................................................................................................................................. 11
Hospital care............................................................................................................................................... 12
Circumstances beyond our control................................................................................................................... 13
Services requiring our prior approval............................................................................................................... 13
Section 4. Your costs for covered services........................................................................................................................ 14
Copayments ................................................................................................................................................ 14
Deductible................................................................................................................................................... 14
Coinsurance ................................................................................................................................................ 14
Your catastrophic protection out-of-pocket maximum ................................................................................... 14
Section 5. Benefits.............................................................................................................................................................. 15
Overview ........................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals .............. 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals .......... 25
(c) Services provided by a hospital or other facility, and ambulance services ......................................... 29
(d) Emergency services/ accidents............................................................................................................... 32
(e) Mental health and substance abuse benefits ......................................................................................... 34
(f) Prescription drug benefits...................................................................................................................... 36 5.
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2004 HMO Health Ohio Table Of Contents 3
(g) Special features ...................................................................................................................................... 39
Flexible Benefits Option................................................................................................................. 39
Heart Sense TM .................................................................................................................................. 39
Baby Link ® ...................................................................................................................................... 39
Breathe Easy ® ................................................................................................................................. 39
Diabetes Advantage TM .................................................................................................................. .39
(h) Dental benefits ....................................................................................................................................... 40
Section 6. General exclusions --things we don't cover..................................................................................................... 41
Section 7. Filing a claim for covered services................................................................................................................... 42
Section 8. The disputed claims process ............................................................................................................................. 43
Section 9. Coordinating benefits with other coverage ...................................................................................................... 45
When you have other health coverage.......................................................................................................... 45
What is Medicare................................................................................................................................. 45
Should I enroll in Medicare? ............................................................................................................... 45
Medicare + Choice............................................................................................................................... 48
TRICARE and CHAMPVA................................................................................................................ 48
Workers' Compensation...................................................................................................................... 48
Medicaid............................................................................................................................................... 49
Other Government Agencies ............................................................................................................... 49
When others are responsible for injuries............................................................................................. 49
Section 10. Definitions of terms we use in this brochure.................................................................................................. 50
Section 11. FEHB facts ...................................................................................................................................................... 51

Coverage information ....................................................................................................................................... 51
No pre-existing condition limitation........................................................................................................ 51

Where you can get information about enrolling in the FEHB Program................................................. 51
Types of coverage available for you and your family............................................................................. 51
Children's Equity Act............................................................................................................................... 52
When benefits and premiums start........................................................................................................... 52
When you retire ....................................................................................................................................... 52
When you lose benefits..................................................................................................................................... 53
When FEHB coverage ends ..................................................................................................................... 53
Spouse equity coverage........................................................................................................................... 53
Temporary Continuation of Coverage (TCC) ........................................................................................ 53
Converting to individual coverage.......................................................................................................... 53
Getting a Certificate of Group Health Plan Coverage ........................................................................... 54

Two new Federal Programs complement FEHB benefits.................................................................................................. 55
The Federal Flexible Spending Account Program Ð FSA FEDS.................................................................... 55
The Federal Long Tern Care Insurance Program ............................................................................................ 58 6.
6 Page 7 8
2004 HMO Health Ohio 4 Table of Contents
Index ........................................................................................................................................................................ 59
Summary of benefits............................................................................................................................................................ 61
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover 7.
7 Page 8 9
2004 HMO Health Ohio 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of HMO Health Ohio under our contract (CS 2015) with the United States Office
of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.

Medical Mutual of Ohio, dba HMO Health Ohio
2060 East Ninth Street
Cleveland, Ohio 44115-1355

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2004. Rates are shown at the end of this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and
changes are summarized on page 10. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language 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 HMO Health Ohio.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States 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 United States Office of Personnel Management, Insurance Services Program Planning and
Evaluation Group, 1900 E Street, NW Washington, DC 20415-3650.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud Ð Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative. 8.
8 Page 9 10
2004 HMO Health Ohio 6 Introduction/ Plain Language/ Advisory
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or

service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 522-2066 and explain the situation.
If we do not resolve the issue:

CALL -THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415-1100

Do not maintain as a family member on your policy: Your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or
Your child over age 22 (unless he/ she is disabled and incapable of self-support). If you have any questions about the eligibility of a dependent, check with your personnel office if you are

employed or with your retirement office (such as OPM) if you are retired, or with the National Finance Center if
you are enrolled under Temporary Continuation of Coverage.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer

enrolled in the Plan.

Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from
medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death
is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital
stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your
risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps:

1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers. Choose a doctor with whom you feel comfortable talking.

Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take.
Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.
Tell them about any drug allergies you have. Ask about side effects and what to avoid while taking the medicine.
Read the label when you get your medicine, including all warnings. Make sure your medicine is what the doctor ordered and know how to use it.
Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure.
Ask when and how you will get the results of test or procedures. Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by
mail. 9.
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2004 HMO Health Ohio 7 Introduction/ Plain Language/ Advisory
Call your doctor and ask for your results. Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.

Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
Ask your doctor, "Who will manage my care when I am in the hospital?" Ask your surgeon:
Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.

Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available
a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality
healthcare providers and improve the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare
for you and your family.
www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is
dedicated to improving communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare
professionals working to improve patient safety.
www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help
prevent mistakes in the nation's healthcare delivery system. 10.
10 Page 11 12
2004 HMO Health Ohio 8 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. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

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 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.
Your Rights HMO Health Ohio is a mixed model prepayment plan that provides care through a network of doctors, using groups of
doctors, staff model arrangements, and IPA systems. Both primary care and specialist doctors are part of the network.
Different members of the same family may select different centers or doctors.

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.
Medical Mutual of Ohio is the oldest health insurance company in Ohio. HMO Health Ohio has been in existence since January 1, 1989.

HMO Health Ohio has over 28,000 participating physicians. Medical Mutual of Ohio has been awarded three-year Excellent accreditation status for HMO Health Ohio by the
National Committee for Quality Assurance (NCQA), a leading independent evaluator of health plans.
If you want more information about us, call 800/ 522-2066, or write to HMO Health Ohio, P. O. Box 6018, Cleveland,
Ohio 44101, Attn: HMO Member Services. You may also contact us by fax at 216/ 687-2817 or visit our website at
http:// www. MedMutual. com. 11.
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2004 HMO Health Ohio 9 Section 1
Service Area To enroll in this plan, you must live in or work in our service area. This is where our providers practice.
Our service area is:
The Ohio counties of Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Huron, Lake, Lorain,
Medina, Portage, Richland, Stark, Summit, Tuscarawas and Wayne.

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
dependants live out of the area (for example, if your child goes to college in a 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 employer or retirement
office. 12.
12 Page 13 14
2004 HMO Health Ohio 10 Section 2
Section 2. How we change for 2004
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 added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending Account Program -FSAFEDS and the Federal Long Term Care Insurance Program. See

page 55.
We added information regarding Preventing medical mistakes. See page 6. We added information regarding enrolling in Medicare. See page 45

We revised the Medicare Primary Payer Chart. See page 47. Changes to this Plan

Your share of the non-Postal premium will increase by 13% for Self Only or 18.6% for Self and Family.
Retail prescription drug copayment for non-formulary brand name drugs is now $30. Copayment for generics and formulary brand name drugs have not changed.

Mail order prescription drug copayment for non-formulary brand name drugs is now $60. Copayments for generics and formulary brand name drugs have not changed.
Members who purchase a brand name drug when a generic drug is available now pay the GENERIC copayment in addition to the difference between the cost of the generic drug and brand name drug. Previously,
member paid the BRAND NAME copayment in addition to the difference between the cost of the generic drug and brand name drug. 13.
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2004 HMO Health Ohio 11 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at
800/ 522-2066 or write to us at Medical Mutual of Ohio, 2060 E. 9 th Street,
Cleveland, OH 44115-1355. You may also request replacement cards
through our website at http:// www. MedMutual. com.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
Both primary care and specialist doctors are part of the network. Different
members of the same family may select different centers or doctors.

