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U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Insurance Services Programs

HealthPlus of Michigan

Federal Employees Health Benefits Program
2004 Plan Brochure
Accessible Version

Pages 1--68 from HealthPlus of Michigan

Page 1 2
HealthPlus of Michigan http:// www. healthplus. com
2004 A Health Maintenance Organization

Serving: Greater Flint and Saginaw areas
Enrollment in this Plan is limited. You must live in our Geographic service area to enroll. See page 9 for requirements.

Enrollment codes for this Plan:
X51 Self Only X52 Self and Family

RI 73-648

This Plan has Excellent accreditation
from the NCQA. See the 2004 Guide
for more information on accreditation.

For changes
in benefits,
see page 10.

United States
Office of Personnel Management

Center for
Retirement and Insurance Service
http:// www. opm. gov/ insure 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The
brochure describes the benefits this plan offers you for 2004. Because benefits vary from year to year, you should
review your plan's brochure every Open Season Ð especially Section 2, which explains how the plan changed.

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

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

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

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

Sincerely,

Kay Coles James
Director 2.
2 Page 3 4
2004 HealthPlus of Michigan
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

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

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

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

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

OPM may use or give out your personal medical information for the following purposes under limited
circumstances:

° For Government health care oversight activities (such as fraud and abuse investigations).
° For research studies that meet all privacy law requirements (such as for medical research or education), and
° To avoid a serious and imminent threat to health or safety.

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

By law, you have the right to:
° See and get a copy of your personal medical information held by OPM.
° Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information. 3.
3 Page 4 5
° 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.
° 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 the 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.

2004 HealthPlus of Michigan 4.
4 Page 5 6
2004 HealthPlus of Michigan 2 Table of Contents
Table of Contents
Introduction.................................................................................................................................................................... 4
Plain Language .............................................................................................................................................................. 4
Stop Health Care Fraud! ................................................................................................................................................ 5
Preventing medical mistakes.......................................................................................................................................... 6
Section 1. Facts about this HMO plan.................................................................................................................... 8
How we pay providers ........................................................................................................................... 8
Who provides my healthcare? ............................................................................................................... 8
Your Rights ............................................................................................................................................ 8
Service Area........................................................................................................................................... 9
Section 2. How we change for 2004..................................................................................................................... 10
Program-wide changes......................................................................................................................... 10
Changes to this Plan ............................................................................................................................ 10
Section 3. How you get care ................................................................................................................................ 11
Identification cards .............................................................................................................................. 11
Where you get covered care ................................................................................................................ 11
c Plan providers................................................................................................................................ 11
c Plan facilities ................................................................................................................................. 11
What you must do to get covered care ................................................................................................ 11
c Primary care .................................................................................................................................. 12
c Specialty care ................................................................................................................................ 12
c Hospital care.................................................................................................................................. 13
Circumstances beyond our control ...................................................................................................... 13
Services requiring our prior approval .................................................................................................. 13
Section 4. Your costs for covered services ........................................................................................................... 14
c Copayments................................................................................................................................... 14
c Deductible ..................................................................................................................................... 14
c Coinsurance................................................................................................................................... 14
Your catastrophic protection out-of-pocket maximum........................................................................ 14
Section 5. Benefits ................................................................................................................................................ 15
Overview.............................................................................................................................................. 15
(a) Medical services and supplies provided by physicians and other health care professionals ....... 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals.... 25
(c) Services provided by a hospital or other facility, and ambulance services .................................. 29
(d) Emergency services/ accidents....................................................................................................... 32
(e) Mental health and substance abuse benefits ................................................................................. 34
(f) Prescription drug benefits .............................................................................................................. 36
(g) Special features ............................................................................................................................. 39
c NCQA "Excellent" Accreditation c High risk pregnancies 5.
5 Page 6 7
c Disease Management Program
c Centers of Excellence for transplants, heart surgery, etc.
c HealthQuest and health resource library
c College students c Flexible benefits option
(h) Dental benefits .............................................................................................................................. 40
Section 6. General exclusions Ñ things we don't cover ...................................................................................... 41
Section 7. Filing a claim for covered services...................................................................................................... 42
Section 8. The disputed claims process ................................................................................................................ 43
Section 9. Coordinating benefits with other coverage.......................................................................................... 45
When you have other health coverage ................................................................................................ 45
c What is Medicare .......................................................................................................................... 45
c Should I enroll in Medicare? ........................................................................................................ 45
c Medicare + Choice ........................................................................................................................ 48
c TRICARE/ and CHAMPVA ......................................................................................................... 48
c Workers' compensation ................................................................................................................. 49
c Medicaid........................................................................................................................................ 49
c Other Government agencies.......................................................................................................... 49
c When others are responsible for injuries ...................................................................................... 49
Section 10. Definitions of terms we use in this brochure....................................................................................... 50
Section 11. FEHB facts........................................................................................................................................... 54
Coverage information .......................................................................................................................... 54
c No pre-existing condition limitation ............................................................................................. 54
c Where you can get information about enrolling in the FEHB Program....................................... 54
c Types of coverage available for you and your family................................................................... 54
c Children's Equity Act.................................................................................................................... 55
c When benefits and premiums start................................................................................................ 55
c When you retire............................................................................................................................. 55
When you lose benefits........................................................................................................................ 56
c When FEHB coverage ends .......................................................................................................... 56
c Spouse equity coverage................................................................................................................. 56
c Temporary Continuation of Coverage (TCC) ............................................................................... 56
c Converting to individual coverage ................................................................................................ 56
c Getting a Certificate of Group Health Plan Coverage .................................................................. 57
Two new Federal Programs complement FEHB benefits ........................................................................................... 58
The Federal Flexible Spending Account Program -FSAFEDS.......................................................... 58
The Federal Long Term Care Insurance Program ............................................................................... 61
Index ............................................................................................................................................................................ 62
Summary of benefits .................................................................................................................................................... 64

Rates............................................................................................................................................................... Back cover
2004 HealthPlus of Michigan 3 Table of Contents 6.
6 Page 7 8
2004 HealthPlus of Michigan 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of HealthPlus of Michigan under our contract (CS 2712) with the United
States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.
The address for HealthPlus of Michigan administrative offices is:

HealthPlus of Michigan, Inc.
2050 South Linden Road
P. O. Box 1700
Flint, MI 48501-1700

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 care 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 10. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the
public. For instance,

c Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means HealthPlus of Michigan.

