Document Body Page Navigation Panel

Arnett HMO

Pages 1--56 from Arnett HMO

Enrollment codes for this Plan:
G21 Self Only
G22 Self and Family

Arnett HMO Health Plan
2004

R1 73-288
For
changes in
benefits see
. page 8

http: / / www. arnettplans. com

Authorization for distribution by the:
United States Office of Personnel Management

Center for Retirement and Insurance Services
http: / / www. opm. gov/ insure

This Plan has an excellent accreditation
from the NCQA. See the 2004 Guide
for more information on NCQA. 1.
1 Page 2 3
2 2004 Arnett HMO
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 Healthier Feds
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 2.
2 Page 3 4
3 2004 Arnett HMO
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 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 healthcare 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 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. 3.
3 Page 4 5
4 2004 Arnett HMO
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
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under FEHB Program. You also may file a complaint with the Secretary of the
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. 4.
4 Page 5 6
5 2004 Arnett HMO 2
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Preventing Medical Mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 2. How we change for 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . 14
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . 20
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
( e) Mental Health and Substance Abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( g) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Table of Contents 5.
5 Page 6 7
6 2004 Arnett HMO 3
Section 6. General Exclusions Things we don t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Should I enroll in Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
The Original Medicare Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Medicare + Choice Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Workers Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Other Government Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Coverage information
No pre-existing coverage limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Types of coverage available to you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Children s Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When you lose benefits
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Two new Federal Programs complement FEHB benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
The Federal Flexible Spending Account Program FSAFEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
The Federal Long Term Care Insurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

Table of Contents 6.
6 Page 7 8
7 2004 Arnett HMO Introduction
Introduction
This brochure describes the benefits of Arnett HMO under our contract ( CS 2171) with the United States Office of Personnel
Management, as authorized by the Federal Employees Health Benefits law. The address for Arnett HMO administrative office is:

Arnett HMO
415 N. 26th Street, Suite 101
Lafayette, IN 47903-6108

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, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and changes are
summarized on page 8. 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 Arnett HMO

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

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

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 FEHBP Program regardless of the
agency that employs you or from which you retired.

Protect Yourself From Fraud -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.
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 765/ 448-7440 and explain the situation.

4 7.
7 Page 8 9
8 2004 Arnett HMO
If we do not resolve the issue:
CALL Ð 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

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 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 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 medications 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.
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.

Introduction 5 8.
8 Page 9 10
9 2004 Arnett HMO Introduction 6
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 America 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. 9.
9 Page 10 11
10 2004 Arnett HMO Section 1 7
Section 1. Facts about this HMO plan
This plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. 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 or see www. arnettplans. com.

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

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

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

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

Arnett HMO is a group model HMO. There are over 250 participating physicians. Plan members may select their primary care
physicians among the participating family practice physicians, internists, pediatricians, or obstetrician/ gynecologists.

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

If you want more information about us, call 888-448-7440, or write to Arnett HMO P. O. Box 6108, Lafayette, IN 47903-6108. You
may also contact us by fax at 765-448-7700, or visit our website at www. arnettplans. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our services area for this
Plan are available in the following area: The Greater Lafayette, Indiana area; including the counties of Benton, Boone, Carroll, Cass,
Clinton, Fountain, Fulton, Howard, Jasper, Montgomery, Newton, Pulaski, Tippecanoe, Warren, and White counties.

Ordinarily you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only
for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the
area ( for example, if your child goes to college in another state) , you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to
change plans. Contact your employing or retirement office. 10.
10 Page 11 12
11 2004 Arnett HMO
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 44
°We added information regarding Preventing Medical Mistakes. See page 5
°We added information regarding enrolling in Medicare. See page 35
°We revised the Medicare Primary Payer Chart. See page 37

Changes to this Plan
°Your share of the non-Postal premium will decrease by 8.5% for Self Only or 27% for Self and Family.
°You pay $100 copay for Emergency Room visits. The copay is waived if admitted.
°You pay 25% coinsurance with a $7,500 out of pocket maximum for surgical treatment of Morbid Obesity.
°You pay the following co-pays for prescription drugs:
$10 for generic drugs
$20 for peferred brand name drugs
$40 for non-preferred drugs

Section 2 8 11.
11 Page 12 13
12 2004 Arnett HMO
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 toll free at 888-448-7440 or 765-
448-7440. You may write to us at 415 N. 26th Street, Suite 101, Lafayette, IN 47903, or
request replacement cards through our website at www. arnettplans. 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.

