AH/1999/FEHB/Benefits Brochure

AmeriHealth HMO, Inc. 1999 A Health Maintenance Organization

This plan has one year accreditation from the NCQA. See the FEHB Guide

for more information on NCQA. Serving: All of Delaware and all of New Jersey

Enrollment in this plan is limited; see page 9 for requirements.

Delaware

Enrollment code: SP1 Self Only SP2 Self and Family

New Jersey

Enrollment code: FK1 Self Only FK2 Self and Family

QU ALIT

Y A

S SURANC

E NATIO

NA L

C OMM

ITTEE F

O R

A C C R E D I T E D B Y

For changes in benefits

see page 22.

Authorized for distribution by the:

United States Office of Personnel Management

RI 73- 065 Visit the OPM website at http:// www. opm. gov/ insure

AmeriHealth HMO

AmeriHealth HMO, Inc., 1901 Market Street, 36th Floor, Philadelphia, PA 19101- 1480, has entered into a contract (CS 1893) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called AmeriHealth HMO, AmeriHealth, or the Plan.

This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page 22 of this brochure.

Table of Contents page Inspector General Advisory on Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3- 6

Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage; Certificate of Creditable Coverage)

Facts about this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7- 9

Information you have a right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Experimental/ Investigational determinations; Other considerations; The Plans service area; Reciprocity

General Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10- 11

Important notice; Circumstances beyond Plan control; Arbitration of claims; Other sources of benefits

General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12- 18

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Dental care; Vision care

Non- FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20- 21 How AmeriHealth HMO Changes January 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Rate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

3 Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to

obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD. This could result in CRIMINAL PENALTIES. Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital or pharmacy, charged your plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:

Call the provider and ask for an explanation sometimes the problem is a simple error. If the provider does not resolve the matter, or if you remain concerned, call your plan from Delaware at 800/ 444- 6282 or from New

Jersey at 800/ 877- 9829 and explain the situation. If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300

The Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, N. W., Room 6400 Washington, D. C. 20415

The inappropriate use of membership identification cards, e. g., to obtain services for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.

General Information Confidentiality Medical and other information provided to the Plan, including claim files, is kept confidential

and will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan, coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.

Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.

If you are a If you are a new member of this Plan, benefits and rates begin on the effective date of your

new member enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged

by a Plan doctor except in the case of emergency as described on page 15. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 4.

Inspector General Advisory: Stop Health Care Fraud!

4 FEHB plans may not refuse to provide benefits for any condition you or a covered family member

may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.

If you are hospitalized If you change plans or options, benefits under your prior plan or option cease on the effective date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.

Your It is your responsibility to be informed about your health benefits. Your employing office or

responsibility retirement system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military

service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.

Things to The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if

keep in you changed plans or plan options, see If you are a new member on page 3. In both cases,

mind however, the Plans new rates are effective the first day of the enrollees first full pay period that begins on or after January 1 (January 1 for all annuitants).

Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.

The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.

An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits. You will not be informed by your employing office (or your retirement system) or your Plan

when a family member loses eligibility. You must direct questions about enrollment and eligibility, including whether a dependent

age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system. An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to

receive benefits under any other FEHB plan. Report additions and deletions (including divorces) of covered family members to the Plan

promptly.

General Information continued

5 If you are an annuitant or former spouse with FEHB coverage and you are also covered by

Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.

Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.

You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. See page 19 for information on the Medicare prepaid plan offered by this Plan.

Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).

Coverage after When an employees enrollment terminates because of separation from Federal service or when a

enrollment family member is no longer eligible for coverage under an employee or annuitant enrollment,

ends and the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free 31- day extension of coverage. The employee or family member may also be eligible for

one of the following:

Former When a Federal employee or annuitant divorces, the former spouse may be eligible to elect

spouse coverage coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employees employing office (personnel office) or retirees retirement system to get more facts about electing coverage.