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

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

What you must do to get The first and most important decision each member must make is the covered care selection of a primary care doctor. The decision is important since it
is through this doctor that all other health services, particularly those of
specialists, are obtained. It is the responsibility of your primary care
doctor to obtain any necessary authorizations from the Plan before
referring you to a specialist or making arrangements for hospitalization.
Services of other providers are covered only when there has been a referral
by a member's primary care doctor.

Primary Care Your primary care physician can be a physician, or group of physicians, trained in family or general practice, internal medicine, pediatrics or
osteopathic medicine who has a contractual obligation with HMO Health
Ohio to provide the primary care services listed in this brochure. Your
primary care physician will provide most of your health care, or give you a
referral to see a specialist.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a Plan Obstetrician/ Gynecologist without a referral.

For mental conditions and substance abuse call HMO Health Ohio
Behavioral Health Care Management Department at 800/ 258-3186.

Here are other things you should know about specialty care: 14.
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2004 HMO Health Ohio 12 Section 3
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop
a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

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

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to
a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800/ 522-2066. If you are new
to the FEHB Program, we will arrange for you to receive care.

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

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

These provisions apply only to the hospital benefit of the hospitalized
person. If your plan terminates participation in the FEHB Program in
whole or in part, or of OPM orders an enrollment change, this continuation
of coverage provision does not apply. In such case, the hospitalized family
member's benefits under the new plan begin on the effective date of
enrollment. 15.
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2004 HMO Health Ohio 13 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.

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

We call this review and approval process precertification. Your physician
must obtain approval before sending you to a hospital, referring you to a
specialist, or recommending follow-up care. 16.
16 Page 17 18
2004 HMO Health Ohio 14 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: You pay a copayment of $10 per office visit or outpatient
therapy session.

Deductible We have no deductible.
Coinsurance We have no coinsurance.

Your catastrophic protection Your out-of-pocket expenses for benefits under this Plan are limited to out-of-pocket maximum the stated copayments required for a few benefits.
for copayments 17.
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2004 HMO Health Ohio 15 Section 5
Section 5. Benefits Ð OVERVIEW (See page 10 for how our benefits changed this year and page 61 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/ 522-2066 or at our website at www. MedMutual. com.
(a) Medical services and supplies provided by physicians and other health care professionalsÉÉÉÉÉÉ. 16-24

Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies
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........................... 25-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services.......................................................... 29-31
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ............................................................................................................................... 32-33
Medical emergency Ambulance

(e) Mental health and substance abuse benefits.......................................................................................................... 34-35
(f) Prescription drug benefits ...................................................................................................................................... 36-38
(g) Special features............................................................................................................................................................. 39
Flexible Benefits Option Baby Link ®

Diabetes Advantage ª
Heart Sense ª Breathe Easy ®

(h) Dental benefits.............................................................................................................................................................. 40
Summary of benefits...................................................................................................................................................... 61-62 18.
18 Page 19 20
2004 HMO Health Ohio 16 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
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.

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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion (in office)

$10 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Nothing

Professional services of physicians
At home
Nothing

Diagnostic and treatment services --Continued on next page 19.
19 Page 20 21
2004 HMO Health Ohio 17 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 visit.

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol Ð once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening Ð every five years starting at age 50

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

Routine Prostate Specific Antigen (PSA) test Ð 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 20.
20 Page 21 22
2004 HMO Health Ohio 18 Section 5( a)
Preventive care, adult (Continued) You pay
Routine mammogram Ðcovered 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 office 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 Ð once every 10 years, ages 19 and over (except as provided for under childhood immunizations)

Influenza/ vaccines, annually
Pneumococcal vaccine, age 65 and over

$10 per office visit

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics

Examinations done on the day of immunizations (through age 22)
$10 per office visit

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

$10 per office visit 21.
21 Page 22 23
2004 HMO Health Ohio 19 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 pre-certify 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).

Circumcision is a surgical benefit, not a maternity benefit.

$10 per office
visit; initial visit
only

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b)
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office
visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges. 22.
22 Page 23 24
2004 HMO Health Ohio 20 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)

$10 per office
visit

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

Cost of donor sperm
Cost of donor egg

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.
Treatment therapies
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 28.