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

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

What you must do It depends on the type of care you need. First, you and each family member must choose
a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your healthcare.

Primary Care Your primary care physician can be a family practitioner, internist, pediatrician, or
obstetrician gynecologist. 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. When you
receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral.

Section 3

to get covered care
9 12.
12 Page 13 14
13 2004 Arnett HMO
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your
treatment plan.

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 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 765-448-7440 or 888-448-7440. 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 alternate care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefit of the hospitalized person; we cover
your other non-hospital care

Section 4 10 13.
13 Page 14 15
14 2004 Arnett HMO
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.

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

Services requiring our Your physician must obtain prior approval by the Plan for the following service, but not
prior approval limited to: All Inpatient Admissions

Same Day Surgeries
Outpatient Mental Health and Substance Abuse visits
Home Health Care
Skilled Nursing Facilities
Rehabilitation Therapies
Some Durable Medical Equipment and Prosthetics
Out of Plan Network Referrals

Section 3 11 14.
14 Page 15 16
15 2004 Arnett HMO
Section 4. Your costs for covered Services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. ,
when you receive services.

Example: When you see your primary care physician you pay a copayment of $ 10 per
office visit.

Deductible We do not have a deductible with this Plan.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. In
our Plan, you pay 20% of our fees for durable medical equipment and prosthetics. You
pay 50% of our allowance for infertility services by a non-primary care physician in our
plan.

Your out-of-pocket maximum We have an out-of-pocket maximum for the surgical treatment of morbid obesity only.
There are no other out-of-pocket maximum limits.

Section 4 12 15.
15 Page 16 17
16 2004 Arnett HMO
Section 5. Benefits Ð OVERVIEW (See page 7 for how our benefits changed this year and page 47 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
claim filing advice, or more information about our benefits, contact us at 765-448-7440 or at our website at www. arnettplans. com.

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-19
Diagnostic and treatment services Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services ( testing, treatment, and supplies)
Preventive care, adult Vision services ( testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment ( DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical, occupational, and cardiac therapies Educational classes and programs

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

( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-24
Inpatient hospital Hospice care
Outpatient hospital or ambulatory surgical center Ambulance
Extended care benefits/ skilled
nursing facility benefits

( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-26
Medical emergency Ambulance

( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29
( g) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Section 5 13 16.
16 Page 17 18
17 2004 Arnett HMO
I M
P O
R T
A N
T

Nothing
( Copays may apply to associated
visits)

Preventative care, adult Ñ Continued on next page
Nothing
( Copays may apply to associated
visits)

Section 5 ( a) . Medical services and supplies provided by physicians and
other health care professionals

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4. Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

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

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

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Ultrasound
Electrocardiogram and EEG

CAT scans and MRI $ 50 copay

Section 5( a)

I M
P O
R T
A N
T

14 17.
17 Page 18 19
18 2004 Arnett HMO Section 5( a)
Routine screenings, such as: Nothing
Total Blood Cholesterol once every three years ( ( Copays may apply to associated
Colorectal Cancer Screening, including visits)
-Fecal occult blood test
-Sigmoidoscopy, screening every five years starting at age 50
Routine Prostate Specific Antigen ( PSA) test one annually for men
age 40 and older.
Routine pap test
Routine mammogram covered from 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

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

Routine immunizations, limited to: Nothing
Tetanus-diphtheria ( Td) booster -once every 10 years, ages 19 and over ( Copays may apply to associated
( except as provided for under Childhood immunizations) visits)
Influenza vaccines annually
Pneumococcal vaccine, age 65 and over

Preventive care, children
Childhood immunizations recommended by Nothing
the American Academy of Pediatrics ( Copays may apply to associated
Well-child care charges for routine examinations, immunizations and visits)
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 hearing correction.
-Examinations done on the day of immunizations ( through age 22)

Maternity care
Complete maternity ( obstetrical) care, such as: $ 10 for the initial office visit
Prenatal care and nothing thereafter
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 10 for
other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your impatient
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 or injury. See pages 20 and 23 for more information.