Temporary If you are an employee whose enrollment is terminated because you separate from service, you

continuation may be eligible to temporarily continue your health benefits coverage under the FEHB Program

of coverage in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.

Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another free 31- day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.

Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31- day extension of coverage when they may convert to nongroup coverage.

General Information continued

6 NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is

still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.

Notification Separating employees Within 61 days after an employees enrollment terminates because of

and election separation from service, his or her employing office must notify the employee of the opportunity

requirements to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.

Children You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.

Former spouses You or your former spouse must notify the employing office or retirement system of the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.

The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.

Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60- day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.

Conversion to When none of the above choices are available or chosen when coverage as an employee or

individual family member ends, or when TCC coverage ends (except by cancellation or nonpayment of

coverage premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.

Certificate of Under Federal law, if you lose coverage under the FEHB Program, you should automatically

creditable receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This

coverage certificate, along with any certificates you receive from other FEHB plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non- FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.

General Information continued

Facts about this Plan

This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty care doctor can only be received by referral from the selected primary care doctor. There are no claim forms when Plan doctors are used.

Your decision to join an HMO should be based on your preference for the plans benefits and delivery system not because a particular provider is in the plans network. You cannot change plans because a provider leaves the HMO.

Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits, physicals, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.

Information you have All carriers in the FEHB Program must provide certain information to you. If you did not

a right to know receive information about this Plan, you can obtain it by calling the carrier at 800- 444- 6282 in Delaware or 800- 877- 9829 in New Jersey or you may write the carrier at AmeriHealth HMO, Inc.,

P. O. Box 41574, Philadelphia, PA 19101- 1574. Information that must be made available to you includes: Disenrollment rates for 1997. Compliance with State and Federal licensing or certification requirements and the dates met. If

noncompliant, the reason for noncompliance. Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency,

confidentiality and transfer of medical records.

Who provides care to AmeriHealth is an individual practice plan (IPP) HMO. The Plan is comprised of over 30,000

Plan members? private practice doctor sites who practice from their own private offices. Over 7,700 of these doctors are participating as primary care doctors. A wide range of specialty care is represented

throughout the Plan. Inpatient services are provided by 176 hospitals conveniently located throughout the Plans service area.

Role of a primary The first and most important decision each member must make is the selection of a primary care

care doctor doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to

obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when there has been a referral by the members primary care doctor except for eye exams, dental care, and visits to the OB/ GYN for preventive care, routine maternity or for problems related to gynecological conditions when medically necessary. Non- routine care provided by Reproductive Endocrinologists/ Infertility Specialists, and Gynecologic Oncologists continue to require a referral from the primary care physician. Treatment for mental conditions and substance abuse may be obtained directly from Green Spring Health Management Services; call 800/ 688- 1911.

Choosing your The Plans provider directory lists primary care doctors (generally family practitioners,

doctor pediatricians, and internists) with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at

the time of enrollment or upon request by calling the Member Services Department from New Jersey at 1- 800/ 877- 9829 or from Delaware at 1- 800/ 444- 6282; you can also find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still

8 participates with the Plan and is accepting new patients. Important note: When you enroll in this

plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider cannot be guaranteed.

If you enroll, you will be asked to complete a primary care doctor selection form and send it directly to the Plan, indicating the name of the primary care doctor( s) selected for you and each member of your family. Members are required to select a personal doctor from among participating plan primary care doctors located within the Plans service area. Members dependents may select a personal doctor from among participating plan primary care doctors regardless of the location of the practitioner. Members and their dependents may only have one dentist who must be selected from a list of participating Plan dentists located within the Plans service area. Members may change their doctor selection by notifying the Plan 30 days in advance.

If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can make reasonable medically appropriate provisions for you to be seen by another participating doctor.

Referrals for Except in a medical emergency, outpatient mental health, or when a primary care doctor has

specialty care designated another doctor to see his or her patients, you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services. Referral to a participating

specialist is given at the primary care doctors discretion; if non- Plan specialists or consultants are required, the primary care doctor will arrange appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow- up care must be provided or arranged by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If additional services or visits are suggested by the consultant, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the plan has issued an authorization for the referral in advance.