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

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

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You
may also write to OPM at the United States Office of Personnel Management, Insurance Services Program,
Planning and Evaluation Group, 1900 E Street, NW, Washington, DC 20415-3650. 7.
7 Page 8 9
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium.

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

Protect Yourself From Fraud Ñ Here are some things you can do to prevent fraud:

c Be wary of giving your plan identification (I. D.) number over the telephone or to people you do not know,
except to your doctor, other provider, or authorized plan or OPM representative.

c Let only the appropriate medical professionals review your medical record or recommend services.
c 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.

c Carefully review explanations of benefits (EOBs) that you receive from us.
c 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.

c 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:
c Call the provider and ask for an explanation. There may be an error.
c If the provider does not resolve the matter, call us at (800) 332-9161 and explain the situation.
c If we do not resolve the issue:

c Do not maintain as a family member on your policy:
c Your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or
c Your child over age 22 (unless he/ she is disabled and incapable of self support).
c 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.
c 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 elibigle member or who is no longer
enrolled in the Plan.

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

2004 HealthPlus of Michigan 5 Introduction/ Plain Language/ Advisory 8.
8 Page 9 10
2004 HealthPlus of Michigan 6 Introduction/ Plain Language/ Advisory
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from
medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While
death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended
hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and
understanding your risks, you can improve the safety of your own health care, and that of your family members.
Take these simple steps:

1. Ask questions if you have doubts or concerns.
° Ask questions and make sure you understand the answers.
° Choose a doctor with whom you feel comfortable talking.
° Take a relative or friend with you to help you ask questions and understand answers.

2. Keep and bring a list of all the medicines you take.
° Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription
medicines.
° Tell them about any drug allergies you have.
° Ask about side effects and what to avoid while taking the medicine.
° Read the label when you get your medicine, including all warnings.
° Make sure your medicine is what the doctor ordered and know how to use it.
° Ask the pharmacist about your medicine if it looks different than you expected.

3. Get the results of any test or procedure.
° Ask when and how you will get the results of test or procedures.
° Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by
mail.
° Call your doctor and ask for your results.
° Ask what the results mean for your care.

4. Talk to your doctor about which hospital is best for your health needs.
° Ask your doctor about which hospital has the best care and results for your condition if you have more than
one hospital to choose from to get the health care you need.
° Be sure you understand the instructions you get about follow-up care when you leave the hospital.

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

Want more information on patient safety?
ã 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.

ã www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for
you and your family.

ã 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. 9.
9 Page 10 11
ã www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
ã www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals
working to improve patient safety.

ã 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.

2004 HealthPlus of Michigan 7 Introduction/ Plain Language/ Advisory 10.
10 Page 11 12
2004 HealthPlus of Michigan 8 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. The Plan is
solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent
provider directory.

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

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

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

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

Who provides my healthcare
Each family member that is covered by HealthPlus must choose a Primary Care Physician from the Provider
Directory (parents are expected to select for their children). This list includes hundreds of doctors who specialize
in Family Practice, Internal Medicine, or Pediatrics. The listing for each Primary Care Physician also shows a
"primary hospital." This is the hospital where your Primary Care Physician will direct you for hospital services in
most instances. When you select a Primary Care Physician, you also are agreeing to use the hospital listed.

The Primary Care Physician you choose will coordinate your overall medical care, including arranging for hospital
admissions or care by a specialist when medically necessary with the following exception: a woman may see her
Plan gynecologist for her annual routine examination without a referral.

HealthPlus strives to keep the Provider Directory as up-to-date as possible. However, information may change
after the Directory has been printed. If the physician you select is no longer accepting patients, please select
another. You may want to call the physician you have chosen prior to calling the HealthPlus Customer Service
Department at (800) 332-9161 with your selection. You must notify HealthPlus before receiving covered services
from the new Primary Care Physician.

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

c HealthPlus service area
c HealthPlus Federal brochure
Ð Covered benefits, including prescription drug coverage
Ð Description of emergency health coverages and benefits
Ð Out-of-area coverage and benefits
Ð An explanation for copayments and any other out-of-pocket expense 11.
11 Page 12 13
2004 HealthPlus of Michigan 9 Section 1
c Continuity of treatment
Ð Arrange for the continuation of treatment by that provider; or
Ð Assist the member in selecting a new provider

c Additional information
Ð Provider information
Ð Physician credentials
Ð Physician status/ discipline
Ð Specific benefits
Ð Financial arrangement with physicians
Ð Who to contact

c Years in existence
c Profit status

If you want more information about us, call (800) 332-9161, or write to our Customer Service Department at:
2050 South Linden Road, P. O. Box 1700, Flint, MI 48501-1700. You may also contact us by fax at
(810) 230-2093 or visit our website at www. healthplus. com.

Service Area
To enroll in this plan, you must live in our Service Area. This is where our providers practice.
Our service area is: All of Arenac (except Moffat and Clayton Township), Bay, Genesee, Lapeer, Livingston,
Saginaw, Shiawassee, and Tuscola Counties in Michigan.

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 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, you should consider enrolling in a fee-for-service plan or an HMO that has
agreements with affiliates in other areas. Eligible college students are covered for emergency illnesses or injuries
that occur when they are out of the service area. 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. 12.
12 Page 13 14
2004 HealthPlus of Michigan 10 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section
5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here
is a clarification that does not change benefits.

