Pages 1--36 from Untitled

For changesin 3 benefitssee
page

Serving Eastern and Western Massachusetts Southern New Hampshire Southern Vermont
Northwestern Connecticut Southeastern Maine and Eastern New York

Enrollment in this Plan is limited see pages 4 6 for requirements
Enrollment code
681 Self Only
682 Self and Family

This Plan has Excellent Accreditation from NCQA
See FEHB Guide for more information on NCQA

Visit the OPM website at http www opm gov insure
and
this Plan s website at http www harvardpilgrim org

Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Services
RI 73 021 1
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Harvard Pilgrim Health Care 2000
Table of Contents

Introduction 1
Plain Language 1
How To Use This Brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How We Change For 2000 3
Section 3 How To Get Benefits 4 9
Section 4 What To Do If We Deny Your Claim Or Request For Service 10 11
Section 5 Benefits 12 22
Section 6 General Exclusions Things We Don t Cover 23
Section 7 Limitations Rules That Affect Your Benefits 23 24
Section 8 FEHB FACTS 25 29
Inspector General Advisory Stop Healthcare Fraud 30
Summary of Benefits 31
Notes 32 33
Premiums Back Cover 2
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Harvard Pilgrim Health Care 2000
Introduction
Harvard Pilgrim Health Care 10 Brookline Place West
Brookline Massachusetts 02146
This brochure describes the benefits you can receive from Harvard Pilgrim Health Care under its contract CS 1331 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official

statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 2 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government s communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences

We refer to Harvard Pilgrim Health Care as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan s benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make compari
sons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don t cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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Harvard Pilgrim Health Care 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copay ments and coinsurance listed in this brochure

When you receive emergency services 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 Our providers follow generally accepted medical practice when prescribing any course of treatment

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Section 2 How We Change For 2000
Program wide This year you have a right to more information about this Plan care management our networks facilities changes and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the second
or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3 How to get
benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a record that is not

accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to the record If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Your share of the non postal premium will increase by 54.2 for Self Only or 42.1 for Self and Family Plan See back cover
Under Medical and Surgical Benefits the office visit copay for primary and specialty care increases from 5 to 10 However the copay for routine allergy shots mental conditions and substance abuse will not
change See pages 12 21
Under Prescription Drug Benefits the copay increased from 5 to 15 for brand name formulary Drugs The copay for brand name non formulary Drugs increases from 10 to 35 See pages 19 20

Under the Prescription Drug Benefits coverage is provided for Norplant See page 20
Under Prescription Drugs a limited Mail Order Program is being added See page 20
Under Hospital and Extended Care a 100 copay per inpatient admission is being added This copay does not apply to inpatient admissions covered under Mental Conditions Substance Abuse Benefits

See pages 14 15
Under Emergency Benefits the emergency room copay will increase from 30 to 50 See pages 16 17
Under Emergency Benefits the copay increased from 5 to 10 for an in network urgent care center i e doctor s office walk in clinic See page 16

Under Medical and Surgical Limited Benefits following a mastectomy breast prostheses and surgical bras including their replacements are covered See page 13
The catastrophic limit has been reduced See page 7
Improved coverage is now available for the extraction of impacted teeth See page 13
A clarification on coverage for newborn screening tests is provided See page 12
Members covered under the Federal Employees Health Benefits Program do not have access to the entire Harvard Pilgrim Health Care provider network See page 7

Under Medical and Surgical Limited Benefits a clarification on coverage for nutritional formulas is provided in Enteral Formulas See page 14
Under Medical and Surgical Limited Benefits coverage is provided for the cost of wigs for cancer or leukemia patients See page 13

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Harvard Pilgrim Health Care 2000
Section 3 How To Get Benefits
What is this Plan s service area
To enroll with us you must live in our service area or live in the geographic area described below This is where our providers practice Our service area is

CONNECTICUT
Canaan North Canaan Salisbury Sharon Thompson Norfolk

MASSACHUSETTS
Abington Cambridge Framingham Lenox Nahant Acton Canton Franklin Leominster Natick
Adams Carlisle Georgetown Lexington Needham Alford Carver Gloucester Lincoln New Ashford
Amesbury Charlemont Grafton Littleton Newbury
Andover Charlton Great Barrington Lowell Newburyport Arlington Chelmsford Groton Lunenburg New Marlboro
Ashby Chelsea Groveland Lynn Newton Ashland Cheshire Halifax Lynnfield Norfolk
Attleboro Chester Hamilton Malden North Adams
Auburn Chesterfield Hancock Manchester North Andover Avon Clarksburg Hanover Mansfield North Attleboro
Ayer Clinton Hanson Marblehead North Reading Barnstable Cohasset Harvard Marlborough Northborough
Becket Concord Haverhill Marshfield Northbridge
Bedford Cummington Hawley Mashpee Norton Bellingham Dalton Hindsdale Maynard Norwell
Belmont Danvers Hingham Medfield Norwood Berkeley Dedham Holbrook Medford Oakham
Berlin Dighton Holden Medway Otis
Beverly Douglas Holliston Melrose Oxford Billerica Dover Hopedale Mendon Paxton
Blackstone Dracut Hopkinton Merrimac Peabody Blanford Dudley Hubbardston Methuen Pembroke
Bolton Dunstable Hudson Middleborough Pepperell
Boston Duxbury Hull Middlefield Peru Bourne East Bridgewater Huntington Middleton Pittsfield
Boxborough Easton Ipswich Milford Plainfield Boxford Egremont Kingston Millbury Plainville
Boylston Essex Lakeville Millis Plymouth
Braintree Everett Lancaster Millville Plympton Bridgewater Falmouth Lanesboro Milton Princeton
Brockton Fitchburg Lawrence Monroe Quincy Brookline Florida Lee Monterey Randolph
Burlington Foxboro Leicester Mt Washington Raynham