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

Preventive care, adult You pay

15 18.
18 Page 19 20
19 2004 Arnett HMO
Nothing
( Copays may apply to
associated visits)

Nothing
( Copays may apply to
associated visits)

Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization. See Surgical procedures Section 5( b)
Surgically implanted contraceptives ( such as Norplant)
Injectable contraceptives drugs ( such as Depo provera)
Intrauterine devices ( IUD s)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

Not covered: °Reversal of voluntary surgical sterilization

° Genetic counseling °Voluntary abortion

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-Intravaginal insemination ( IVI)
-Intracervical insemination ( ICI)
-Intrauterine insemination ( IUI)

Fertility drug Clomiohene citrate ( Clomid)
See Section 5( f)

Not covered:
° Assisted reproductive technology (ART) procedures, such as: -In vitro fertilization

-Embryo transfer, gameteGIFT and zygote ZIFT -Zygote transfer
° Services and supplies related to excluded ART procedures ° Cost of donor sperm
° Cost of donor egg
Allergy care

Testing and treatment
Allergy injection
Allergy serum

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 22.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous ( IV) Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
Note: Growth hormone is covered under the prescription drug benefit.
We will only cover GHT when we preauthorize the treatment from
your physician s referral.

$ 10 per office visit with primary
care physician and 50%
coinsurance for non primary
care physician and services.

All charges

Covered under the prescription
benefit.

All charges

Nothing
( Copays may apply to
associated visits)

Section 5( a) 16 19.
19 Page 20 21
20 2004 Arnett HMO Section 5( a)
Physical, occupational, and cardiac therapies You pay
60 visits per condition for the services of each of the following: Nothing
-qualified physical therapists and ( Copays may apply to
-occupational therapists associated visits)
-cardiac rehabilitation following a heart transplant; bypass surgery
or a myocardial infarction is provided

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

Speech therapy
60 visits per condition for the services of speech therapists Nothing
( Copays may apply to
associated visits)

Hearing services ( testing, treatment, and supplies)
Hearing tests are covered for diagnosis or treatment of disease or injury. Nothing
Hearing exams are covered for diagnosis or treatment of disease ( Copays may apply to
or injury. Children through age 17. ( See Preventative care, children associated visits)

Not covered: All charges
° All other hearing testing
° Hearing aids, testing and examinations for them

Vision services ( testing, treatment, and supplies)
Annual eye exam and refraction through age 17. Nothing
( See Preventive care, children ( Copay may apply to
Diagnosis and treatment of disease or injury of the eyes. associated visits)
Refractions following cataract surgery.

Not covered: All charges
°Eyeglasses or contact lenses, and examinations for them
°Eye exercises and orthoptics
° Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic $ 10 per office visit
or peripheral vascular disease, such as diabetes.
Podiatry care including bunions, spurs, ingrown toe nails, etc.

Not covered: All charges
° Shoe inserts and orthotics
° Cutting, trimming of toenails, and similar routine treatment of
conditions of feet, except as stated above
°Treatment of weak, strained or flat feet and of instability, imbalance
or subluxation of the foot

17 20.
20 Page 21 22
21 2004 Arnett HMO Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes, stump hose 20% coinsurance
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 surgery to insert the device.

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

Not covered: All charges
°Orthopedic devices
° Corrective shoes
°Arch supports
°Foot orthotics
° Heel pads and heel cups
° Lumbosacral supports
° Corsets, trusses, elastic stockings, support hose, and other
supportive devices

Durable Medical Equipment ( DME)
Rental or purchase at our option, including repair and adjustment, of 20% coinsurance
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds
Standard wheelchairs
Crutches
Walkers
Blood glucose monitors
Insulin pumps
Nebulizers

Note: The provider for our durable medical equipment is Lincare. They
can be contacted directly once the physician has prescribed the equipment.
You can reach them at 800-487-0001 to make arrangements
for pick up or delivery. If you would like to know more about this service,
please call us at 888-448-7440.

Not covered: All charges
°Personal comfort or convenience items
° Single patient use, self-administered dressings and
other disposable supplies

18 21.
21 Page 22 23
22 2004 Arnett HMO
Nothing; 50% after 8 weeks
Section 5( a)

Home health services You pay
Home health care ordered by a Plan physician and provided by a Nothing
registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aid.
Services include oxygen therapy, intravenous therapy, and medications.