Program-wide changes
c 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
pages 58-61.

c We added information regarding Preventing Medical Mistakes. See page 6.
c We added information regarding enrolling in Medicare. See page 45.
c We revised the Medicare Primary Payer Chart. See page 47.

Changes to this Plan
c Your share of the non-Postal premium will increase by 36.1% for Self Only or 7.3% for Self and Family.
c Prescription drug copayments are now $10 for generic drugs and $20 for brand-name drugs. Previously, you
paid $5 for generics and $10 for brand-name drugs.

c We have added a new Mail Order prescription drug benefit that covers a 35-90 day supply subject to a $20
copayment for generics and a $40 copayment for brand-name drugs.

c Out-of-area emergency benefits copayments are now $10 per doctor's office visit, $25 per urgent care visit and
$25 per hospital visit. Previously, you paid no copayments. 13.
13 Page 14 15
2004 HealthPlus of Michigan 11 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at (800)
332-9161 or write to us at P. O. Box 1700, Flint, MI 48501-1700.

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.

c 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.
Participating providers strive to provide quality health care consistent with
recognized medical standards, HealthPlus policy, and your subscriber
benefits. Health care services must be obtained through, or under the
direction of, your Primary Care Physician. He or she will coordinate your
health care and, when medically necessary, refer you to a specialist from our
network of health care providers. Your role is to always work with your
Primary Care Physician for your health care needs. The selection of your
Primary Care Physician is the key to obtaining the benefits available to you.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. The HealthPlus Provider
Directory is a convenient reference that lists independent primary
physicians, specialist physicians, and other health care providers who have
agreed to provide services to HealthPlus members. This directory will assist
you in the selection of a Primary Care Physician for you and each member
of your family.

c 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 Each family member that is covered by us must choose a Primary Care to get covered care Physician from the Provider Directory (parents are expected to select for
their children). This list includes doctors who specialize in Family Practice,
Internal Medicine, or Pediatrics. The listing for each Primary Care
Physician also shows a "primary hospital." This is the hospital where your
Primary Care Physician will direct you for hospital services in most
instances. When you select a Primary Care Physician you are also agreeing
to use the hospital listed. The Primary Care Physician you choose will
coordinate your overall medical care, including arranging for hospital
admissions or care by a specialist when medically necessary. HealthPlus
strives to keep the Provider Directory as up-to-date as possible. However,
information may change after the Directory has been printed. If the
Physician you select is no longer accepting patients, please select another.
You may want to call the physician you have chosen prior to calling our 14.
14 Page 15 16
2004 HealthPlus of Michigan 12 Section 3
Customer Service Department at (800) 332-9161 with your selection. You
must notify us before receiving covered services from the new Primary Care
Physician.

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

If you want to change your Primary Care Physician or if your Primary Care
Physician leaves the Plan, call us. We will help you select a new one.

c 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. You may see a participating
mental health or substance abuse provider for an initial office visit without a
referral, but continued coverage is dependent upon approval of the
provider's treatment plan. Females may see a participating obstetrician or
gynecologist for a well-woman exam once per year without a referral.

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

c 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.

c 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.

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

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

Ñ 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. 15.
15 Page 16 17
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.

c Hospital care Your Plan Primary Care Physician or specialist will make necessary hospital
arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our
Customer Service Department immediately at (800) 332-9161. 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:

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

These provisions apply only to the hospital benefits of the hospitalized
person. If your plan terminates participation in the FEHB Program in whole
or in part, or if OPM orders an enrollment change, this continuation of
coverage provision does not apply. In such case, the hospitalized family
member's benefits under the new plan begin on the effective date of
enrollment.

Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we our control may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.

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

Your Primary Care Physician or specialist, to whom you have been
appropriately referred, is responsible for coordinating any necessary
hospitalizations. Scheduled admissions require advance authorization from
HealthPlus. Emergency admissions require notification of HealthPlus
within 24 hours, or as soon thereafter as possible. Authorization occurs
when we approve the admission and issue a complete authorization number
to the hospital. The telephone number to call is on the back of your
identification card.

2004 HealthPlus of Michigan 13 Section 3 16.
16 Page 17 18
2004 HealthPlus of Michigan 14 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
c Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment
of $10 per office visit and when you go in the hospital, you pay nothing per
admission.

c Deductible A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for them. We have no
deductible.

NOTE: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective date
of your new plan. If you change plans at another time during the year, you
must begin a new deductible under your new plan.

c Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care. We have no coinsurance.

Your catastrophic protection We have no out-of-pocket maximum. Your out-of-pocket expenses covered out-of-pocket maximum under this Plan are limited to stated copayments that are required for a few
benefits. 17.
17 Page 18 19
Section 5. Benefits Ñ OVERVIEW
(See page 10 for how our benefits changed this year and page 63 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 forms, claims filing advice, or more information about our
benefits, contact us at (800) 332-9161 or at our website at www. healthplus. com.

(a) Medical services and supplies provided by physicians and other health care professionals.......................... 16-21

(b) Surgical and anesthesia services provided by physicians and other health care professionals ...................... 25-28
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 29-31

(d) Emergency services/ accidents ......................................................................................................................... 32-33
(e) Mental health and substance abuse benefits .................................................................................................... 34-35
(f) Prescription drug benefits ................................................................................................................................ 36-38
(g) Special features ..................................................................................................................................................... 39
c NCQA "Excellent accreditation"
c High risk pregnancies
c Disease management program
c Centers of Excellence for transplants/ heart surgery/ etc.
c HealthQuest health resource library
c College students
c Flexible benefits option

(h) Dental benefits ...................................................................................................................................................... 40
Summary of benefits .................................................................................................................................................... 64

c Medical emergency c Ambulance
c Inpatient hospital
c Outpatient hospital or ambulatory surgical center
c Extended care benefits/ skilled nursing care
facility benefits
c Hospice care
c Ambulance

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

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

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

2004 HealthPlus of Michigan 15 Section 5 18.
18 Page 19 20
2004 HealthPlus of Michigan 16 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians
and other health care professionals