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Harvard Pilgrim Health Care 2000
Section 3 How To Get Benefits
What is this Plan s service area continued

MASSACHUSETTS continued
Reading Savoy Sudbury Wareham Westwood Rehoboth Scituate Sutton Washington Weymouth
Revere Sharon Swampscott Watertown Whitman Richmond Sheffield Taunton Wayland Williamstown
Rochester Sherborn Tewksbury Webster Wilmington
Rockland Shirley Tolland Wellesley Winchester Rockport Shrewsbury Topsfield Wenham Windsor
Rowe Somerville Townsend West Boylston Winthrop Rowley Southborough Tyngsboro West Bridgewater Woburn
Rutland Spencer Tyringham West Newbury Worcester
Salem Sterling Upton West Stockbridge Worthington Salisbury Stockbridge Uxbridge Westborough Wrentham
Sandisfield Stoneham Wakefield Westford Sandwich Stoughton Walpole Westminster
Saugus Stow Waltham Weston

NEW HAMPSHIRE
Amherst Freemont Kingston Newfields Sandown Atkinson Goffstown Litchfield Newton Seabrook
Auburn Greenfield Londonderry North Hampton Sharon Bedford Greenland Lyndeboro Pelham South Hampton

Brentwood Greenville Manchester Peterborough Stratham Brookline Hampstead Mason Plaistow Temple
Chester Hampton Merrimack Rye Wilton Danville Hampton Falls Milford Salem Windham

Derry Hollis Mount Vernon East Kingston Hooksett Nashua
Exeter Hudson New Boston Francestown Kensington New Ipswitch

NEW YORK
Ancram Canaan Hillsdale North East Stephantown AusterlitBerlin Chatham Nassau North Petersburg
Copake New Lebanon Petersburg

VERMONT
Bennington Pownal Readsboro Stamford

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Harvard Pilgrim Health Care 2000
Section 3 How To Get Benefits
This Plan accepts enrollments from this additional geographic area

MAINE
Alna Dayton Leeds Phippsburg West Gardner Arrowsic Dresdon Lewiston Poland Westbrook

Arundel Durham Lisbon Pownal Westport Auburn East Waterford Litchfield Raymond Windham
Baldwin Edgecomb Lyman Winthrop Richmond
Bath Eliot Mechanic Falls Sabattus Wiscasset Berwick Falmouth Minot Saco Woolwich
Biddleford Freeport Monmouth Scarborough Yarmouth Boothbay Gardner Naples Sebago York
Boothbay Harbor Georgetown Newcastle South Berwick
Bowdoinham Gorham New Gloucester South Bristol Bridgton Gray North Berwick South Portland
Bristol Greene North Yarmouth Southport Brunswick Harpswell Norway Standish
Buckfield Harrison Ogunquit Topsham
Buxton Hebron Old Orchard Beach Turner Cape Elizabeth Hollis Otisfield Wales
Casco Kennebunk Oxford Wells Cumberland Kennebunkport Paris West Bath
Damariscotta Kittery Perkins

NEW HAMPSHIRE
Barrington Epping New Castle Newmarket Rollinsford Dover Lee Newington Portsmouth Somersworth
Durham Madbury

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Harvard Pilgrim Health Care 2000
Section 3 How To Get Benefits
What is this Plan s service area continued
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 We will not pay for any other health care services

If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another state you should
consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas Many Out of area services are covered for eligible family members who attend school full time outside the
Service Area Please see the Non FEHBP Benefits Available to Plan Members for more information 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

How much do You must share the cost of some services This is called either a copayment a set dollar amount or I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you receive
services services except for prenatal care postpartum care and immunizations when that is the only service at the office visit

After you pay 2,000 in copayments or coinsurance per Self Only enrollment or 4,000 per Self and Family enrollment you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs and dental services do not count toward these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits

Do I have to You normally won t have to submit claims to us unless you receive emergency services from a provider submit claims who doesn t contract with us If you file a claim please send us all of the documents for your claim as soon
as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented
you from filing on time

Who provides Care is provided by Harvard Pilgrim Health Care HPHC doctors HPHC has established a special provider my health care network for FEHBP enrollees This provider network consists of Harvard Vanguard Medical Associates
other multi specialty group practices and other group practices that have served the FEHBP community for many years