Not covered: All charges
° Nursing care requested by, or for the convenience of, the patient or
the patient's family
° Home care primarily for personal assistance that does not include
a medical component and is not diagnostic, therapeutic,
or rehabilitative

Chiropractic

No benefit All charges

Alternative treatments
Not covered: All charges
° Acupuncture
°Naturopathic services
° Hypnotherapy
° Biofeedback

Educational Classes and programs
Smoking Cessation Program (there is an assessment for eligibility)
-8 weeks of Zyban or nicotine patches at no cost
(filled at Arnett pharmacies only)
-smoking cessation counselors
-educational materials

If after 8 weeks there is need for more treatment, it is available. For more
information contact us at 765-448-7453.

Note: Primary Care physicians can write prescriptions for the smoking aids
through the prescription drug benefit; see Prescription drugs

19 22.
22 Page 23 24
23 2004 Arnett HMO
Section 5( b) . Surgical and anesthesia services provided by physicians and other health
care professionals

Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
° Plan physicians must provide or arrange your care.
° Be sure to read Section 4. Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
°The amounts listed below are for the charges billed by a physician or other health care professional
for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e., hospital,
surgical center, etc.).
°YOUR PHYSICIAN MUST GET PRECERTIFICATION OF ALL SURGICAL PROCEDURES.
Please refer to the precertification information shown in Section 3.

Surgical procedures
A comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( see constructive surgery)
Insertion of internal prosthetic devices. See 5( a) Orthopedic
and prosthetic device coverage information.
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.
Voluntary sterilization
Treatment of burns

Surgical treatment of morbid obesity which is defined in our Plan as 25% % Coinsurance with $ 7500
-A weight of at least two ( 2) times the ideal weight for frame, age, out of pocket maximum.
height, and gender as specified in the 1983 Metropolitan Life
Insurance tables;
-A body mass index of at least thirty-five ( 35) kilograms per meter
squared with comorbidity or coexisting medical conditions such as
hypertension, cardiopulmonary conditions, sleep apnea, or diabetes;
-A body mass index of at least forty ( 40) kilograms per meter
squared without comorbidity
-Morbid obesity that has persisted for at least five ( 5) years;
-For which non-surgical treatment that is supervised by a physician
has been unsuccessful for at least eighteen ( 18) consecutive months.
Note: For purposes of this section, body mass index equals weight in
kilograms divided by height in meters squared.

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

Section 5( b)

I M
P O
R T
A N
T

I M
P O
R T
A N
T

( Copays may apply to
associated visits)

Benefit Description You pay

20 23.
23 Page 24 25
24 2004 Arnett HMO Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect Nothing
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 for the common form or norm. Examples of
congenital anomalies are: protruding ear deformities, cleft lip, cleft
palate, birth marks, webbed fingers, webbed toes.

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

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

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Nothing
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe
functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve teeth or their

supporting structures.

Not covered: All charges
°Oral implants and transplants
°Procedures that involve the teeth or their supporting structures (such as
periodontal membrane, gingiva, and alveolar bone.
°Any dental care involved in treatment of temporomandibular
joint (TMJ) pain dysfunction syndrome.

21 24.
24 Page 25 26
25 2004 Arnett HMO Section 5( b)
Organ/ tissue transplants
Limited to: Nothing
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic ( donor) bone marrow transplants
Autologous bone marrow transplants ( autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic leukemia; advanced Hodgkin s lymphoma; advanced
non-Hodgkin s lymphoma; advanced neurpblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
Intestinal transplants ( small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
National Transplant Program ( NTP)

Limited Benefits Treatment of 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 as
long as the recipient is enrolled into our Plan.

Not covered: All charges
° Donor screening tests and donor search expenses, except those
performed for the actual donor.
° Implants of artificial organs
°Transplants not listed as covered

Anesthesia
Professional services provided in: Nothing
Hospital inpatient
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

22 25.
25 Page 26 27
26 2004 Arnett HMO
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5( c)

Section 5( c) . Services provided by a hospital or other facility,
and ambulance services

Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
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 5( b) .
YOUR PHYSICAL MUST GET PRECERTIFICATION OF ALL SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3.

Benefit Description You pay
Inpatient hospital
Room and board, such as: Nothing
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets

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

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines given while admitted.
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home supplies
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home.