If you have a chronic, complex, or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.

For new members If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you prior to your joining the Plan is now your Plan primary care doctor, you need only call to explain that you now belong to this Plan and ask that a referral form be sent to the specialist for your next appointment.

If you are selecting a new primary care doctor, you must schedule an appointment so the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.

Hospital care If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.

Out- of- pocket Copayments are required for a few benefits. However, copayments will be reimbursed for the

maximum remainder of the calendar year after your out- of- pocket expenses for services provided or arranged by the Plan reach $650 per person. This copayment maximum does not include costs of

prescription drugs and dental services. You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out- of- pocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.

Facts about this Plan continued

Deductible If you changed to this Plan during open season from a plan with a deductible and the effective

carryover date of the change was after January 1, any expenses that would have applied to that plans deductible will be covered by your old plan if they are for care you got in January before the

effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective January 1.

Submit claims When you are required to submit a claim to this Plan for covered expenses, submit your claim

promptly promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred unless timely filing was

prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Experimental/ To establish if a biological, medical device, drug or procedure is experimental/ investigative or not

Investigational a technology assessment is performed. The results of the assessment provide the basis for the

determinations determination of the services status (e. g., medically effective, experimental, etc.). Technology assessment is the review and evaluation of available data from multiple sources using industry

standard criteria to assess the medical effectiveness of the service. Sources of data used in technology assessment include but are not limited to clinical trials, position papers or articles published by local and/ or nationally accepted medical organizations or peer- reviewed journals, information supplied by government agencies, as well as regional and national experts and/ or panels and, if applicable, literature supplied by the manufacturer.

Other Plan providers will follow generally accepted medical practice in prescribing any course of

considerations treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.

The Plans service The service area for this Plan, where Plan providers and facilities are located, is described below.

area (You must live or work in the service area to enroll in this Plan.) Benefits for care outside the service area are limited to emergency services, as described on page 15, unless covered under the

Reciprocity Program. If you or a covered family member move outside the service area, or you no longer work there, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.

The service area for enrollment codes SP1 and SP2 includes all of Delaware. The service area for enrollment codes FK1 and FK2 includes all of New Jersey.

Reciprocity As an AmeriHealth HMO member, you have access to physician care through a nationwide network of HMOs in which AmeriHealth HMO participates. This nationwide network of HMOs is one of the largest HMO networks in the country, offering coverage in more than 200 U. S. cities. If you become ill while visiting one of these cities, contact the network at 1- 800- 446- 6872. This number is also found on the back of your I. D. card. The network referral coordinator will schedule an appointment with a network physician in the area from which you are calling. No office visit copayment will be required and you will not need to file a claim form. Also, your prescription drug card works in more than 52,000 pharmacies in the U. S.

Facts about this Plan continued

General Limitations Important notice Although a specific service may be listed as a benefit, it will be covered for you only if, in the

judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.

Circumstances In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant

beyond Plan number of Plan providers, complete or partial destruction of facilities, or other circumstances

control beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plan will not be responsible for any delay or failure in providing service due

to lack of available facilities or personnel.

Arbitration of Any claim for damages for personal injury, mental disturbance, or wrongful death arising out of

claims the rendition of or failure to render services under this contract must be submitted to binding arbitration. This is not the Plans internal grievance/ disputed claims procedure.

Other sources This section applies when you or your family members are entitled to benefits from a source other

of benefits than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.

Medicare If you or a covered family member is enrolled in this Plan and Medicare Part A and/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.

Group health This coordination of benefits (double coverage) provision applies when a person covered by this Plan

insurance and also has, or is entitled to benefits from, any other group health coverage, or is entitled to the

automobile payment of medical and hospital costs under no- fault or other automobile insurance that pays

insurance benefits without regard to fault. Information about the other coverage must be disclosed to this Plan. When there is double coverage for covered benefits, other than emergency services from non- Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary plan.