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Here are some important things to keep in mind about these benefits:
c 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.

c Plan physicians must provide or arrange your care.
c We have no calendar year deductible.
c 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
c In physician's office $10 per office visit

c In an urgent care center
c During a hospital stay
c In a skilled nursing facility
c Initial examination of a newborn child covered under a family
enrollment by the Member's Primary Care Physician

c Office medical consultations
c Second surgical opinion

$25 per visit
Nothing
Nothing
Nothing if examination occurs during
hospital stay; otherwise, $10 per visit

$10 per office visit
$10 per office visit

At home $10 per visit 19.
19 Page 20 21
2004 HealthPlus of Michigan 17 Section 5( a)
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
c Blood tests
c Urinalysis
c Non-routine pap tests
c Pathology
c X-rays
c Non-routine Mammograms
c CAT Scans/ MRI
c Ultrasound
c Electrocardiogram and EEG

Nothing

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

$10 per office visit
Preventive care, adult You Pay

Routine pap test Ð every 1-3 years beginning at age 18
Note: The office visit is covered if pap test is received on the same day;
see Diagnostic and Treatment.

Routine mammogram Ð covered for women age 35 and older, as follows:
c Baseline by the age of 40
c From age 40 through 49, one mammogram every one or two years
c At age 50, one yearly

$10 per office visit
$10 per office visit

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

c Examinations, reports, or any other services related to requirements
or documentation of health status for employment, licenses,
insurance, travel, or for educational or sports/ recreational
purposes;

All charges

Preventive Care, Adult-Continued on next page

Routine Prostate Specific Antigen (PSA) test Ð one annually for men age
40 and older $10 per office visit 20.
20 Page 21 22
2004 HealthPlus of Michigan 18 Section 5( a)
Preventive care, adult (continued) You Pay
Routine immunizations, limited to:
c Tetanus-diphtheria (Td) booster Ð once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

c Influenza vaccine annually
c Pneumococcal vaccine, age 65 and over

Nothing

c Childhood immunizations recommended by the American Academy
of Pediatrics
Nothing

c Well-child care charges for routine examinations, immunizations and
care (under age 22)

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

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

Ñ Examinations done on the day of immunizations
(under age 22).

$10 per office visit
Preventive care, children You Pay

Maternity care You Pay
Complete maternity (obstetrical) care, such as:
c Prenatal care
c Delivery
c Postnatal care
Note: Here are some things to keep in mind:
c You do not need to precertify your normal delivery; see page 11 for
other circumstances, such as extended stays for you or your baby.

c You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend your
inpatient stay if medically necessary.

c 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. Note: (Surgical
benefits, not maternity benefits, apply to circumcision.)

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

$10 for initial visit;
nothing thereafter

Not covered: Routine sonograms to determine fetal age, size or sex All charges 21.
21 Page 22 23
2004 HealthPlus of Michigan 19 Section 5( a)
Family planning You Pay
A range of voluntary family planning services, limited to:
c Voluntary sterilization (see surgical procedures Section 5 (b))
c Surgically implanted contraceptives (such as Norplant)
c Injectable contraceptive drugs (such as Depo provera)
c Intrauterine devices (IUDs)
c Diaphragms
c Medically-indicated genetic testing and counseling per generally
accepted medical practice

Note: We cover oral contraceptives under the prescription drug benefit.

Nothing

Not covered:
c Reversal of voluntary surgical sterilization and all associated cost
c Premarital exams or classes

All charges

Diagnosis and treatment of infertility, such as:
c Artificial insemination:
Ñ Intravaginal insemination (IVI)
Ñ Intracervical insemination (ICI)
Ñ Intrauterine insemination (IUI)
c Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Nothing
Infertility services You Pay

Not covered:
c Assisted reproductive technology (ART) procedures, such as:
Ñ In vitro fertilization
Ñ Embryo transfer, GIFT and zygote ZIFT
Ñ Zygote transfer
c Services and supplies related to excluded ART procedures
c Reversal of a voluntary sterilization and all associated costs
c Pre-embryo cryo preservation techniques and associated services
c Infertility services if one of the partners has previously undergone
surgical sterilization or if one of the partners is menopausal or post
menopausal

c All services related to a surrogate parenting arrangements of any
kind

c Cost of donor sperm and all associated costs
c Cost of donor egg

All charges 22.
22 Page 23 24
2004 HealthPlus of Michigan 20 Section 5( a)
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges

c 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 25.

c Respiratory and inhalation therapy
c Dialysis Ð hemodialysis and peritoneal dialysis
c Intravenous (IV)/ Infusion Therapy Ð Home IV and antibiotic therapy
c Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment.
Your Primary Care Physician calls us for a referral. We will ask the
Primary Care Physician to submit information that establishes that GHT
is medically necessary. The submitted request is reviewed by our Medical
Director to determine medical necessity. Ask us to authorize GHT before
you begin treatment; otherwise, we will only cover GHT services from the
date you submit the information. If you do not ask or if we determine
GHT is not medically necessary, we will not cover the GHT or related
services and supplies. See services requiring our prior approval in
Section 3.

$10 per office visit
Treatment therapies You Pay

Allergy care You Pay
Testing and treatment
Allergy injection
$10 per office visit
Nothing; $10 office visit copay may
apply. 23.
23 Page 24 25
2004 HealthPlus of Michigan 21 Section 5( a)
Physical and occupational therapies You Pay
c Two consecutive months per condition are covered if significant
improvement can be expected within the two months. Services are
covered for each of the following:

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

c Cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, is covered with no visit limits.

Nothing

Benefits for a Hearing aid and hearing tests for fitting and post
performance evaluation of a Hearing aid
Nothing

Not covered:
c Hearing aids ordered prior to the effective date of coverage under
this contract

c Replacement and/ or repair because of loss or misuse;
c Batteries
c The additional cost of an eyeglass-type Hearing aid or other
Hearing aid with special features that are not medically necessary
over the conventional type of Hearing aid.