Respiratory and inhalation therapy
Dialysis Ð hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Ð Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

$10 per office
visit 23.
23 Page 24 25
2004 HMO Health Ohio 21 Section 5( a)
Physical and occupational therapies You pay
Physical therapy and occupational therapy --
For the greater of 20 visits or up to two months per condition, on an inpatient or outpatient basis, if significant improvement can be expected within two

months, for each of the following:
qualified physical therapists
occupational therapists and
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, provided at a Plan facility as
prescribed by your primary care doctor.

$10 copayment
Nothing per visit
during covered
inpatient
admission.

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges.

Speech therapy
For the greater of 20 visits or up to two months per condition $10 copayment per office visit.

Nothing per visit
during covered inpatient admission.

Hearing services (testing, treatment, and supplies)
Hearing evaluations $10 per office visit

Not covered:
hearing aids, testing and examinations for hearing aids All charges. 24.
24 Page 25 26
2004 HMO Health Ohio 22 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
We provide the following vision care benefits when received from Cole
Network Managed Vision Providers:

One eye refraction, including lens prescription, every year.
Members must use a Cole Network Managed Vision provider.
Member is responsible for any difference in cost between an examination for glasses and an examination for contact lenses.

NOTE: For medical and surgical benefits provided for the diagnosis and
treatment of diseases of the eye, members must continue to be referred to a
HMO Health Ohio optometrist or ophthalmologist for care.

$10 per visit

Not covered:
Corrective lenses or frames
Eye exercises and orthoptics
Sunglasses

All charges.

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

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

$10 per office
visit

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

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

by open cutting surgery)

All charges. 25.
25 Page 26 27
2004 HMO Health Ohio 23 Section 5( a)
Orthopedic and prosthetic devices You pay
Orthopedic devices, such as braces; foot orthotics
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: We pay internal prosthetic devices as hospital
benefits; see Section 5( c) for payment information. See 5( b) for
coverage of the surgery to insert the device.

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

Nothing

Not covered:
arch supports
heel pads and heel cups
trusses, elastic stockings, support hose, and other supportive devices

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 us at 800/ 522-2066 as soon as your Plan physician prescribes
this equipment. We will arrange with a health care provider to rent or sell
you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Nothing

Not covered:
Specially designed wheel chairs for use in sporting events All charges. 26.
26 Page 27 28
2004 HMO Health Ohio 24 Section 5( a)
Home health services You pay
Home health services of nurses and health aides, including intravenous fluids and medications, when prescribed by your Plan doctor, who will periodically review the
program for continuing appropriateness and need.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not Covered:
nursing care requested by, or for the convenience of, the patient or the patient's family
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
° Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy,
and cold pack application

$10
copayment

Alternative treatments
Acupuncture Ð by a doctor of medicine or osteopathy for: anesthesia, pain relief $10 copayment

Not covered:
° naturopathic services
° hypnotherapy
° biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

° Smoking cessation
° Diabetes self-management

$10 per
office visit 27.
27 Page 28 29
2004 HMO Health Ohio 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Any costs associated with the facility charge (i. e. hospital,

surgical center, etc.) are covered in Section 5 (c).
Your physician must get precertification of some surgical procedures.

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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)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting
standards; eligible members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) Ð Orthopedic and prosthetic devices for device coverage information.

$10 per office
visit; nothing for
hospital visits

Surgical procedures --continued on next page. 28.
28 Page 29 30
2004 HMO Health Ohio 26 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization (e. g. Tubal Ligation, Vasectomy) 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.

$10 per office visit;
nothing for hospital
visits

Not covered:
Reversal of voluntary sterilization Surgery primarily for cosmetic purposes

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.

$10 per office visit;
nothing for hospital
visits 29.
29 Page 30 31
2004 HMO Health Ohio 27 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.

$10 per
office visit;
nothing for
hospital visits

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

of accidental injury
Surgeries related to sex transformation

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.
TMJ treatment and services (non-dental)

$10 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 care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges. 30.
30 Page 31 32
2004 HMO Health Ohio 28 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single ÐDouble
Pancreas
Allogeneic 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) Ð Ohio Department of Health and Ohio Organ Transplant Consortium
Limited Benefits Ð 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

All charges.