If the Primary Care Physician PCP you select is not part of the special network for FEHBP enrollees HPHC will assign a PCP within the federal network
HPHC s federal provider network does not include some community independent primary care physicians who may be Harvard Pilgrim participating providers HPHC maintains the special federal provider network
for FEHBP enrollees in order to continue offering affordable high quality health care coverage to the FEHBP community

HPHC created a special Provider Directory for Federal Employees that lists primary care doctors family practitioners pediatricians and internists with their locations and phone numbers These primary care
doctors are part of the special provider network for FEHBP enrollees Directories are provided to all enrollees shortly after enrollment or upon request by calling the Member Services Department at 1 888
333 4742 TDD 1 800 637 8257 Directories are subject to change without notice and are updated on a regular basis If you are interested in receiving care from a specific provider please contact our Member
Services Department at 1 888 333 4742
Usually for adults your personal doctor will be a specialist in internal medicine for children a specialist in pediatrics Or at some locations you can choose a doctor in family practice for all covered family mem

bers Your primary care doctor who may work with a nurse practitioner or physician assistant supervises your care providing advice and treatment and arranging for laboratory tests hospitalization and the
services of other specialists when required Should you or a covered family member require care from a specialist your primary care physician will refer you to a participating specialist Referrals are usually
made to those specialists affiliated with the same medical location or hospital as the primary care physician In cases where the needed service is not available you will be referred to a participating provider at another
location in the HPHC HMO network 7 9
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Harvard Pilgrim Health Care 2000
Section 3 How To Get Benefits
What do I do if Call us We will help you select a new one my primary care
physician leaves the Plan

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will I need to go make the necessary hospital arrangements and supervise your care
into the hospital

What do I do if First call our Member Service Department at 1 888 333 4742 If you are new to the FEHB Program we I m in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when your former plan will pay for the hospital stay until I join this Plan
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will arrange your referral to a specialist specialty care
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your specialist for a certain

number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan

What do I do if Your primary care physician will decide what treatment you need If he or she decides to refer you to a I am seeing a specialist your doctor will probably recommend a specialist affiliated with his or her own practice
specialist when Typically the doctor you see for primary care is associated with a group or network of providers If your I enroll 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

What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan

But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing have a serious your provider for up to 90 days after we notify you that we are terminating our contract with the provider
illness and my unless the termination is for cause If you are in the second or third trimester of pregnancy you may provider leaves continue to see your OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and Plan leaves the you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
Program condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your
second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care

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Harvard Pilgrim Health Care 2000
Section 3 How To Get Benefits
How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice

Services that While in most cases you will need a referral from your primary care physician to get covered care from do not require any other provider you do not need a referral for the services listed below However you must get these
a referral services from an HPHC Provider HPHC Providers are listed in the HPHC Provider Directory for Federal Employees The Plan urges you to keep your primary care physician informed about such care so that your
medical records are current and up to date Your primary care physician should be aware of your entire medical situation

Family Planning Services Family planning consultation including pregnancy testing Contraceptive monitoring Tubal ligation
Prenatal Services Consultation for expectant parents Prenatal care
Gynecological Services Annual gynecological exam Cervical cryosurgery Colposcopy with biopsy Excision of labial lesions Laser cone vaporization of the cervix Loop electrosurgical excisions of the

cervix LEEP Treatment of amenorrhea Treatment of condyloma
Dental Services Pediatric preventive dental care for children through age 13 Emergency dental care Extraction of impacted teeth

Other Services Routine eye exam
If your PCP is located at one of the Harvard Vanguard Medical Associates your routine eye exam must be provided at a Harvard Vanguard Visual Services Department in order to be covered Likewise if your

PCP is located at one of the Harvard Vanguard Medical Associates your impacted tooth extractions must be provided at a Harvard Vanguard Dental Department in order to be covered

How do you A service procedure device or drug will be deemed experimental or investigational by HPHC for use in decide if a the diagnosis or treatment of a particular medical condition if any of the following is true
service is The service procedure device or drug is not recognized in accordance with generally accepted medical experimental
standards as being safe and effective for use in the evaluation or treatment of the condition in question In or investigational determining whether a service has been recognized as safe or effective in accordance with generally

accepted medical standards primary reliance will be placed upon data from published reports in authorita tive medical or scientific publications that are subject to peer review by qualified medical or scientific
experts prior to publication In absence of any such reports it will generally be determined that a service procedure device or drug is not safe and effective for the use in question

In the case of a drug the drug has not been approved by the United States Food and Drug Administration FDA This does not include off label uses of FDA approved drugs

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Harvard Pilgrim Health Care 2000
Section 4 What To Do If We Deny Your Claim or Request For Service
If we deny services or won t pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our

decision based on the information we already have

When may I You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM ask OPM to
will determine if we correctly applied the terms of our contract when we denied your claim or request review a
for service denial

What if I have Call us at 888 333 4742 and we will expedite our review a serious or
life threatening condition and
you haven t responded to
my request for service

What if you If we expedite your review due to a serious medical condition and deny your claim we will inform OPM have denied so that they can give your claim expedited treatment too Alternatively you can call OPM s Health
my request Benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening for care and conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
my condition soon as possible is serious or life
threatening