All charges
Hearing services (testing, treatment, and supplies) You Pay

Speech therapy You Pay
c 60 visits per condition Nothing

Not covered:
c long-term rehabilitative therapy
c exercise programs
c vocational rehabilitation services

All charges 24.
24 Page 25 26
2004 HealthPlus of Michigan 22 Section 5( a)
Foot care You Pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

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

$10 per office visit

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

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

All charges

Orthopedic and prosthetic devices You Pay
Orthotic appliances and prosthetic devices (including breast prosthesis
following a mastectomy)

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

c Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See 5( b) for coverage of the surgery to insert the
device.

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

Nothing

Vision services (testing, treatment, and supplies)
Initial pair of glasses after cataract surgery

Not covered:
c Refractions
c Eyeglasses or contact lenses and, examinations for them
c Eye exercises and orthoptics
c Radial keratotomy and other refractive surgery
c Eyeglasses for ocular injury

You Pay
$10 per office visit

All charges
Eye exam to determine the need for vision correction for children through
age 17. (See Preventive Care, Children)
$10 per office visit 25.
25 Page 26 27
2004 HealthPlus of Michigan 23 Section 5( a)
Durable medical equipment (DME) You Pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

c Hospital beds;
c Wheelchairs;
c Crutches;
c Walkers;
c Blood glucose monitors; and
c Insulin pumps.

Nothing

c Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.

c Services include oxygen therapy, intravenous therapy and
medications.

Nothing

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

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

c Personal comfort or convenience items such as television and
telephone services

c Skilled nursing services provided on a twenty-four (24) hour basis in
the home

c Private duty nursing services (except if medically necessary in an
inpatient hospital setting).

All charges
Home health services You Pay
Not covered: Equipment that is not deemed medically necessary or is an
upgrade to accepted standards.
All charges

Orthopedic and prosthetic devices (continued) You Pay
Not covered:
c Equipment that is not deemed medically necessary or is an
upgrade to accepted standards.

c Orthotic appliances when they are not used to support, align,
prevent, correct or improve a defect of body form or function.

c Prosthetic devices when they do not replace a limb or other part of
the body after accidental or surgical removal and/ or when your
body growth necessitates a replacement.

All charges 26.
26 Page 27 28
2004 HealthPlus of Michigan 24 Section 5( a)
Educational classes and programs You Pay
Not covered: Premarital exams or classes All charges
c Medical Self-Care program utilizing the Healthwise Handbook
c Tobacco Cessation Program based upon the Stages of Change
behavioral model.

c Health Resource Library stocked with over 200 books, videos, and
audiocassettes for members to checkout.

c Anonymous telephonic depression screening available 24 hours
seven days a week.

c Extensive community resource directory that identifies health
promotion and disease prevention programs available in the
communities we serve. Program discounts are negotiated whenever
possible.

c Educational initiatives designed to encourage members to receive
age/ gender appropriate preventive care services.

c Comprehensive Health Management programs for diabetes and
asthma that offer:

Ð Valuable information from HealthPlus every three months
Ð Seminars related to your illness, given by qualified
professionals

Ð Enrollment in a program tailored especially to your needs
c Some benefits you may expect from participation include:
Ð A healthier, more active lifestyle
Ð Reduced symptoms
Ð Fewer emergency room, urgent care visits, or hospitalizations
Ð Support from qualified professionals to help you manage
your illness

Nothing
Alternative treatments You Pay
No benefit All charges

Chiropractic You Pay
Not covered:
c Hypnosis
c Biofeedback
c Acupuncture

All charges

c Spinal Manipulation when provided by, or under the direction of,
your Primary Care Physician, or provided by a Specialist Physician
to whom you are appropriately referred.

$10 per office visit 27.
27 Page 28 29
2004 HealthPlus of Michigan 25 Section 5( b)
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals

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

c Orthognathic surgery prior to the age of twenty-one (21) for
congenital defects directly affecting the growth, development, and
function of the jaw

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

Nothing

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

c 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.)

c YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME
SURGICAL PROCEDURES. Please refer to the precertification information
shown in Section 3 to be sure which services require precertification and
identify which surgeries require precertification. 28.
28 Page 29 30
2004 HealthPlus of Michigan 26 Section 5( b)
Reconstructive surgery You Pay
c Surgery to correct a functional defect
c Surgery to correct a condition caused by injury or illness if:
Ñ the condition produced a major effect on the member's
appearance and

Ñ the condition can reasonably be expected to be corrected by
such surgery

c Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

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

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

Ñ treatment of any physical complications, such as lymphedemas;
Ñ breast prostheses and surgical bras and replacements (see
Prosthetic devices)

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

Nothing

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

c Surgeries related to sex transformation
c Other services and procedures for Cosmetic purposes, such as
procedures to correct baldness or wrinkling

c Wigs, prosthetic hair, hair transplants, or other procedures or
supplies to enhance hair growth

All charges

Surgical procedures (continued) You Pay
Not covered:
c Reversal of voluntary sterilization
c Routine treatment of conditions of the foot; see foot care

All charges

c Voluntary sterilization (e. g., tubal ligation, vasectomy)
c Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit 29.
29 Page 30 31
2004 HealthPlus of Michigan 27 Section 5( b)
Oral and maxillofacial surgery You Pay
Not covered:
c Oral implants and transplants
c Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)

c Dental care and associated supplies, services, and tests, except as
specifically provided in this section.

All charges

Limited to:
c Cornea
c Heart
c Heart/ lung
c Lung (single and double)
c Pancreas
c Kidney
c Liver
c Allogeneic (donor) bone marrow transplants
c Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions; acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal, and ovarian germ
cell tumors.