Anesthesia
Professional services provided in Ð

Hospital (inpatient) Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Office

Nothing 31.
31 Page 32 33
2004 HMO Health Ohio 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

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

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).

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

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

General nursing care; and Meals and special diets.

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

Nothing

Inpatient hospital --continued on next page. 32.
32 Page 33 34
2004 HMO Health Ohio 30 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed private nursing care

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 Medical supplies, appliances, medical equipment, and any covered items billed by
a hospital for use at home

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care Non-covered facilities, such as schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

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

Nothing

Not covered:
Blood and blood derivatives not replaced by the member
All charges. 33.
33 Page 34 35
2004 HMO Health Ohio 31 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit:
The Plan provides a comprehensive range of benefits for 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 as
determined by a Plan doctor and approved by the Plan. All necessary
services are covered, including:

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

doctor.

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care
Personal comfort items, such as telephone and television

All charges.

Hospice care
Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient care, family
counseling, and durable medical equipment; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal stages of illness,
with a life expectancy of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate Nothing 34.
34 Page 35 36
2004 HMO Health Ohio 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure 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.

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

What to do in case of emergency:
If you are in an emergency situation, please call your primary care doctor. 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.

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

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

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

The Plan pays reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers. 35.
35 Page 36 37
2004 HMO Health Ohio 33 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center Nothing
Emergency care as an outpatient at a hospital, including doctors' services.

Note: If the emergency results in admission to a hospital, the emergency
care copayment is waived.

$50 copayment per visit

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

Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center Nothing
Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

Note: If the emergency results in admission to a hospital, the emergency
care copayment is waived.

$50 copayment per visit

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

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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance when ordered or authorized by a Plan doctor
See 5( c) for non-emergency service.

Nothing 36.
36 Page 37 38
2004 HMO Health Ohio 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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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 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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefit description below.

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

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

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

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

Medication management

$10 per visit

Mental health and substance abuse benefits--Continued on next page 37.
37 Page 38 39
2004 HMO Health Ohio 35 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing

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

Nothing

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow the following authorization process:
Call the HMO Health Ohio Behavioral Health Care Management Department at
800/ 258-3186. It is not necessary to obtain a referral from your primary care
doctor.

Limitation We may limit your benefits if you do not obtain a treatment plan. 38.
38 Page 39 40
2004 HMO Health Ohio 36 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
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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There are important features you should be aware of. These include:
Who can write your prescription. A plan or referral physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy, except for out-of-area emergencies, or by mail for a maintenance medication.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. A formulary is a list of selected FDA approved, prescription medications
reviewed by an independent Pharmacy and Therapeutics Committee brought together by Medco
Health Solutions, Inc. These drugs are made by many different pharmaceutical manufacturers. To
order a prescription drug brochure, call 800/ 417-1961.

Mail Order Program. To receive mail order prescription drug benefits, you mail your prescription order and the prescription drug deductible amount which is specified below to a contracting mail

order pharmacy. No benefits are payable if your prescription order is sent to a pharmacy other than
a contracting mail order pharmacy. The contracting mail order pharmacy will fill your prescription
order and send you up to a 90-day supply of the mail order prescription drug which your physician
has prescribed. The contracting mail order pharmacy will dispense the medication and mail it to you
within 72 hours. If the contracting mail order pharmacy fails to send you the mail order prescription
drug within ten days after you mailed in your prescription order, you may call the contracting mail
order pharmacy directly to determine the status of the prescription order.

These are the dispensing limitations. Prescription drugs obtained at a Plan pharmacy will be dispensed for up to a 30-day supply. Prescription drugs obtained by using the mail order prescription

drug program will be dispensed for up to a 90-day supply. When a generic substitution is
permissible (i. e. generic drug is available), but you request the name brand drug, you pay the price
difference between the generic and name brand drug, as well as the generic copayment per
prescription unit or refill. Members called to active military duty in a time of national or other
emergency who need to obtain a greater-than-normal supply of prescribed medications should call us
at 1-800-522-2066.