Not covered: All charges
° Custodial care
° Non-covered facilities, such as nursing homes and schools
°Personal comfort items, such as telephone, television,
barber services, guest meals and beds
°Private nursing care
°Take home drugs

23 26.
26 Page 27 28
27 2004 Arnett HMO Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
Drugs and medications given at the facility
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood or blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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

CAT Scans and MRIs $ 50 copay
Not covered: All charges
°Take home drugs

Extended care benefits/ skilled nursing facility benefits
Extended care/ skilled nursing benefit Nothing
Note: 90 day annual limit

Not covered: All charges
° Custodial care

Hospice Care
Care for a terminally ill member is covered in the home or skilled facility Nothing
as long as there are skilled components medically necessary. 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.

Ambulance
Local professional ambulance service when medically appropriate Nothing

24 27.
27 Page 28 29
28 2004 Arnett HMO
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Section 5( d)

Section 5( d). Emergency services/ accidents
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.
Be sure to read Section 4. Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

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

What to do in case of emergency: Benefits are provided for urgent and emergency medical services whether rendered inside or outside of the Plan s Service
Area.
Urgent Care: Medical direction and advice is available through your primary care physician, seven ( 7) days a week, twenty
four ( 24) hours a day. All urgent care services whether inside or outside of the service area must be referred in advance by
your primary care physician.

Emergency Care: Benefits are not provided for the use of an emergency room except for emergency care. In the event of an
Emergency, you should go to a participating practitioner, unless the condition requires you to go to the nearest emergency
room. If you are admitted, the applicable copay would be waived. If admitted in an out of area facility, please notify the
Plan within 48 hours of admitting, unless it is not reasonably possible to do so. If this is the case, notify the Plan as soon as
possible.

Benefit Description You pay
Emergency within our service area
Emergency care at doctor s office $ 10 copay

Emergency care at an approved urgent care center $ 25 copay
Emergency care at a hospital, and not admitted. $ 100 copay
Emergency care at a hospital, and admitted. Nothing
Not covered: All charges
° Elective care or non-emergency care

25 28.
28 Page 29 30
29 2004 Arnett HMO Section 5( d)
Emergency outside our service area You pay
Emergency care at an urgent care center $ 25 copay

Emergency care at a hospital, and not admitted. $ 100 copay
Emergency care at a hospital, and admitted. Nothing
Not covered: All charges
° Elective care or non-emergency care
° Emergency care provided outside the service area is the need for care
could have been foreseen before leaving the service area
° Medical and hospital costs resulting from a normal full-term delivery
of a baby outside the service area

Ambulance
Professional ambulance service when medically appropriate. Nothing
See 5( c ) for non-emergency service.

26 29.
29 Page 30 31
30 2004 Arnett HMO Section 5( e)
When you get our approval for services and follow a treatment plan we approve, cost-sharing and
limitation for Plan mental and substance abuse benefits will be no greater than for similar benefits for
other illnesses and conditions.

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

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

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

27
Benefit Description You pay
Network mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and Your cost sharing responsibilities
contained in a treatment plan that we approve. The treatment plan may include are no greater than for
services, drugs, and supplies described elsewhere in this brochure. other illness or conditions

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

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

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

Not covered: Services we have not approved All charges

Note: OPM s review of disputes about the network treatment plans will be
based on the treatment plan s clinical appropriateness. OPM will generally
not order one clinically appropriate treatment plan in favor of another.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all of our network authorization processes.

Note: Your primary care physician will make the referrals for the treatment plan.
Please contact your physician if you have questions, or call us at 765-448-7440 or toll
free at 888-448-7440.

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

I M
P O
R T
A N
T

I M
P O
R T
A N
T 30.
30 Page 31 32
31 2004 Arnett HMO Section 5( f)
Section 5( f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to 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.

There are important features you should be aware of. These include:
Who can write your prescription . A plan physician must write the prescription.
Where can you obtain them. Prescriptions must be dispensed by a participating pharmacy, In order to receive this
benefit you must present your Arnett HMO membership card at the time the prescription is filled. The participating
pharmacy will then charge you the applicable copayment amount. There are some specific drugs that require prior
authorization by Arnett HMO. Your ordering physician or the participating pharmacy will then charge you the
applicable copayment amount. Take-home prescriptions dispensed from a hospital facility will not be covered.