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

Nothing
Organ/ tissue transplants You Pay

Oral surgical procedures, limited to:
c Reduction of fractures of the jaws or facial bones;
c Surgical correction of cleft lip, cleft palate, or severe functional
malocclusion;

c Removal of stones from salivary ducts;
c Excision of leukoplakia or malignancies;
c Excision of cysts and incision of abscesses when done as
independent procedures;

c Orthognathic surgery prior to the age of twenty-one (21) for
congenital defects directly affecting the growth, development, and
function of the jaw;

c Hospitalization charges for multiple extractions which must be
performed in a Hospital due to a concurrent hazardous medical
condition; and

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

Nothing 30.
30 Page 31 32
2004 HealthPlus of Michigan 28 Section 5( b)
All charges
Professional services provided in Ð
c Hospital (inpatient)
Nothing

Professional services provided in Ð
c Hospital outpatient department
c Skilled Nursing Facility
c Freestanding Emergency Center
c Office

Nothing

Anesthesia You Pay

Organ/ tissue transplants (continued) You Pay
Not covered:
c Medical expenses incurred by a Member who donates an organ or
tissue to a non-Member

c Medical expenses incurred by a non-Member who donates an
organ or tissue to a Member will only be covered if the non-Member
does not have coverage for these services

c Implants of artificial organs
c Transplants not listed as covered

c National Transplant Program (NTP) Ð A case manager is assigned
upon notification of a member needing a transplant. The physician,
member and case manager develop a treatment plan specific to the
member's medical needs.

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

Nothing 31.
31 Page 32 33
2004 HealthPlus of Michigan 29 Section 5( c)
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Here are some important things to remember about these benefits:
c 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.

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

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

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

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Benefit Description You Pay
Inpatient hospital

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

Nothing
Room and board, such as:
c ward, semiprivate, or intensive care accommodations
c general nursing care; and
c meals and special diets.

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

Nothing

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

Inpatient hospital -Continued on next page 32.
32 Page 33 34
2004 HealthPlus of Michigan 30 Section 5( c)
Inpatient hospital (continued) You Pay
c Operating, recovery, and other treatment rooms
c Prescribed drugs and medicines
c Diagnostic laboratory tests, X-rays, and pathology services
c Administration of blood, blood plasma, and other biologicals
c Blood and blood plasma, if not donated or replaced
c Pre-surgical testing
c Dressing, casts, and sterile tray services
c Medical supplies, including oxygen
c Anesthetic and anesthesia service

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

Nothing

Not covered
c Custodial or domiciliary care, basic care, or housekeeping
c Non-covered facilities, such as nursing homes, schools
c Services or products provided by Convalescent Homes, Homes for
the Aged, or Adult Foster Care Facilities

c Personal comfort items such as telephone, television, barber
services, guest meals and beds

c Private duty nursing, unless medically necessary
c Blood and blood derivatives not replaced by the Member

All charges

Outpatient hospital or ambulatory surgical center You Pay

Not covered:
c Custodial or domiciliary care, basic care, or housekeeping
c Personal comfort or convenience items such as television and
telephone services

c Blood and blood derivatives not replaced by the member
c Private duty nursing

All charges 33.
33 Page 34 35
2004 HealthPlus of Michigan 31 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You Pay
Benefits for care in a skilled nursing facility shall be limited to a
maximum of one hundred (100) days per Member per calendar year when
full-time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan.

Nothing

Hospice services provided by a Hospice under the direction of a Plan
doctor who certifies that the member is in the terminal stages of illness,
with a life expectancy of approximately six months or less. Services must
be ordered by your Primary Care Physician and authorized in advance by
us. Services are limited to:

c Room and board charges
c Medical supplies, drugs and medicines
c Medical-social services

Nothing

Not covered:
c Custodial or domiciliary care, basic care
c Independent nursing, homemaker services
c Personal comfort or convenience items such as television and
telephone services

c Private duty nursing services
c Skilled Nursing Services provided on a twenty-four (24) hour basis
in the home

All charges

Hospice care You Pay

Ambulance You Pay
Local professional ambulance service when medically appropriate Nothing

Not covered:
c Custodial or domiciliary care, basic care, or housekeeping
c Personal comfort or convenience items such as television and
telephone services

c Private duty nursing services
c Blood and blood derivatives not replaced by the member

All charges 34.
34 Page 35 36
2004 HealthPlus of Michigan 32 Section 5( d)
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Section 5 (d). Emergency services/ accidents

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

What to do in case of emergency:
Emergencies within our service area: Members are covered for treatment when a true emergency exists. If you are in doubt of the seriousness of the medical condition and have time to call your Primary Care Physician, you
should do so. If your physician feels that the problem requires immediate attention, he or she will direct your
treatment. Please note: Emergency health services rendered by a participating provider within our service area are
covered. Also, services will be covered if they are rendered by a non-affiliated provider because an emergency
prevents you from receiving services from a participating provider.

Emergencies outside our service area: In case of an emergency when you are out of the HealthPlus service area, we provide coverage for necessary care. If your problem is too serious to wait until you return to the HealthPlus
service area, go to a physician, after-hours care center, or the hospital nearest you for treatment. Emergency
admissions require notification to HealthPlus within 24 hours, or as soon thereafter as possible. You may call
HealthPlus 24 hours a day at the Emergency Services number on the back of your HealthPlus identification card.
Please call promptly after an emergency in order to confirm coverage, ensure proper follow-up care and assure
payment for covered services you receive.

Note: We reserve the right not to pay for non-emergency treatment received at emergency facilities. If you are
hospitalized at non-affiliated hospital, you may be transferred to an affiliated hospital upon request of your Primary
Care Physician as soon as it is medically appropriate in the opinion of the attending physician. Should you, or
your designee, refuse a transfer to an affiliated hospital, continued care provided to you at a non-affiliated hospital
shall not constitute covered services and shall no longer be the financial responsibility of us. Follow-up visits to
non-affiliated providers of emergency health services outside the service area shall be limited to two (2) Visits
within thirty (30) days of the emergency, or the number of visits specified in a treatment plan approved by us.

c We have no calendar year deductible.
c 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. 35.
35 Page 36 37
2004 HealthPlus of Michigan 33 Section 5( d)
You Pay
Not covered:
c Elective care or non-emergency care
c Blood and blood derivatives not replaced by the member

All charges

c Emergency care at a doctor's office
c Emergency care at an urgent care center, including doctor's services
c Emergency care as an outpatient or inpatient at a hospital, including
doctor's services

NOTE: Emergency care, urgent care center and hospital copay waived if
you are admitted to a hospital.