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Harvard Pilgrim Health Care 2000
Section 4 What To Do If We Deny Your Claim or Request For Service
Are there You must write to OPM and ask them to review our decision within 90 days after we uphold our initial other time denial or refusal of service You may also ask OPM to review your claim if
limits 1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for

additional information

What do I send Your request must be complete or OPM will return it to you You must send the following information OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person s representative They must send a copy of the person s specific written consent with the

review request

Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs Contract mail my disputed Division III P O Box 436 Washington D C 20044
claim to OPM

What if OPM OPM s decision is final There are no other administrative appeals If OPM agrees with our decision your upholds the only recourse is to sue
Plan s denial 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 or supplies

What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover
only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to the Privacy Act determine if our denial of your claim is correct The information OPM collects during the review process
becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the disputed claim

decision If you file a lawsuit this information will become part of the court record

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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Medical and Surgical Benefits continued

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 10 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 judgment of the Plan doctor such care is necessary and appropriate you pay a 15 copay for a doctor
nurse practitioner or physician s assistant home visits You pay 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 and periodic check ups
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 one or two years 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 exempt from the office visit copay
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays and newborn screening tests such as metabolic disease screening tests sickle cell disease test and hearing impairment screening tests

Complete obstetrical maternity care for all covered females including prenatal delivery and postpartum care by a Plan doctor Prenatal and postpartum care are exempt from office visit copay
The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean 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 mother s 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
The Plan covers services provided by a certified nurse midwife when the nurse midwife is listed in the Provider Directory for Federal Employees or practices with a participating Plan Provider

Voluntary sterilization and family planning services including injectable contraceptive drugs
Diagnosis and treatment of infertility is covered you pay a 10 office visit copay The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI

and intrauterine insemination IUI you pay a 10 office visit copay cost of donor sperm is covered when medically indicated the male partner is a Plan member and has not been voluntarily sterilized
and when the couple is diagnosed with male factor infertility Fertility drugs are covered under the Prescription Drug Benefit Other assisted reproductive technology ART procedures such as in vitro
fertilization IVF gamete intra fallopian transfer GIFT zygote intra fallopian transfer ZIFT and intracytoplasmic sperm injection ICSI are covered

Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum If only an allergy injection is provided you pay a 5 office visit copay for routine allergy injection

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Bone marrow cornea heart heart lung kidney liver pancreas kidney and lung single or double 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 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 Breast cancer and multiple myeloma services
may be provided through randomized or non randomized clinical trials Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Medical and Surgical Benefits continued

What is covered Women who undergo mastectomies 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
Lenses following cataract removal
Home health physical speech and occupational therapies services of home health nurses and health aides including intravenous fluids and medications are covered under home health 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

Oxygen

Limited Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for Benefits 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 and excision of tumors and cysts You pay a 10 copay for extractions of impacted teeth The service must
be provided by a Plan provider the procedure is covered in full when performed at a hospital outpatient department day surgery or inpatient basis 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

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 member s appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis Outpatient services required during a 90 consecutive day period per condition are

covered for members over the age of 3 the 90 consecutive day limit does not apply to children under age 3 you pay a 10 copay for each outpatient session Inpatient services are provided for up to 100
days per calendar year Speech therapy is limited to treatment for physical abnormality resulting from injury or disease 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
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided up to 3 months upon Plan approval you pay a 10 copay per outpatient session

Orthopedic devices such as braces prosthetic devices such as artificial limbs breast prostheses surgical bras and their replacement following mastectomy and durable medical equipment such as
wheelchairs and hospital beds are covered you pay 20 of the charges up to a maximum of 1,000 per calendar year There is no coverage after 5,000 in equipment cost has been paid including member
copayments The 5,000 benefit maximum does not apply to breast prostheses surgical bras and their replacement respiratory equipment including oxygen glucometers or durable medical equipment
ordered as part of authorized home health care
Wigs are covered up to 350 per member per calendar year when needed for hair loss suffered due to treatment for any form of cancer or leukemia The Plan pays the first 350 in costs you pay all charges

thereafter
Low protein foods that are prescribed for a member s inherited diseases of amino acids and organic acids are limited to 2,500 per member per year

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Medical and Surgical Benefits continued

Limited Special infant formulas are covered for the treatment of the following congenital conditions Benefits phenylketonuria PKU homocystinuria tyrosinemia maple syrup urine disease priopionic acidemia
methylemalonic acidemia You pay nothing
Health education programs such as Smoking Cessation and Stress management you pay 4 per hour plus all charges for the cost of the materials

Enteral formulas are covered for treatment of Crohn s disease ulcerative colitis gastroesophogeal reflux gastrointestinal motility or chronic pseudo obstructive disease

What is not Physical examinations that are not necessary for medical reasons except premarital school and sports covered examinations such as those required for obtaining or continuing employment or insurance
governmental licensing or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services
Foot orthotics
Blood and blood derivatives

Hospital Extended Care Benefits
What is covered
Hospital The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized Care
under the care of a Plan doctor You pay 100 per admission All necessary services are covered
including

Semi private 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 The Plan provides a comprehensive range of benefits for up to100 days per calendar year when full time Care
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 100 per admission 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 Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Care 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