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name

drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.
When you have to file a claim. You should contact Medco Health at 800/ 417-1961 for prescription drug claim forms. You should submit all claims to Paid Prescriptions, L. L. C. , P. O. Box 2277, Lee

Summit, MO 64063-2277. Normally, when you use plan pharmacies, you will not have to file
claims.

Prescription drug benefits begin on the next page. 39.
39 Page 40 41
2004 HMO Health Ohio 37 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and
obtained from a Plan pharmacy or through our mail order program:

Drugs for which a prescription is required by Federal Law Insulin

Disposable needles and syringes for the administration of covered medications Contraceptive drugs and devices
Smoking cessation drugs and medication, including nicotine patches Growth hormone

Limited benefits:
Sexual dysfunction drugs have dispensing limitations. Contact the Plan for details.

Retail Pharmacy (up to a 30-day supply)
$10 copayment per
prescription or refill
for generic drugs

$20 copayment per
prescription or refill
for formulary name
brand drugs

$30 copayment per
prescription or refill
for non-formulary
name brand drugs

Mail Order (up to a
90-day supply)

$20 copayment per
prescription or refill
for generic drugs

$40 copayment per
prescription or refill
for formulary name
brand drugs

$60 copayment per
prescription or refill
for non-formulary
name brand drugs. 40.
40 Page 41 42
2004 HMO Health Ohio 38 Section 5( f)
Covered medications and supplies (Continued) You pay
Things to keep in mind:
A generic equivalent will be dispensed if it is available. If you purchase a Brand Name Prescription Drug when a Federally-approved Generic Drug is available, you will be
required to pay any applicable Generic Drug Copayment plus the difference between the
cost of the Generic Prescription Drug and the Brand Name Drug. You are still responsible
for paying the difference between the cost of the Generic Prescription Drug and the Brand
Name Drug, even if your Physician prescribes a brand name prescription drug and
indicates that this drug is to be dispensed as written.

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

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
Vitamins and nutritional substances that can be purchased without a prescription.
Medical supplies such as dressings and antiseptics
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Diabetic supplies, except as specified, including glucose test tablets and test tape, Benedict's solution, or equivalent, and acetone test tablets

Diet pills and appetite suppressants

All charges. 41.
41 Page 42 43
2004 HMO Health Ohio 39 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible Benefits Option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

Congestive Heart Failure (Heart
Sense TM )

For any of your health concerns, 24 hours a day, 7 days a week,
you may call 1-877-726-2715 and talk with a cardiac nurse
disease manager who will set up a program of telephone and
home visit( s) that will help you learn more about your condition
and how to manage your symptoms.

Maternity Care (BabyLink ® ) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-338-4114 and talk with a maternity care nurse who can answer your questions and provide necessary information and additional resources
that you may need concerning maternity care, during and after pregnancy.

Asthma (Breathe Easy ® ) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-888-244-6906 and talk with a specially trained respiratory nurse who will set up a program of telephone calls that will help you learn more about
your breathing conditions and how to manage your symptoms.

Chronic Obstructive
Pulmonary Disease (Breathe
Easy ® )

For any of your health concerns, 24 hours a day, 7 days a week, you may
call 1-888-244-6906 and talk with a specially trained respiratory nurse who
will set up a program of telephone calls that will help you learn more about
your breathing condition (also known as COPD or emphysema) and how to
manage your symptoms.

Diabetes (Diabetes
Advantage TM )

For any of your health concerns, 24 hours a day, 7 days a week, you may
call 1-800-861-4826 and talk with a Diabetes Care Coordinator who will set
up a program of telephone calls that will help you learn more about your
condition and how to manage your symptoms. You can also speak with a
certified dietician and receive diabetes testing supplies at no out-of-pocket
cost once you are enrolled in the program. 42.
42 Page 43 44
2004 HMO Health Ohio 40 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

medically necessary.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health

of the patient; See Section 5 (c) for inpatient hospital benefits. 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

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. These services must be initiated within 90
days from the date of the accident. We do not cover services necessary
because of injury as a result of chewing or biting.