$10 per office visit
$25 per visit
$25 per visit

Emergency outside our service area You Pay
c Emergency care at a doctor's office
c Emergency care at an urgent care center, including doctor's services
c Emergency care as an outpatient or inpatient at a hospital, including
doctor's services

NOTE: Emergency care, urgent care center and hospital copay waived if
you are admitted to a hospital.

$10 per office visit
$25 per visit
$25 per visit

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

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

c Blood and blood derivative not replaced by the member

All charges

Ambulance You Pay
Professional ambulance service when medically appropriate Nothing

Benefit Description
Emergency within our service area 36.
36 Page 37 38
2004 HealthPlus of Michigan 34 Section 5( e)
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Benefit Description You Pay
Mental health and substance abuse benefits

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

c Medication management

$10 per visit

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

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

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

Mental health and substance abuse benefits -Continued on next page
c Diagnostic tests Nothing

When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.

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

Section 5 (e). Mental health and substance abuse benefits 37.
37 Page 38 39
2004 HealthPlus of Michigan 35 Section 5( e)
Mental health and substance abuse benefits (continued) You Pay
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor of
another.

All charges

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

Nothing

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and follow all of the following authorization processes:
We have designated mental health/ substance abuse providers throughout our
service area. The program's preferred provider panel is comprised of a
select group of psychiatrists, psychologists, social workers and substance
abuse providers. You may obtain mental health/ substance abuse services
from our preferred providers without a referral from your Primary Care
Physician. Services from mental health/ substance abuse providers not on
our preferred provider panel require prior authorization from us.

For coverage of mental health and substance abuse services, you may access
your benefits in any of the following ways:

1. Call the HealthPlus Behavioral Service department at (800) 555-5025.

2. Contact a panel provider from the HealthPlus Provider Directory and
schedule an appointment. The provider you select will obtain the
referral.

3. Contact your Primary Care Physician to coordinate your care.
Because our preferred panel of providers changes periodically, you may
want to obtain an updated list by calling our Behavioral Services department
at (800) 555-5025.

Limitation We may limit your benefits if you do not obtain a treatment plan. 38.
38 Page 39 40
2004 HealthPlus of Michigan 36 Section 5( f)
Section 5 (f). Prescription drug benefits
There are important features you should be aware of. These include:
c Who can write your prescription. Prescriptions for covered drugs must be written by your
Primary Care Physician or by a specialist to whom you have been appropriately referred.

c Where you can obtain them. You may fill the prescription at a participating pharmacy, or
through Express Scripts. A list of participating pharmacies may be found in our Provider
Directory. If you have questions about mail order pharmacy services, call HealthPlus at
(800) 332-9161 or Express Scripts at (877) 322-8471

c We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with
the Plan's drug formulary. The Plan's drug formulary is based on the effectiveness and costs of
drugs. Non-formulary drugs will be covered when prescribed by a Plan doctor. When generic
substitution is permissible (i. e., a generic drug is available and the prescribing doctor does not
require the use of a brand-name drug), but you request the brand-name drug, you pay the price
difference between the generic and brand-name drug in addition to the generic copayment.

c These are the dispensing limitations. Prescription drugs covered by a Plan or referral doctor
and obtained at a Plan pharmacy will be dispensed for a 34-day supply. You pay a $10 copay per
prescription for generic drugs or a $20 copay per prescription for brand-name drugs. Mail order
prescription drugs covered by a Plan or referral doctor and obtained through Express Scripts may
be dispensed for up to a 90-day supply, for which you will pay two times the normal copayment
per perscription (i. e.: $20 for a 90-day supply of generic drugs, and $40 for a 90-day supply of
brand name drugs). If no generic equivalent is available, you will still be required to pay the
brand-name copayment. Members called to active duty in a time of national or other emergency
who need to obtain a greater-than-normal supply of prescribed medications should call our
Customer Service Department at (800) 332-9161.

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

c When you have to file a claim. Our members may occasionally receive bills for health care
services. This could occur for a number of reasons, such as computer errors or out-of-area
emergency treatment. If you receive a bill or statement, or are requesting reimbursement, mail
the bills to us within 90 days of the date of service. Please be sure that the bill contains the
following information:
Ñ Patient name
Ñ Subscriber number and the patient's two-digit relationship code as shown on your
identification card (for example: 345123789-01)
Ñ Amount billed
Ñ Amount paid

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

c We cover prescribed drugs and medications, as described in the chart beginning
on the next page.

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Prescription drug benefits begin on next page 39.
39 Page 40 41
2004 HealthPlus of Michigan 37 Section 5( f)
Benefit Description You Pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

c Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except as
excluded below.

c Full range of FDA-approved drugs, prescriptions, and devices for
birth control

c Insulin and insulin syringes
c Diabetic testing reagents and supplies, including glucose test strips,
test tape, and alcohol swabs

c Smoking cessation drugs and medications; limited to one course of
therapy every two years when prescribed by the Plan doctor or
psychiatrist and accompanied by enrollment in a smoking cessation
program approved by the Plan doctor or psychiatrist

c Disposable needles and syringes for the administration of covered
medications

c Drugs for sexual dysfunction (see next page)
c Intravenous fluids and medication for home use, and some injectable
drugs are covered under medical and surgical benefits.

c Fertility drugs (when used in conjunction with prior authorized
treatment plan)

c Growth hormone

Retail pharmacy
$10 per generic drug
$20 per brand-name drug

Mail Order (35-90 day supply)
$20 per generic drug
$40 per brand-name drug

Covered medications and supplies -Continued on next page

c When you have to file a claim. (continued)
Ñ Description of service and procedure codes
Ñ Diagnosis and diagnosis codes
Ñ Location of service
Ñ Date of service

Address the envelope as follows:

HealthPlus of Michigan
Attention: Claims Department
P. O. Box 1700
Flint, MI 48501-1700

If you need further assistance, or have questions, please call our Customer Service Department at
(800) 332-9161. 40.
40 Page 41 42
2004 HealthPlus of Michigan 38 Section 5( f)
Covered medications and supplies (continued) You Pay
Not covered:
c Drugs and supplies for cosmetic purposes
c Vitamins, nutrients and food supplements even if a physician
prescribes or administers them

c Nonprescription medicines (or their Prescription Drug
equivalents)

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

c Medical supplies such as dressings and antiseptics
c Drugs to enhance athletic performance
c Replacement of lost, stolen, or destroyed medication.