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Hospital Extended Care Benefits continued

What is covered continued
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor Services

Limited Benefits
Acute Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment Inpatient of medical conditions and medical management of withdrawal symptoms acute detoxification if the
Detoxification Plan doctor determines that outpatient management is not medically appropriate See page 18 19 for non medical Substance Abuse Benefits

What is not Personal comfort items such as telephone and television covered
Custodial care rest cures domiciliary or convalescent care
Hospitalization for dental procedures
Blood and blood derivatives

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 17
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency 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 If you are in an emergency situation please call your primary care doctor In extreme emergencies if you within the are unable to contact your doctor contact the local emergency system e g the 911 telephone system or
service area go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member should notify the Plan within 48 hours
It is your responsibility to ensure that the Plan has been timely notified
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 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 50 per hospital emergency room visits 10 per visit to an office based setting i e doctor s office walk in clinic or freestanding urgent care center If the emergency results in admission to a hospital you pay a
100 hospital admission copay The emergency care copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required because of outside the injury or unforeseen illness

service are If you need to be hospitalized the Plan must be notified within 48 hours of your hospitalization The
telephone number is printed on the front of your ID card The Plan covers inpatient care outside the service area only until your condition permits safe travel to the service area To be covered all follow up

care must be arranged by your primary care doctor
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
You pay 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital you pay a 100 hospital admission copay The emergency
care copay is waived if you are admitted to a hospital

What is covered Emergency care at a doctor s 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
Emergency care for trauma reduction of swelling and pain relief associated with a dental injury
Prescription drugs obtained outside the service area because of unforeseen illness or injury

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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Emergency Benefits continued
What is not Elective care or non emergency care covered
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

Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency care upon for non Plan receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are
providers required to pay for the services submit itemized bills and your receipts to the Plan along with an explana tion of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions of
the contract on which denial was based If you disagree with the Plan s decision you may request recon sideration in accordance with the disputed claims procedure described on pages 10 11

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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Mental Conditions Substance Abuse Benefits
If you need mental health care or drug or alcohol rehabilitation services call the Mental Health Case Manager for your primary care site He or she will assist you in determining the type of care you need finding the appropriate providers and arranging the services
you require To get the name and telephone number of the Mental Health Care Manager please call 1 888 777 4742 HPHC covered both inpatient and outpatient services The Mental Health Case Manager will determine the service appropriate to your needs

Mental To the extent shown below the Plan provides the following services necessary for the diagnosis and conditions treatment of acute psychiatric conditions and the treatment of mental illness or disorders
What is covered Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient Covered up to 25 visits per calendar year within that limit covered up to 20 visits for individual therapy care and up to 25 visits for group therapy You pay nothing for covered group therapy sessions You pay a 5
copay for individual therapy sessions after visit 8 all charges thereafter
If treatment is needed for both a psychiatric condition and a substance abuse disorder you pay a 5 per visit copay for the first 16 visits with the remaining 4 visits up to the 20 visit maximum subject to the

copay levels described above
Outpatient visits for medication monitoring and evaluation are not subject to the 20 visit maximum you pay a 5 copay per visit

If a member has a severe psychiatric or substance abuse disorder as determined by the Plan certain recommended treatments including individual case management and intensive outpatient care will be
provided with no visit or dollar limit you pay a 5 per visit copay

Inpatient Up to 60 days of hospitalization each calendar year you pay nothing for the first 60 days all charges care thereafter These 60 days of inpatient mental health coverage can be exchanged on a two for one basis
for up to 120 days of day treatment

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to covered 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 This Plan provides medical and hospital services such as acute detoxification services for the medical non What is covered 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 Up to 20 outpatient visits or 500 in benefit value per calendar year whichever is greater for evaluation care diagnosis treatment and crisis intervention You pay a 5 copay per visit for group therapy sessions For
individual therapy you pay a 5 copay per visit for visits 1 8 a 25 copay per visit for visits 9 20 all charges thereafter

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 20
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Mental Conditions Substance Abuse Benefits
Substance Abuse What is covered
continued

Inpatient Up to 30 days of substance abuse rehabilitation intermediate care per calendar year in an alcohol detoxi care fication or rehabilitation center approved by the Plan You pay nothing during the benefit period all
charges thereafter These 30 days of inpatient substance abuse care can be exchanged on a two for one basis for up to 60 days of day treatment

What is not Treatment that is not authorized by a Plan doctor covered

Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and dispensed by a Plan pharmacy are covered A
copay will be charged for each prescription unit or refill up to a 30 day supply of medication Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan s drug formulary Non

Formulary Drugs will be covered when prescribed by a Plan doctor
A small number of drugs require a Plan authorization It is your doctor s responsibility to obtain the required authorization If the doctor prescribes a medication without obtaining a Plan authorization the

medication will be dispensed by the Plan pharmacy and you pay the required copay
The amount of the copay will vary as described below depending upon whether the prescription is Ge neric Drugs Brand Name Formulary Drugs Or Brand Name Non Formulary Drugs