Nothing.

Dental benefits
We have no other dental benefits. 43.
43 Page 44 45
2004 HMO Health Ohio 41 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness 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, drugs, or supplies you receive without charge while in active military service. 44.
44 Page 45 46
2004 HMO Health Ohio 42 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 800/ 522-2066.

When you must file a claim --such as for services you receive outside of
the Plan's service area --submit it on the HCFA-1500 or a claim form
that includes the information shown below. Bills and receipts should be
itemized and show:

Covered member's name and ID number;
Name and address physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and

Receipts, if you paid for your services.
Submit your claims to: HMO Health Ohio, P. O. Box 6018, Cleveland, Ohio 44101, Attn: HMO Member Services. You may also
contact us by fax at 216/ 687-2817, or visit our website
http:// www. MedMutual. com.

Prescription drugs Submit your claims to: Paid Prescriptions, L. L. C. , P. O. Box 2277, Lee Summit, MO 64063-2277.

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. 45.
45 Page 46 47
2004 HMO Health Ohio 43 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies Ð 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: HMO Health Ohio, P. O. Box 6018, Cleveland, Ohio 44101; 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 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 medical provider for more information. If we ask your provider, we will send you a copy of our requestÑ go to step 3.

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

We will write to you with our decision.

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

Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health
Insurance Group 3, 1990 E Street, NW, Washington, D. C. 20415-3630.

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

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim. 46.
46 Page 47 48
2004 HMO Health Ohio 44 Section 8
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must 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.
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
800/ 522-2066 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 may call OPM's Health Insurance Group 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 47.
47 Page 48 49
2004 HMO Health Ohio 45 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage 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 first plan pays, we will pay either what is left of our allowance
or our regular benefit. We will not pay more than our allowance. If we
are the secondary payer, we may be entitled to receive payment from
your primary plan.

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.
° Should I enroll in Medicare? The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It's easy. Just call the
Social Security Administration toll-free number 1-800-772-1213 to set up an
appointment to apply. If you do not apply for one or both Parts of Medicare,
you can still be Covered under the FEHB Program.

If you can get premiums-free part A coverage, we advise you to enroll in it.
Most Federal employees and annuitants are entitled to Medicare Part A at
age 65 without cost. When you don't have to pay premiums for Medicare
Part A, it makes good sense to obtain the coverage. It can reduce your out-of-
pocket expenses as well as costs to the FEHB, which can help keep FEHB
premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social
Security Administration can provide you with premium and benefit
information. Review the information and decide if it makes sense for you
to buy the Medicare Part B coverage. 48.
48 Page 49 50
2004 HMO Health Ohio 46 Section 9
If you are eligible for Medicare, you may have choices in how you get
your health Care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you
have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in (Part A or B) 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 this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. Your Plan
PCP must continue to authorize your care.

Claims process when you have the Original Medicare Plan Ð You probably will never have to file a claim form when you have both our
Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated
automatically and we will then provide secondary benefits for
covered charges. You will not need to do anything. To find out if
you need to do something to file your claims, call us at 800/ 522-
2066, or visit our website at http:// www. MedMutual. com.

We do not waive any costs if the Original Medicare Plan is your primary payer.

Medicare always makes the final determination as to whether they are the primary payer. The following chart
illustrates whether Medicare or this Plan should be the primary payer for you according to your employment status
and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

(Primary payer chart begins on next page.) 49.
49 Page 50 51
2004 HMO Health Ohio 47 Section 9
Primary Payer Chart
The primary payer for the
individual with Medicare isÉ A. When you -or your covered spouse -are age 65 or over and have Medicare and youÉ

Medicare This Plan
1) Are an active employee with the Federal government andÉ
You have FEHB coverage on your own or through your spouse who is also an active employee .

You have FEHB coverage through your spouse who is an annuitant .
2) Are an annuitant andÉ
You have FEHB coverage on your own or through your spouse who is also an annuitant . You have FEHB coverage through your spouse who is an active employee .