One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners. When benefits are payable under automobile insurance, including no- fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

CHAMPUS If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

Medicaid If you are covered by both this Plan and Medicaid, this Plan will pay benefits first.

Workers The Plan will not pay for services required as the result of occupational disease or injury for

compensation which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers compensation (under section 8103 of title 5, U. S. C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers compensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP (or the agency).

DVA facilities, Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian

DoD facilities, and Health Service are entitled to seek reimbursement from the Plan for certain services and

Indian Health Service supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.

Other Government The Plan will not provide benefits for services and supplies paid for directly or indirectly by any

agencies other local, State, or Federal Government agency.

Liability insurance If a covered person is sick or injured as a result of the act or omission of another person or party,

and third party the Plan requires that it be reimbursed for the benefits provided in an amount not to exceed

action the amount of the recovery, or that it be subrogated to the persons rights to the extent of the benefits received under this Plan, including the right to bring suit in the persons name. If you

need more information about subrogation, the Plan will provide you with its subrogation procedures.

General Exclusions

All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your illness or condition. The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits); Expenses incurred while not covered by this Plan; Services furnished or billed by a provider or facility barred from the FEHB Program; Services not required according to accepted standards of medical, dental, or psychiatric

practice; Procedures, treatments, drugs or devices that are experimental or investigational; Procedures, services, drugs and supplies related to sex transformations; and Procedures, services, drugs and 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.

General Limitations continued

Medical and Surgical Benefits What is covered A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors

and other Plan providers. This includes all necessary office visits; you pay a $5 office visit copay, but no additional copay for laboratory tests and X- rays. Within the service area, house calls will be provided if, in the judgement of the Plan doctor, such care is necessary and appropriate; you pay a $10 copay for a doctors house call; nothing for home visits by nurses and health aides.

The following services are included and are subject to the office visit copay unless stated otherwise:

Preventive care, including well- baby care, periodic check- ups and routine gynecological care. Mammograms are covered as follows: for women age 35 through age 39, one mammogram

during these five years; for women age 40 through 49, one mammogram every year; for women age 50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness. Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery

and postnatal care by a Plan doctor. (The $5 office visit copay applies only to the first visit for obstetrical care). The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after caesarean delivery. Inpatient stays will be extended if medically necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment. Voluntary sterilization and family planning service Diagnosis and treatment of diseases of the eye Allergy testing and treatment, including testing and treatment materials (such as allergy

serum) The insertion of internal prosthetic devices, such as pacemakers and artificial joints. Cornea, heart, heart- lung, kidney, liver, lung (single or double), and pancreas transplants;

allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan. Women who undergo masectomies may, at their option, have this procedure performed on an

inpatient basis and remain in the hospital up to 48 hours after the procedure. Dialysis Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Orthopedic devices, such as braces (initial device only) Prosthetic devices, such as artificial limbs (initial device only) and lenses following cataract

surgery

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

13 Durable medical equipment, such as wheelchairs and hospital beds (initial device only)

Home health services of nurses and health aides, including intravenous fluids and medications, when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need All necessary medical or surgical care in a hospital or extended care facility from Plan doctors

and other Plan providers, at no additional cost to you.

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures, excision of tumors and cysts, and extractions of impacted teeth partially or totally covered by bone. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. Preapproval by the Plan is required.

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance and if the condition can reasonably be expected to be corrected by such surgery. Preapproval by the Plan is required.

Short- term rehabilitative therapy (pulmonary, physical, speech and occupational) is provided on an inpatient or outpatient basis for up to 60 consecutive days per condition if significant improvement can be expected within two months; you pay nothing. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.

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

Diagnosis and treatment of infertility is covered; the following types of artificial insemination are covered: intravaginal insemination (IVI); intracervical insemination (ICI) and intrauterine insemination (IUI); you pay a $5 copay per visit; cost of donor sperm is not covered. Noninjectable fertility drugs are covered under the Prescription Drug Benefit. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer, are not covered.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 12 weeks; you pay nothing. Preapproval by the Plan is required.