You pay a 5 copay for Generic Drugs You pay a 15 copay for Brand Name Formulary Drugs
You pay a 35 copay for Brand Name Non Formulary Drugs
You may obtain a copy of the Harvard Pilgrim Formulary by calling the Member Service Department at 1 888 333 4742

The copay must be paid to the pharmacy at the time of purchase
Covered medications and accessories include

Drugs for which a prescription is required by law
Insulin
Oral contraceptive drugs contraceptive diaphragms IUDs and cervical caps
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies limited insulin syringes needles and blood and urine testing products
Nicotinic acid
Fertility drugs a 10 office visit copay applies for drugs administered by a Plan provider
Intravenous fluids and medication for home use covered implantable drugs and some injectable drugs including injectable contraceptives such as Depo Provera are covered under Medical and Surgical

Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19 21
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Prescription Drug Benefits continued
Limited benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
There is a special 180 copay for Norplant
Prescription smoking cessation drugs and medication gum and patches are covered if the member is enrolled in a smoking cessation program subject to prescription drug copay

Limited Mail A limited mail order prescription service is provided for certain covered medications Only maintenance Order
medications for which you require a 90 day supply may be obtained by mail The copays for mail order Prescription
service prescriptions differ from your standard prescription copays Drug Service

Under the Mail Service Program
You pay a 10 copay for a 90 day supply of Generic Drugs You pay a 30 copay for a 90 day supply of Brand Formulary Drugs

You pay a 105 copay for a 90 day supply of Brand Non Formulary Drugs
The following items may not be purchased through the mail service

compounded medications requiring the mixing of drugs by a pharmacist
any drugs for which mail order is prohibited by law and prescriptions determined by HPHC to be excluded from the mail order service

For further information contact Member Services at 1 888 333 4742

What is not Drugs available without a prescription or for which there is a nonprescription equivalent available covered
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Medical supplies such as dressings and antiseptics
Vitamins
Drugs for cosmetic purposes and weight loss
Drugs to enhance athletic performance
Drugs related to transsexual surgery
Compound prescriptions that do not contain an agent that requires a prescription by law

Changes and HPHC s Pharmacy and Therapeutics Committee regularly reviews prescription drugs and may add drugs Exceptions to the list of Brand Name Formulary Drugs at any time The Committee will remove drugs from the list
to Drug Coverage only in January of each year or in response to a FDA advisory recommending limitations on the use of a Policies Brand Name Formulary Drug Notice will not be sent to members of changes in the list of Brand Name
Formulary Drugs
The Committee may require prior authorization for coverage of certain drugs including Brand Name Formulary Drugs

The Committee may add drugs to the list of drugs for which coverage is excluded or limited at any time without prior notice to members HPHC Providers may request an exception on behalf of a member for
coverage of any drug that is excluded or limited Exceptions will be granted only for clinical reasons Exceptions will not be granted to the limits on the coverage of Viagra

HPHC will not grant members individual exceptions to the classification of a drug as a Brand Non Formulary Drug Likewise HPHC will not waive the applicable Copayment required of any Brand Name
Non Formulary Drug However HPHC Providers may request the review of a drug for designation as a Brand Name Formulary Drug at any time

20 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 22
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Other Benefits
Dental Care The following preventive services are provided for children through age 13 when received from Plan What is covered dentists up to two exams per year you pay nothing

Oral examinations and X rays
Dental prophylaxis cleaning
Scaling
Topical application of fluoride
Treatment of accidental dental injuries is covered under Emergency Benefits See page15

What is not covered Other dental services not shown as covered

Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye What is covered you are covered for one routine eye examination per calendar year to provide a written lens prescription
and eye exercises which must be obtained from Plan providers You pay a 10 copay per visit

What is not covered Corrective lenses and frames

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Harvard Pilgrim Health Care 2000
Section 5 Benefits

Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB but are made available to all enrollees and family members who are members of this Plan The cost of the
benefits described on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductible or out of pocket maximums These benefits are not subject to the
FEHB disputed claims procedure
Out of Area Out of area services are covered for eligible family members who attend school full time outside the
Students Service Area Benefits are provided for the following

Inpatient All inpatient services listed in this brochure are covered except for elective procedures Elective proce care dures are services that can be delayed until the member returns to the Plan Service Area without permanent
damage to the member s health

Outpatient The outpatient mental health and substance abuse rehabilitation services listed in this brochure are each
care for covered up to a maximum of 8 visits per calendar year to the extent such benefits have not been provided
mental within the HPHC Service Area
conditions

Other All outpatient care is covered except the following care is not covered outpatient
Routine examinations and preventive care including immunizations care
Home health care including maternity home care programs and house calls
Health education programs
Maintenance of or the replacement of prosthetic devices or durable medical equipment
Cosmetic surgery
Elective outpatient surgical procedures Such procedures are services that can be delayed until the member returns to the Plan Service Area without permanent damage to the member s health

Second opinions

Medicare Choice This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated Plan on page 20 annuitants and former spouses with FEHB coverage and Medicare Part B may suspend their
Enrollment FEHB coverage and enroll in a Medicare Choice plan when one is available in their area They may then later re enroll 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 suspending your FEHB enrollment and changing to a Medicare Choice Plan