We use a preferred drug list. The Arnett Preferred Prescription Drug List is based on the recommendations of our
Pharmacy and Therapeutics ( P& T) Committee and from the input we receive from our physicians. The P& T
Committee is made up of pharmacists and physicians who make decisions regarding the formulary. They review
medications on an ongoing basis to decide which are the safest and most effective. The Committee meets every four
months to develop and update the preferred list. Many medications have the same chemical structure but are
packaged differently. The preferred list limits the number of similar drugs from which providers may choose. This
allows us to purchase drugs in volume at greater discounts. This cost savings is passed on to our members in the
form of reduced premiums and increased benefits.

These are the dispensing limitations. All prescriptions are filled for up to a one month supply.
We offer three levels of copayments for this prescription:
-Generic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 copay ( up to a one month supply)
-Preferred Brand Name Drugs . . . . . . . . . . . . . . . . . . . $ 20 copay ( up to a one month supply)
-Non-Preferred Brand Name Drugs . . . . . . . . . . . . . . . $ 40 copay ( up to a one month supply)

Note: If a generic drug is available and the prescription is filled with a brand name drug, ( preferred or non-
preferred) member pays the difference in cost between the generic and brand name drug in addition to the
copayment. Drugs that require prior authorization must be authorized prior to the prescription being filled in order to
be considered for payment.

If you are called to active military duty, or there is a National emergency that requires an extended supply of
prescriptions, call us at ( 765) 448-7440.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and
dosage to the original brand name product. Generic drugs cost you and your plan less money than a name-brand
drug.

When you have to file a claim. Our network providers should bill us directly, but if by chance you receive a bill of
charges, you may contact us at 765-448-7440 or mail them to us:

Arnett Health Plans, Attn HMO Claims Department, P. O. Box 6108, Lafayette, IN 47903

I M
P O
R T
A N
T

I M
P O
R T
A N
T

28
Prescription drug benefits begin on next page 31.
31 Page 32 33
32 2004 Arnett HMO 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:

Drugs for which a prescription is required by
Federal law
Insulin, with a copay charge applied to each visit.
Diabetic supplies, including insulin syringes, needles,
glucose test tablets and test tape, Benedict s solution
or equivalent, and acetone test tablets
Disposable needles and syringes needed for injecting
covered prescribed medication
Oral contraceptive drugs; contraceptive devices

Not covered: All charges.
°Drugs available without a prescription or for which
there is a nonprescription equivalent available
°Drugs obtained at a non-Plan pharmacy except for
out-of-area emergencies where the network does
not extend.
°Vitamins, nutrients, and food supplements even if
a physician prescribes or administers them
° Medical supplies such as dressings and antiseptics
° Drugs and supplies for cosmetic purposes
° Drugs to enhance athlete performance
°Fertility drugs except for Chomiphene (Clomid)

$ 10 copay Generic Drugs
$ 20 copay Formulary Brand Name Drugs
$ 40 copay Non--Formulary Brand Name Drugs
Note: You receive up to a one month supply for each copay.
If there is no generic available, you will still
have to pay the brand name copay.

29 32.
32 Page 33 34
33 2004 Arnett HMO Section 5( g)
I M
P O
R T
A N
T

I M
P O
R T
A N
T

30

Section 5( g). Dental benefits
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 providers must arrange your care.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health
of the patient; we do not cover the dental procedure.
Be sure to read Section 4. Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

Accidental injury benefit You pay
We cover restorative services and supplies necessary to
promptly repair ( but not replace) sound natural teeth.
The need for these services must result from an accidental
injury. Services must be received within 72 hours
of the injury.

In physician s or referral specialist s office $ 10 copay
In an urgent care center $ 25 copay
In a hospital emergency room $ 100 copay
Dental Benefits You pay
We have no other dental benefits. All charges. 33.
33 Page 34 35
34 2004 Arnett HMO Section 6
Section 6. General exclusions Ð things we don't cover
The exclusions in this section apply to all benefits. Although we list a specific service as a benefit, we will not cover it unless your
Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:
° Care by non-Plan providers except for authorized referrals or emergencies (see Emergency benefits);
° Services, drugs, or supplies you receive while you are not enrolled in this Plan;
° Services, drugs, or supplies that are not medically necessary;
° Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
° Experimental or investigational procedures, treatments, drugs, or devices;
° Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried
to term or when the pregnancy is the result of an act of rape or incest;

° Services, drugs, or supplies related to sex transformations;
° Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
° Services, drugs, or supplies you receive without charge while in active military service.