What is not Physical examinations that are not necessary for medical reasons, such as those required

covered for obtaining or continuing employment or insurance, attending school or camp, or travel Reversal of voluntary, surgically- induced sterility

Surgery primarily for cosmetic purposes Transplants not listed as covered Blood and blood derivatives not replaced by the member Hearing aids Long- term rehabilitation services Homemaker services Foot orthotics Dental prosthetics Providers charges for missed appointments

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Medical and Surgical Benefits continued

Hospital/ Extended Care Benefits What is covered

Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing. All necessary services are covered, including:

Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care Specialized care units, such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for up to 180 days per calendar year when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay nothing.

All necessary services are covered, including: Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled

nursing facility when prescribed by a Plan doctor.

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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor. Preapproval by the Plan is required, unless for emergency.

Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there

procedures is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care,

detoxification diagnosis, treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 16 for nonmedical substance abuse benefits.

What is not covered Personal comfort items, such as telephone and television Blood and blood derivatives not replaced by the member Custodial care, rest cures, domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you

emergency? 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 the Plan may determine are medical emergencies what they all have in common is the need for quick action.

Emergencies within If you are in an emergency situation, please call your primary care doctor. In extreme

the service area emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room.

If you are hospitalized in non- Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non- Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

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

Plan pays... Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

You pay... $35 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the copay is waived.

Emergencies outside Benefits are available for any medically necessary health service that is immediately required

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

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

Plan pays... Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers.

What is covered Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctors services Ambulance service approved by the Plan Prescription drugs related to covered services for emergency or urgent care obtained outside the

Plans service area; see the Prescription Drug Benefit on page 17

What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen

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

service area

Emergency Benefits

Filing claims for non- With your authorization, the Plan will pay benefits directly to the providers of your emergency

Plan providers care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan

along with an explanation of the services and the identification information from your ID card. Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 20.

Mental Conditions/ Substance Abuse Benefits

Treatment for mental conditions and substance abuse may be obtained directly from Green Spring Health Services. Green Spring Health Services, acting as a vendor for AmeriHealth HMO, Inc., manages all care related to mental health and substance abuse services. Questions about related benefits and pre- certification should be directed to Green Spring Health Services at 1- 800/ 688- 1911.

Mental conditions What is covered To the extent shown below, the Plan provides the following services necessary for the

diagnosis and treatment of acute psychiatric conditions, including the treatment of mental illness or disorders:

Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)

Outpatient care Up to 20 outpatient visits to Plan doctors, consultants, or other psychiatric personnel each calendar year, you pay a $25 copay for each covered visit all charges thereafter.

Inpatient care Up to 35 days of hospitalization each calendar year, you pay nothing for the first 35 days all charges thereafter. Inpatient days may be exchanged on a 1- for- 2 basis for additional outpatient mental health visits.

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short- term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless

determined by a Plan doctor to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriate treatment of a

short- term psychiatric condition

Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the

medical, non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition and, to the extent shown below, the services necessary for diagnosis and treatment.

Outpatient care Up to 60 full visits per calendar year, subject to a lifetime maximum of 120 full visits. You pay a $5 copay for each visit.

Emergency Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Inpatient care Up to 30 days per calendar year in a residential alcohol and/ or drug treatment rehabilitation center approved by the Plan, subject to a lifetime maximum of 90 days. Based on medical necessity, members may receive up to 15 additional substance abuse days per calendar year by exchanging any two available outpatient substance abuse visits for one inpatient treatment facility day. You pay nothing during the benefit period; all charges thereafter.

Detoxification services Outpatient and inpatient treatment is provided for up to 7 days per episode, subject to a lifetime benefit maximum of 4 episodes.

What is not covered Treatment that is not authorized by the mental health and substance abuse vendor.

Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will

be dispensed for up to a 34- day supply, or 120 unit supply, or maximum allowed dosage as prescribed by law, whichever is less. You pay a $5 copay per prescription unit or refill. Up to a 90- day supply of maintenance medications may be purchased at a participating pharmacy; you pay a $15 copay per 90- day supply. Refills will be dispensed only if 75% of the previously dispensed quantity has been consumed.

Drugs are dispensed in accordance with the Plans drug formulary. Non- formulary drugs will be covered when prescribed by a Plan doctor. This Plans formulary is a list of select FDA approved drugs that the Plan has researched and found to be safe, effective, and help contain costs. Each medication is reviewed based on the drugs efficacy, safety profile, and cost. The Plans Pharmacy and Therapeutics Committee ensures the formulary promotes rational therapeutic alternatives, the appropriate use of generics, and discourages the unnecessary use of high- cost alternatives.

A Mail Order program is available for up to a 90- day supply of maintenance medications. You pay a $5 copay per 90- day supply. Covered medications and accessories include:

Drugs for which a prescription is required by Federal law Oral and injectable contraceptive drugs up to a three- cycle supply may be obtained for a

single copay charge Contraceptive diaphragms and IUDs; you pay a $5 copay for the device and a $5 copay for the

office visit Implanted time- release medications, such as Norplant. You pay a $5 copay for the implant and

a $5 copay for the office visit. There is no charge when the device is implanted during a covered hospitalization. Removal of the implanted time- release medication before the end of the expected life is not covered unless medically necessary and approved by the Plan. Insulin, with a copay charge applied to each vial Diabetic supplies, including syringes, needles, glucose test tablets and test tape, Benedicts

solution or equivalent and acetone test tablets and glucometers. Disposable needles and syringes needed to inject covered prescribed medication Prenatal and pediatric vitamins Non- injectable fertility drugs Intravenous fluids and medication for home use (provided under home health services at

no charge) and some covered injectable drugs are covered under Medical and Surgical Benefits.

Limited benefits Drugs from a non- participating pharmacy. Covered drugs or supplies furnished by a non- participating pharmacy are covered when you submit acceptable proof of payment with a direct reimbursement form. Reimbursement for covered drugs or supplies will not exceed 100% of the usual and customary charge, less the drug copay. You will be entitled to reimbursement only if your purchase is related

Mental Conditions/ Substance Abuse Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

18 to covered services for emergency care or urgent care obtained outside of the Plans service area. All

claims for payment must be received within 90 days of the date of purchase. Direct reimbursement forms may be obtained by contacting the Plans Member Service Department.

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Injectable fertility drugs Contraceptive devices (except diaphragms and IUDs) Drugs for cosmetic purposes Drugs to enhance athletic performance Drugs to aid in smoking cessation

Other Benefits Dental care

What is covered The following dental services are covered when provided by participating Plan general dentists.

You pay a $5 copay per office visit.

Preventive Oral examination and diagnosis (limited to once in 6 months); prophylaxis/ teeth cleaning to

services include scaling and polishing (limited to once in six months); topical fluoride (includes child and adult); oral hygiene instruction.

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

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

Out- of- area- The program will reimburse member for dental services in connection with dental

dental services emergencies requiring palliative treatment (relieve pain) when the member is 50 miles or more from the member Primary Dental Office, up to a maximum of $50 for each occurrence less the $5

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

Accidental injury Restorative services and supplies necessary to promptly repair (but not replace) sound natural

benefit teeth. The need for these services must result from an accidental injury. You pay a $5 copay per visit.

What is not Other dental services not shown as covered

covered Vision care

What is In addition to the Medical and Surgical Benefits provided for diagnosis and treatment of

covered diseases of the eye, one eye refraction every two calendar years (to provide a written lens prescription) may be obtained from Plan providers. Call Customer Service at 888/ 393- 2583 in Delaware or New Jersey for information on Plan providers. You pay a $5 copay per visit.