Contact us at 1 800 779 7723 for information on the Medicare Choice Plan and the cost of that enrollment

22 BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 24
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Harvard Pilgrim Health Care 2000
Section 6 General exclusions Things We Don t Cover

The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
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

Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is
responsible for paying for medical services and we will coordinate the payments On occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan offered by
this Plan see page 22

HPHC s If you are covered through HPHC and enrolled in Medicare Parts A B or Medicare Part B only HPHC Coordination will coordinate benefits as the secondary payer with Medicare Medicare is the primary payer for Medi
of Benefits for care covered services if Medicare
you are age 65 or over have Medicare Parts A B or Medicare Part B only and are not actively covered services employed by the Federal Government or another employer who insures you for health benefits

you are under age 65 are not actively employed by the Federal Government or another employer who provides health benefit and are eligible for Medicare on the basis of disability
you are entitled to Medicare as a result of End Stage Renal Disease permanent kidney failure Medicare becomes the primary payer after 30 months of Medicare coverage regardless of employment
status

When HPHC is the secondary payer it is HPHC not you that is responsible for office visit and emer gency room copayments for Medicare covered services Examples of Medicare covered services include
treatment of an illness or injury preventive procedures such as influenza and pneumonia vaccinations mammograms and pap smears

23 25
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Harvard Pilgrim Health Care 2000
Section 7 Limitations Rules That Affect Your Benefits

Procedure The following helps explain when you are responsible for the copayment
Medicare Part A only You pay an office visit or emergency room copayment Medicare Part B only You do not pay an office visit or emergency room copayment for Medicare

covered services Medicare Parts A B You do not pay an office visit or emergency room copayment for Medicare
covered services No Medicare coverage You pay an office visit or emergency room copayment

If you have Medicare Parts A B or Medicare Part B only please bring your Medicare card with you and show it to the receptionist or billing clerk when you receive services Please tell them to bill Medicare first
if it is a Medicare covered service If Medicare covers the service the provider s office will waive your copayment at the time of the visit or collect the copayment and reimburse you after receiving payment for
both Medicare and HPHC
Other group When anyone has coverage with us and with another group health plan it is called double coverage You insurance must tell us if you or a family member has double coverage You must also send us documents about other

coverage insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the National Associa

tion of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is less

We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond out them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that another are responsible person caused you must reimburse us for whatever services we paid for We will cover the cost of

for injuries treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for our subroga
tion procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the prim

ary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation
Programs OWCP or a similar Federal or State agency determine they must provide

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or Government indirectly pays for

Agencies

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Harvard Pilgrim Health Care 2000
Section 8 FEHB FACTS
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to to information information about your health plan its networks providers and facilities You can also find out about care
about your HMO management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM s website www opm gov lists the
specific types of information that we must make available to you
If you want specific information about us call 1 888 865 4742 or write to us at 1200 Crown Colony Drive Quincy MA 02169 You may also visit our website at http www harvardpilgrim org

Information that must be made available to you includes all of the following The following information can be found in the HPHC Provider Directory for Federal Employees

Number of primary care and specialty providers
Name the name and geographic location of all contracting primary care providers whether they are accepting new patients and language s spoken

Names of hospitals where physicians have admitting privileges
Names and geographic location of hospitals

The following information can be obtained from the following outside sources
Administrators in Medicine website www docboard org Massachusetts Board of Registration in Medi cine 800 377 0550 or the Rhode Island Office of Medical Licensure and Discipline at 401 222 3855

Name education and board certification status and geographic location of providers
Names of hospitals where physicians have admitting privileges
Years in practice as a physician and as a specialist if so identified
Accreditation status
Cancellation suspension or exclusion from participation in Federal programs or sanctions from Federal agencies any suspension or revocation of medical licensure Federal controlled substance

license or hospital privileges

If you are not able to obtain the information you need from the provider or facility you may call 1 888 865 4742 and request an information sheet with the following
Customer satisfaction measures
Provider compensation including base payment method e g capitation salary fee schedule and additional financial incentives e g bonus withhold etc

Methods of compensation ownership or interest in health care facilities
Whether the facility s affiliation with a provider network would make it more likely that a consumer would be referred to health professionals or other organizations in that network

name and geographic location of participating home health agencies rehabilitation and long term care facilities
Disenrollment rates for 1998
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
Carrier s 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

25 27
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Harvard Pilgrim Health Care 2000
Section 8 FEHB FACTS
You have a right If you are not able to obtain the information you need from the provider or facility you may call HPHC to information Member Services at 888 333 4742 for assistance for the following

about your HMO continued Specific information on the availability of interpreters for non English speaking and those with
communication disabilities and whether the provider s office or facility is accessible to the disabled
Name and geographic location of all contracting specialists
Whether provider is accepting new patients and language s spoken
Corporate form of provider practice
Experience with performing certain medical or surgical procedures e g volume of care services delivered adjusted for case mix and severity

Consumer satisfaction clinical quality and service performance measures
Accreditation status of hospitals home health agencies rehabilitation and long term care facilities whether they are accepting new patients language s spoken and availability of interpreters for non