31 34.
34 Page 35 36
35 2004 Arnett HMO 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, such as emergency care services.
Check with the provider. If you need to file the claim, here is the process:

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 765-448-7440 or toll free at 888-448-7440.

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

Submit your claims to: Arnett Health Plans
Attn: HMO Claims Department
P. O. Box 6108
Lafayette, IN 47903

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.

Medical, hospital,
and drug benefits

32 35.
35 Page 36 37
36 2004 Arnett HMO
1
2
3

4

Section 8

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

Step Description
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: Arnett HMO, Member Services Department, P. O. Box 6108, Lafayette, IN 47903
(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.

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

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 Ñ 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,
1900 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.

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.

33 36.
36 Page 37 38
37 2004 Arnett HMO Section 8
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 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 765-448-7440 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 they can give your claim expedited treatment
too, or
-You may call OPM s Health Benefits Insurance Group 3 at 202-606-0737 between 8 a. m. and 5 p. m. eastern time.

5
The Disputed Claims process (Continued)

34 37.
37 Page 38 39
38 2004 Arnett HMO Section 9
Section 9. Coordinating benefits with other coverage
When you have You must tell us if you or a covered family member have coverage under another
group health plan or have automobile insurance that pays medical expenses without
regard to fault. This is called double coverage.

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

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

What is Medicare? Medicare is a health insurance program for:
People 65 years of age and older.
Some people with disabilities under 65 years of age.
People with end-stage renal disease ( permanent kidney failure requiring dialysis or

a transplant) .

Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not have to pay for Part A. If you or
your spouse worked for at least 10 years in Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. ( Someone who was a
Federal employee on January 1, 1983 or since automatically qualifies. ) Otherwise,
if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE
for more information.
Part B ( Medical Insurance) . Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement
check.

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 coverd under the
FEHB Program.

If you can get premium-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.

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

other health coverage

35 38.
38 Page 39 40
39 2004 Arnett HMO
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.

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

When you are enrolled in Original Medicare along with this Plan, you still need to
follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan You probably will
never have to file a claim form when you have both our Plan and the Original
Medicare Plan.

When we are the primary payer, we process the claim first.
When Original medicare is the primary payer, Medicare processes your claim
first. In most cases, your claims will be coordinated automatically, and we will
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 765-448-7440 or toll free at 888-448-7440.

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

Section 9 36

( Part A or Part B) 39.
39 Page 40 41
40 2004 Arnett HMO Section 9 37
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 enrollment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these
requirements correctly.

Primary Payer Chart
A. When you or your covered spouse are age 65 or over and have Medicare and you. . . The Primary payer for the
individual with Medicare is. . .

Medicare This Plan

1) Are an active employee with the Federal government and. . .
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 and. . .
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) and. . .
You have FEHB coverage through 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 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 . Part . other Services
B 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 member. . .

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

It is within the first 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 and. . . . for 30-month
This Plan was the primary payer before eligibility due to ESRD coordination 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 and. . .
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 and. . .
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 40.
40 Page 41 42
41 2004 Arnett HMO 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 + Choice plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare + Choice plans provide all of
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. We will still provide benefits when your
Medicare + Choice plan is primary. We do not waive cost-sharing for your FEHB. If you
enroll in a Medicare + Choice plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare + Choice plan so we can correctly coordinate
benefits with Medicare.

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 will 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, coinsurance, or deductibles. If you enroll in a Medicare + Choice
plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a
Medicare + Choice plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll Medicare + Choice Plan: If you are an annuitant
or former spouse, you can suspend your FEHB coverage to enroll in a Medicare + Choice
plan, eliminating your FEHB premium. ( OPM does not contribute to your Medicare +
Choice 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 loss 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.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in a 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 loss
coverage or move out of 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.

38 41.
41 Page 42 43
42 2004 Arnett HMO
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, or Federal Government
are responsible for your care 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 and 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.