What is not Corrective lenses or frames

covered Eye exercises

Prescription Drug Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Non- FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out- of- pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.

AmeriHealth HMO also offers members these Distinct Enhancement Opportunities:

Weight Management Reimbursement AmeriHealth HMOs Weight Management Reimbursement program gives you the option of participating in any weight management program offered by an AmeriHealth network hospital or Weight Watchers. 100% reimbursement of all fees (up to $200) when you reach and maintain goal weight.

Fitness Programs Members have the option of participating in two fitness programs. Through Fitness Option members may select to pay a $25 annual activation fee and a minimal copay each time they visit a network club or through Fitness Select may receive a 50% reimbursement of yearly membership fees up to $300, at a network club.

Smoking Cessation Program AmeriHealth HMO Delaware and New Jersey members can qualify for 100% reimbursement (up to $200) upon successful completion of an approved smoking cessation program. In addition, members can receive up to an 8 week lifetime supply of the nicotine patch to aid in the cessation of smoking.

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

Baby FootSteps Program AmeriHealth HMO members can receive educational materials and free gifts for you and your baby in our prenatal program.

Mothers Option AmeriHealth HMO pregnant mothers have the option of a 24 or 48 hour length of stay for a normal delivery and a 3 or 4 day length of stay for a cesarean delivery. If member opts for a 24 hour stay for a normal delivery, the mother will receive 2 home care visits. If member opts for a 3 day stay for a cesarean delivery, the mother will receive 1 home care visit.

Bike Safety Program AmeriHealth HMO offers tips for safe cycling, plus special offers on bike safety products.

Poison Prevention Program AmeriHealth HMO members can receive warning stickers to place on poisonous substances, flash cards to educate children under five, and a coupon for a free bottle of syrup of Ipecac.

Child Safety Program AmeriHealth HMO offers its members a child identification record, finger print kit, and a poster listing My Eight Rules of Safety.

American Red Cross CPR and First Aid Course Discounts AmeriHealth HMO members can receive 30% off any course offered by the American Red Cross.

Medicare Prepaid Plan Enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 5, annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area. They may than later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so, what you will have to pay. Contact your retirement system for information on changing your FEHB enrollment. Contact us at 1- 800- 898- 3492 for information on Plan benefits under the Medicare plan and the cost of that enrollment. If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plans FEHB plan, call 1- 800- 898- 3492 for information on the benefits available under the Medicare HMO.

Questions If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Customer Service Department at 800/ 444- 6282 in Delaware and 1- 800/ 877- 9829 in New Jersey, TDD number 215/ 558- 4634 or you may write to the Plan in Delaware at Mellon Bank Center, Suite 1200, 919 North Market Street, Wilmington, DE 19801- 3021. If you live in New Jersey, you may write to the Plan at P. O. Box 41574, Philadelphia, PA 19101- 1574.

Disputed claims review Plan If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing

reconsideration and within six months of the date of the denial, to reconsider its denial before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.) OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.

Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.

OPM review If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plans actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plans letter affirming its initial denial.

You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.

This right is available only to you or the executor of a deceased claimants estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review.

Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.

Your request must include the following information or it will be returned by OPM: A copy of your letter to the Plan requesting reconsideration; A copy of the Plans reconsideration decision (if the Plan failed to respond, provide

instead (a) the date of your request to the Plan or (b) the dates the Plan requested and you provided additional information to the Plan); Copies of documents that support your claim, such as doctors letters, operative reports,

bills, medical records, and explanation of benefit (EOB) forms; and Your daytime phone number.

Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy Act.

How to Obtain Benefits

21 Send your request for review to: Office of Personnel Management, Office of Insurance

Programs, Contracts Division III, P. O. Box 436, Washington, DC 20044. You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plans decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plans benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Plans denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.

Privacy Act statement If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.

How to Obtain Benefits continued

How AmeriHealth HMO Changes January 1999

Do not rely on this page; it is not an official statement of benefits.

Program- wide changes Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights.