All charges

Here are some things to keep in mind about our prescription drug
program:

c Benefits for Prescription Drugs in our formulary will be limited to
the reasonable cost of generically available products, unless no
generically equivalent product exists or a Member-specific review
for medical necessity by us determines the need for brand name
medication. We reserve the right to determine generic equivalency
of products available to HPM Members. We reserve the right to
review Prescription Drug products and procedures for medical
necessity, efficacy of use, and quality to determine if they should be
available to HPM Members.

c Prescription Drugs for Treatment of sexual dysfunction:
Coverage is limited to fifty percent (50%) of covered charges and
will not exceed six (6) doses per thirty (30) day period and will be
limited to the original prescription and up to two (2) refills prior to
follow up with the treating physician.

50% per unit or refill 41.
41 Page 42 43
2004 HealthPlus of Michigan 39 Section 5( g)
Section 5 (g). Special features
NCQA "Excellent"
accreditation

We have been awarded "Excellent" Accreditation status for our Commercial
HMO Ð the highest level possible by the National Committee for Quality
Assurance (NCQA). NCQA is an independent, not-for-profit organization
dedicated to measuring the quality of America's health care.

High risk pregnancies A case manager is assigned upon notification of a high risk pregnancy. The physician, member, and case manager develop a treatment plan specific to the
member's medical needs.

Centers of excellence for
transplants/ heart
surgery/ etc

The following are Centers of excellence available when appropriately referred:
Ð Cleveland Clinic Foundation
Ð University of Michigan

HealthQuest health
resource library

The Health Resource Library is a service dedicated to providing our members
with a wide range of health information. Our library is stocked with over 200
books, videos, audiocassettes, and pamphlets that can be checked out just like
at a public library, but in the comfort of your home. This is a free service; we
even pay for all the postage. To learn more about the Health Resource Library,
call the HealthQuest Program at (800) 345-9956, extension 1943 and select
option 5.

College students Eligible college students are covered for emergency illnesses or injuries that occur when they are out of the service area. Contact us at (800) 332-9161 for
eligibility requirements.

Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
c We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative benefit.

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

c The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.

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

Disease management
program

If you have diabetes, asthma or certain heart diseases, you may be eligible to
participate in our Disease Management Program. The program is designed to
help you better understand and manage your condition, so you can enjoy
improved health and quality of life. Ask your physician to refer you, or contact
us at (800) 332-9161 for more information. 42.
42 Page 43 44
2004 HealthPlus of Michigan 40 Section 5( g)
Section 5 (h). Dental benefits
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c Plan physicians or dentists must provide or arrange your care.
c We have no calendar year deductible.
c We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health
of the patient. See Section 5( c) for inpatient hospital benefits. We do not cover
the dental procedure unless it is described below.

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

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Accidental injury benefit You Pay

We have no other dental benefits.
Nothing
Dental benefits
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. 43.
43 Page 44 45
Section 6. General exclusions Ñ things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.

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

c Experimental or investigational procedures, treatments, drugs or devices;
c 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;

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

2004 HealthPlus of Michigan 41 Section 6 44.
44 Page 45 46
2004 HealthPlus of Michigan 42 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical, hospital, and In most cases, providers and facilities file claims for you. Physicians must drug benefits file on the form HCFA-1500, Health Insurance Claim Form. Facilities will
file on the UB-92 form. For claims questions and assistance, call us at
(800) 332-9161.

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

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

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

c Receipts, if you paid for your services.

Submit your claims to: HealthPlus of Michigan
Attn: Claims
2050 S. Linden Rd.
P. O. Box 1700
Flint, MI 48501-1700

Important Note: Charges for the completion of claim forms, interest on late
payments, or charges for failure to keep scheduled appointments are not
covered.

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 45.
45 Page 46 47
2004 HealthPlus of Michigan 43 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision
on your claim or request for services, drugs, or supplies Ð including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 2050 South Linden Road, P. O. Box 1700, Flint, MI 48501-1700; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial 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.

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

We will write to you with our decision.

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

c 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:
c A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

c Copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms;

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim. 46.
46 Page 47 48
2004 HealthPlus of Michigan 44 Section 8
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the
suit against OPM in Federal court by December 31 of the third year after the year in which you received the
disputed services, drugs or supplies, or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
(800) 332-9161 and we will expedite our review; or

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

c You may call OPM's Health Insurance Group 3 at (202) 606-0737 between 8 a. m. and 5 p. m. eastern
time. 47.
47 Page 48 49
2004 HealthPlus of Michigan 45 Section 9
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you or a covered family member have coverage under health coverage another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according
to the National Association of Insurance Commissioners' guidelines.

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

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

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

Medicare has two parts:
c 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.

c 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.

c 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 (800) 772-1213 to set up an
appointment to apply. If you do not apply for one or both Parts of
Medicare, you can still be covered under the FEHB Program.

If you can get 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. 48.
48 Page 49 50
2004 HealthPlus of Michigan 46 Section 9
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.

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

When you are enrolled in Original Medicare, along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be authorized by your Plan PCP, or precertified as required.

We wil