39 42.
42 Page 43 44
43 2004 Arnett HMO Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For enrollees, the calendar year begins on the effective date of their enrollment and ends in December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered Services Care we provide benefits for, as described in this brochure.
Custodial Care Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic or rehabilitative.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 12.
Experimental or Drugs, devices, services, supplies, medical treatments or procedures which are
Investigational services experimental or investigational in nature. The Plan will apply the following criteria in determining whether services or supplies are experimental or investigational:

a. Any medical device, drug or biological product must have received final approval to
market by the United States Food and Drug Administration ( FDA) for the particular
diagnosis or condition.

b. Conclusive evidence from the published peer-review medical literature must exist that
over time the technology has a definite positive effect on health outcomes; such evidence
must include well-designed investigations that have been reproduced by nonaffiliated
authoritative sources, with measurable results, backed up by the positive endorsements of
national medical bodies or panels regarding the efficacy and rationale.

c. Demonstrated evidence as reflected in the published peer-review literature must exist
that over time the technology leads to improvements in health outcomes, i. e., the
beneficial effects outweigh the harmful effects.

d. Proof as reflected in the published peer-reviewed literature must exist that the
technology is at least as effective in improving health outcomes as established
technology, or is usable in appropriate clinical contexts in which established technology
is not employable.

e. Proof as reflected in the published peer-reviewed medical literature must exist that
improvements in health outcomes, as defined in paragraph c, is possible in standard
conditions of medical practice, outside clinical investigatory settings.

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

40 43.
43 Page 44 45
44 2004 Arnett HMO
Section 11. FEHB facts
Coverage Information:

We will not refuse to cover the treatment of a condition that you had before you enrolled
in this Plan solely because you had the condition before you enrolled.

See www. opm. gov/ insure. Also, your employing or retirement office can answer your
questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures
for other plans, and other materials you need to make an informed decision about your
FEHB coverage. These materials 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.

Self Only Coverage is for you alone. Self and Family coverage is for you, your spouse,
and your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for. Under certain
circumstances, you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if
you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the first
day of the pay period in which the child is born or becomes an eligible family member.
When you change to Self and Family because you marry, the change is effective on the
first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no
longer eligible to receive health benefits, nor will we. Please tell us immediately when
you add or remove family members from your coverage for any reason, including
divorce, or when your child under 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not
be enrolled in or covered as a family member by another FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children s Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the Federal
Employees Health Benefits ( FEHB) Program, if you are an employee subject to a court or
administrative order requiring you to provide health benefits for your child( ren) .

Section 11 41

No pre-existing condition
limitation

Where you can get information
about enrolling in the FEHB
Program

Types of coverage available
for you and your family 44.
44 Page 45 46
45 2004 Arnett HMO
If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you involuntarily as
follows:
If you have no FEHB coverage, your employing office will enroll you for self and
family coverage in the option of the Blue Cross and Shield Service Benefit Plan that
provides the lower level of coverage;
if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment
to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live,
your employing office will change your enrollment to Self and Family in the Blue
Cross and Blue Shield Service Benefit Plan s Basic Option.

As long as the court/ administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn t serve the area in
which your children live, unless you provide documentation that you have other coverage
for the children. If the court/ administrative order is still in effect when you retire, and you
have at least one child still eligible for FEHB coverage, you must continue your FEHB
coverage into retirement ( if eligible) and cannot make any changes after retirement.
Contact your employing office for further information.

When benefits and The benefits in this brochure are effective January 1. If you joined this premiums start Plan during Open Season, your coverage begins January 1. Annuitants coverage and
premiums begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage.

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
( TCC) , or a conversion policy ( a non-FEHB individual policy) .

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get
benefits under your former spouse s enrollment. This is the case even when the court has
ordered your former spouse to supply health coverage to you. But, you may be eligible
for your own FEHB coverage under the spouse equity law or Temporary Continuation of
Coverage ( TCC) . If you are recently divorced or are anticipating a divorce, contact
your ex-spouse s employing or retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other information about your coverage choices. You can also
download the guide from OPM s website, www. opm. gov/ insure.

Section 11 42 45.
45 Page 46 47
46 2004 Arnett HMO Section 11
If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage ( TCC) .
For example, you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and you turn
22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, from your employing, or retirement office or from
www. opm. gov/ insure.

You may convert to a non-FEHB policy if:
Your coverage under TCC or the spouse equity law ends ( If you canceled your coverage or
did not pay your premium, you cannot convert) ;
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse equity law.

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