English speaking and those with communication disabilities and whether they are accessible to the disabled

Corporate form
Consumer satisfaction clinical quality and service performance measures
Whether facility specialty programs meet guidelines established by specialty societies or other bodies
Complaint procedures
Whether facility has been excluded from any Federal health programs
Volume of certain procedures performed
Numbers and credentials of providers of direct patient care

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employ information about ees Health Benefits Plans brochures for other plans and other materials you need to make an informed
enrolling in the decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

We don t determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premium effective premiums begin January 1

What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in when I retire the FEHB Program for the last five years of your Federal service If you do not meet this requirement you
may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

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Harvard Pilgrim Health Care 2000
Section 8 FEHB FACTS

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried coverge are dependent children under age 22 including any foster or step children your employing or retirement office
available for my authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 family and me years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days after you
give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access to it claims records
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordination benefit payments and subrogating claims

Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

27 29
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Harvard Pilgrim Health Care 2000
Section 8 FEHB FACTS

Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF cards 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an
Employee Express confirmation letter
What if I Your old plan s deductible continues until our coverage begins paid a

deductible under my
old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled

When You Lose Benefits
What You will receive an additional 31 days of coverage for no additional premium when happens

if my Your enrollment ends unless you cancel your enrollment or enrollment
You are a family member no longer eligible for coverage in this Plan

You may be eligible for former spouse coverage or Temporary Continuation of Coverage ends

What is If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your former former spouse s enrollment But you may be eligible for your own FEHB coverage under the spouse
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse s employing coverage or retirement office to get more information about your coverage choices

What is Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage TCC because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office
Key points about TCC

You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

28 30
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Section 8 FEHB FACTS
How do I If you leave Federal service your employing office will notify you of your right to enroll under TCC You enroll in must enroll within 60 days of leaving or receiving this notice whichever is later
TCC Children You must notify your employing or retirement office within 60 days after your child is no longer
an eligible family member That office will send you information about enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is

later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage
or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

How can I You may convert to an individual policy if convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay coverage your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

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

Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your coverage due to
pre existing conditions

How can I If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that get a indicates how long you have been enrolled with us You can use this certificate when getting health
Certificate insurance or other health care coverage You must arrange for the other coverage within 63 days of of Group leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
Health Plan health related conditions based on the information in the certificate Coverage
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 888 333 4742 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300

U S Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400 Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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Harvard Pilgrim Health Care 2000
Summary of Benefits for Harvard Pilgrim Health Care 2000
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 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 limit care 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 100 per admission 14 15
Extended Care All necessary services for up to 100 days per calendar year You pay 100
per admission 14

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care per calendar year You pay nothing 18

Substance Abuse Up to 30 days per year in a substance abuse treatment facility You pay nothing 19

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care including specialist s care preventive care including well baby care periodic check
ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit copays are waived for prenatal and postpartum
care 15 per house call by a doctor and 5 per allergy injection visit 12 21
Home Health Care All necessary visits by nurses and health aides You pay nothing 13

Mental Conditions Covered up to 25 visits per calendar year within that limit covered up to 20 visits for individual therapy and up to 25 visits for group therapy You pay nothing for covered
group therapy sessions You pay a 5 copay for individual therapy visits 1 8 and a 25 copay for covered individual sessions after visit 8 all charges thereafter Outpatient
visits for medication monitoring are provided without limit you pay a 5 per visit copay These visits do not count against the benefit limit 18

Substance Abuse Up to 20 visits or 500 per calendar year whichever is greater You pay a 5 copay for group therapy sessions For individual therapy you pay a 5 copay for visits 1 8
and a 25 copay for visits 9 20 all charges thereafter 18 19

Emergency care Reasonable charges for services and supplies required because of a medical emergency Outside the service area you pay a 50 copay for each emergency room visit Within
the service area you pay a 10 copay to a doctor s office or office based walk in clinic or urgent care center and a 50 copay to the hospital for each emergency room
visit You pay a 100 inpatient copay 16 17
Prescription drugs Drugs prescribed by a Plan doctor and dispensed at a Plan pharmacy For a 30 day supply you pay a 5 copay for Generic Drugs a 15 copay
for Brand Formulary Drugs and a 35 copay for Brand Non Formulary Drugs 19 20

Dental care Up to two anual preventive dental care visits for children through age 13 per year through age 13 you pay nothing 21
Vision care One routine eye examination each calendar year You pay a 10 copay per visit 21
Out of pocket Copayments are required for a few benefits however after your out of pocket ex maximum penses reach a maximum of 2,000.00 per Self only or 4,000.00 per Self and Family
enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include costs of prescription drugs or dental services 7

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Notes
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Notes
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Harvard Pilgrim Health Care 2000
2000 Rate Information for
Harvard Pilgrim Health Care Inc

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but not a member of a special postal employment class refer to the category definitions in The
Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to deter
mine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes
or associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Gov t Your Gov t Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Self Only 681 78.83 50.22 170.80 108.81 93.06 35.99 93.26 35.79
Self and Family 682 175.97 166.03 381.27 359.73 207.74 134.26 201.02 140.98

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