If you have a chronic, complex, or serious medical condition that causes you to frequently see a Plan specialist, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals (See page 8).

A medical emergency is defined as 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 (See page 15).

The diagnosis, evaluation and medical management of certain mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits. Office visits for the medical aspects of treatment do not count toward the 20 outpatient Mental Conditions visit limit.

Changes to this Plan The copay for outpatient mental health care is simply $25 per visit. Previously, the copay was $25 per visit or 50% of charges, whichever was less.

A full visit for outpatient treatment of substance abuse is no longer defined as being 45 minutes in length. Also, partial visits for such treatment are no longer available.

Summary of Benefits for AmeriHealth HMO 1999

Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF OUTPATIENT MENTAL HEALTH AND EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day

care limit. Includes in- hospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, intensive care and complete maternity care. You pay nothing . . . . . . . . . . . . . . . . 14

Extended Care All necessary services, up to 180 days per calendar year. You pay nothing . . . . . 14 Mental Diagnosis and treatment of acute psychiatric conditions for up to 35 days of

Conditions inpatient care per year. You pay nothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Substance Abuse Up to 30 days per calendar year in a residential alcohol/ drug treatment

rehabilitation center, subject to a lifetime maximum of 90 days. You pay

nothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Outpatient Comprehensive range of services such as diagnosis and treatment of illness or

care injury, including specialists care; preventive care, including well- baby care, periodic check- ups and routine immunizations; laboratory tests and

X- rays; complete maternity care. You pay a $5 copay per office visit; $10 per house call by a doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Home Health All necessary visits by nurses and health aides. You pay nothing . . . . . . . . . . . . . 13 Care

Mental Up to 20 outpatient visits per year. You pay a $25 copay per visit . . . . . . . . . . . 16 Conditions

Substance Abuse Up to 60 full visits per calendar year to Plan mental health providers for follow- up care and counseling, subject to a lifetime maximum of 120 visits.

You pay a $5 copay per visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Emergency care Reasonable charges for services and supplies required because of a medical

emergency. You pay a $35 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan . . . . . . . . . . . . 15

Prescription drugs Drugs prescribed by any doctor and obtained at a participating pharmacy. You pay a $5 copay per prescription unit or refill. A Mail Order program is available for up to a 90 day supply of maintenance medications. You pay a $5 copay per 90 day supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dental care Accidental injury benefit; you pay a $5 copay per visit. Preventive, Diagnostic, and Restorative dental care; you pay a $5 copay per visit . . . . . . . . . 18

Vision care Refractions once every two years. You pay a $5 copay per visit . . . . . . . . . . . . . . 18 Out- of- pocket maximum Copayments are required for a few benefits; however, after your out- ofpocket expenses reach a maximum of $650 per person per calendar year,

covered benefits will be provided at 100%. This copay maximum does not include prescription drugs or dental services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Federal Employees Health Benefits Program

Authorized for distribution by the:

United States Office of Personnel Management

1999 Rate Information for AmeriHealth HMO, Inc.

FEHB Benefits of this Plan are described in brochure 73- 65 The 1999 rates for this Plan follow. Non- Postal rates apply to most non- Postal enrollees. If you are in a special enrollment category, refer to an FEHB Guide or contact the agency that maintains your health benefits enrollment.

Postal rates apply to all USPS career employees and do not apply to non- career Postal employees, Postal retirees or associate members of any Postal employees organization.

Non- Postal Premium Postal Premium Biweekly Monthly Biweekly Type of Govt Your Govt Your USPS Your Enrollment Code Share Share Share Share Share Share

All of Delaware Self Only SP1 72.06 24.82 156.13 53.78 84.98 11.90 Self and Family SP2 160.39 93.94 347.51 203.54 183.29 71.04

All of New Jersey Self Only FK1 72.06 34.85 156.13 75.51 84.98 21.93 Self and Family FK2 160.39 113.98 347.51 246.96 183.29 91.08