3) Are a reemployed annuitant with the Federal government and your position is excluded from the
FEHB (your employing office will know if this is the case) .*

4) Are a reemployed annuitant with the Federal government and your position is not excluded from
the FEHB (your employing office will know if this is the case) andÉ
You have FEHB coverage on your own or through your spouse who is also an active employee . You have FEHB coverage through your spouse who is an annuitant .

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

6) Are enrolled in Part B only, regardless of your employment status . for Part
B services
. for other
services
7) 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) . **

B. When you or a covered family memberÉ

1) Have Medicare solely based on end stage renal disease (ESRD) andÉ
It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period). .

It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD .
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary andÉ
This Plan was the primary payer before eligibility due to ESRD . for 30-month

coordina-
tion period
Medicare was the primary payer before eligibility due to ESRD .

C. When either you or your spouse are eligible for Medicare solely due to disability and you
1) Are an active employee with the Federal government andÉ
You have FEHB coverage on your own or through your spouse who is also an active employee . You have FEHB coverage through your spouse who is an annuitant

.

2) Are an annuitant andÉ
You have FEHB coverage on your own or through your spouse who is also an annuitant .

You have FEHB coverage through your spouse who is an active employee .

D. Are covered under the FEHB Spouse Equity provision as a former spouse .
* Unless you have FEHB coverage through your spouse who is an active employee
** Workers' Compensation is primary for claims related to your condition under Workers' Compensation 50.
50 Page 51 52
2004 HMO Health Ohio 48 Section 9
Medicare + Choice If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare + Choice 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 + Choice plans provide all the benefits that Original Medicare covers.
Some cover extras, like prescription drugs. To learn more about enrolling in a
Medicare + Choice plan, contact Medicare at 1-800-MEDICARE (1-800-633-
4227) or at www. medicare. gov.

If you enroll in a Medicare + Choice plan, the following options are available to
you:

This Plan and our Medicare + Choice plan: You may enroll in our Medicare + Choice plan and also remain enrolled in our FEHB plan. In this case, we do not
waive any of our copayments, coinsurance, or deductibles for your FEHB
coverage.

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

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

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program.
CHAMPVA provides health coverage to disabled Veterans and their eligible
dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first.
See your TRICARE or CHAMPVA Health Benefits Advisor if you have
questions about these programs.

Suspend FEHB coverage to enroll in TRICARE and CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in
one of these programs, eliminating your FEHB premium. (OPM does not
contribute to any applicable plan premiums). 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 under the program.

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. 51.
51 Page 52 53
2004 HMO Health Ohio 49 Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in one of
these State programs, eliminating your FEHB 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
under the State program

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 52.
52 Page 53 54
2004 HMO Health Ohio 50 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Treatment or services that are mainly to help the patient with daily living activities. Custodial care that lasts 90 days or more is sometimes known
as Long term care.

Experimental or A drug, device or medical treatment or procedure is experimental or investigational services investigational:

If the drug or device does not have required Food and Drug Administration (FDA) approval.
If reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I, II, III clinical trials or is
under study to determine maximum tolerated does, toxicity, safety,
efficacy, or efficacy as compared with the standard means of treatment or
diagnosis.

Group Health Coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies.

Medical necessity A service, supply or Prescription Drug that is required to diagnose or treat a Condition and which HMO Health Ohio determines is:
appropriate with regard to the standards of good medical practice; not primarily for your convenience or the convenience of a Provider; and

° the most appropriate supply or level of service which can be safely provided to you.

When applied to the care of an Inpatient, this means that your medical
symptoms or condition requires that the services cannot be safely or
adequately provided to you as an Outpatient. When applied to
Prescription Drugs, this means the Prescription Drug is cost effective
compared to alternative Prescription Drugs, which will produce
comparable effective clinical results.

Plan Allowance The amount a Contracting Institutional Provider or a Participating Professional Provider has agreed with HMO Health Ohio to accept as
payment in full for Covered Services.

Us/ We Us and we refer to HMO Health Ohio.
You You refers to the enrollee and each covered family member. 53.
53 Page 54 55
2004 HMO Health Ohio Section 11 51
Section 11. FEHB facts
Coverage information
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials will tell you:
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 disable