Pages 1--24 from Untitled

of Iowa Inc

A Health Maintenance Organization
Serving The Greater Des Moines Central Iowa and Waterloo area
Enrollment in this Plan is limited see page 4 for requirements For changesin 3 benefitssee
page
Enrollment code

SV1 Self Only
SV2 Self and Family

This Plan has full accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

Important Notice
Effective January 1 2000 Woodbury County will no longer be included in Principal Health Care of Iowa's service
and enrollment area If you live in this county you have the option of changing plans during open season

Visit the OPM website at http www opm gov insure and
our website at http www phcia cvty com or www cvty com

Authorized for distribution by the
United States Office of
Personnel Management

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Principal Health Care of Iowa Inc 2000
Table of Contents
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 7
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16
Section 8 FEHB facts 17
Inspector General Advisory Stop Healthcare Fraud 20
Summary of benefits Inside Back Cover
Premiums Back Cover

Introduction
This brochure describes the benefits you can receive from Principal Health Care of Iowa Inc 4600 Westown Parkway Suite 200 West Des Moines IA 50266 1099 under its contract CS 1983 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 3 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 Principal Health Care of Iowa Inc HMO 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

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Principal Health Care of Iowa Inc 2000
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 comparisons 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

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 copayments 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

Section 2 How we change for 2000
Program wide changes This year you have a right to more information about this Plan care management our networks facilities 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 it If they do not provide you your records call us
and we will assist you

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Principal Health Care of Iowa Inc 2000
Section 2 How we change for 2000 continued
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 Plan Your share of the premium will increase by 4 for Self Only or by 1.7 for Self and Family
The copayment charge for Primary Care office visits will increase from 5 to 10 and specialists office visit copayment charges will increase from 10 to 15

Effective January 1 2000 Woodbury County will no longer be included in Principal Health
Care of Iowa's service and enrollment area If you live in this county you have the option of
changing plans during open season

Section 3 How to get benefits
What is this Plan's To enroll with us you must live in our service area This is where our providers practice Our service area service area is Black Hawk Boone Bremer Clarke Dallas Guthrie Jasper Lucas Madison
Marion Polk Story and Warren Counties
You may also enroll with us if you live in the following places Hamilton Mahaska Marshall and Poweshiek counties

Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other
health care services unless authorized by the Plan
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in
another state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to
wait until Open Season to change plans Contact your employing or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services
After you pay 750 in copayments or coinsurance for one family member or 1,500 for two or more family members 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 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 submit claims provider 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 my Principal Health Care of Iowa Inc contracts with more than 350 doctors representing specialties health care in family practice pediatrics and internal medicine to serve as primary care physicians In addition
over 800 specialists and 26 hospitals participate Principal Health Care of Iowa Inc has
also made arrangements with certain optometrists ophthalmologists and pharmacies to provide
your eye exams and prescription drugs

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Principal Health Care of Iowa Inc 2000
Section 3 How to get benefits continued
What do I do if my primary Call us We will help you select a new one care physician leaves the
Plan
What do I do if I need to go Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist into the hospital will make the necessary hospital arrangements and supervise your care Have your primary
care physician or specialist contact the Plan

What do I do if I'm in the First call our customer service department at 800 257 4692 If you are new to the FEHB hospital when I join this Program we will arrange for you to receive care If you are currently in the FEHB Program
Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 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 specialty care Your primary care physician will arrange your referral to a specialist
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 and will be responsible for obtaining the
appropriate authorization for those services

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you seeing a specialist when to a specialist ask if you can see your current specialist If your current specialist does not
I enrole 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 my Call your primary care physician who will arrange for you to see another specialist You may specialist leaved the Plan receive services from your current specialist until we can make arrangements for you to see
someone else

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

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

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Principal Health Care of Iowa Inc 2000
Section 3 How to get benefits continued
How do you decide if a The Plan's experimental investigational determination process is based on authoritative service is experimental information obtained from medical literature medical consensus bodies health care standards

or investigational database searches evidence from national medical organizations State and Federal government agencies and research organizations The review and approval process for medical policies and
clinical practice guidelines includes clinical input from doctors with specialty expertise in the subject

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
Be in writing Refer to specific brochure wording explaining why you believe our decision is wrong and
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
Maintain our denial in writing Pay the claim
Arrange for a health care provider to give you the service or 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 ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service

What if I have a serious Call us at 515 255 1234 or 1 800 470 6352 and we will expedite our review or life threatening condition
and you haven't responded to my request for service

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can
my condition is serious or call OPM's health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible

Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
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
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 to OPM Your request must be complete or OPM will return it to you You must send the following information
A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

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Principal Health Care of Iowa Inc 2000
Section 4 What to do if we deny your claim or request for service continued
Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
Copies of all letters you sent us about the claim Copies of all letters we sent you about the claim and
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
Anyone enrolled in the Plan The estate of a person once enrolled in the Plan and
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

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

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies

What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base a lawsuit its 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from Privacy Act you and us to 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

Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services are provided by Plan doctors and other Plan providers This includes all necessary office visits laboratory tests and

X ray you pay a 10 copayment for a primary care doctor's office visit and a 15 copayment
for a specialist's office visit following a referral 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 copayment for a primary care doctor's house call nothing for home visits by nurses and
health aides

The following services are included
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

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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
years for women age 50 through 64 one mammogram every year and for women age 65 and over 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 You pay a 50 copayment for all pre natal care This
copayment shall apply at the time of delivery in lieu of copayments for pre natal office visits The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a 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 mother's hospital confinement for maternity
will be covered under either a Self Only or Self and Family enrollment other care of an infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints you pay 40 of charges

Cornea heart heart lung single double lung kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow autologous stem cell support
and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's
lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer
Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be limited to non randomized clinical trials based on recommendations by the National Cancer
Institute Transplants are covered when approved by the Plan's Medical Director Related medical and hospital expenses of the donor are covered when the recipient is covered by this
Plan Organ transplants must be performed in Plan designated facilities
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
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

Chiropractic services including osteopathic manipulative therapy when authorized by the Plan and primary care doctor

8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 8
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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
Growth hormone therapy you pay 25 of charges or a 5 copayment per one month
supply whichever is greater

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 and excision of tumors and cysts All other procedures involving the
teeth or intra oral areas surrounding the teeth are not covered
Treatment of temporomandibular joint TMJ syndrome is covered You pay 20 of eligible
expenses up to a lifetime maximum Plan payment of 2,000 Any covered appliances required
for the treatment of TMJ will be subject to the coinsurance required for prosthetic devices

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 Benefits will be provided for all stages of breast reconstruction
following a mastectomy including treatment of any physical complications including lymphedemas and for breast prostheses including surgical bras and replacements

Short term rehabilitative therapy physical speech occupational and cardiac is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement
can be expected within two months you pay a 10 copayment per outpatient session nothing for inpatient visits 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

Diagnosis and treatment of infertility as well as artificial insemination are covered you pay 50 charges The Plan pays remaining charges The following types of artificial insemination
are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay 50 of charges cost of donor sperm is not covered Fertility drugs
are covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Orthopedic devices such as braces prosthetic devices such as artificial limbs durable medical equipment such as manual wheelchairs and manual hospital beds and foot orthotics
are covered You pay 20 of reasonable and customary charges unless equipment is provided in lieu of hospital confinement then you pay nothing

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Transplants not listed as covered
Hearing aids
Homemaker or custodial services
Long term rehabilitative therapy
Radial keratotomy
Surgery primarily for cosmetic purposes

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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are Hospital care 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 This Plan provides a comprehensive range of benefits up to 62 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
Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a Inpatient dental need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
procedures 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 diagnosis detoxification 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 13 for Non Medical Substance Abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care

Emergency Benefits
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

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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme 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 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 must notify the primary care doctor as soon as possible and or contact
the Plan within 48 hours of the emergency room visit 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 is 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 and any ambulance
charges are 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

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 copayment or 50 of charges whichever is less per hospital emergency room visit or 30
copayment per urgent care center visit for emergency services which are covered benefits of this
Plan

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

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

You pay 50 copayment or 50 of covered charges whichever is less per hospital emergency room visit for emergency services received at a non Plan facility or doctor's office or urgent care center
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 doctor's services
Ambulance service approved by the Plan

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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
What is not covered Elective care or non emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers non 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 the denial was
based If you disagree with the Plan's decision you may request reconsideration in accordance
with the disputed claims procedure described on page 6

Mental Conditions Substance Abuse Benefits
Mental conditions To the extent shown below the Plan provides the following services necessary for the What is covered 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
All mental conditions substance abuse services are coordinated by American Psych Systems APS To access your mental conditions substance abuse benefits call APS directly at
1 800 752 7242 A primary care doctor referral is not required

Outpatient care Up to 30 individual or 45 group therapy outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 15 copayment for each covered visit all
charges thereafter See conversion option below

Inpatient care Up to 30 days of hospitalization per calendar year you pay 20 of facility and supply charges for the first 30 days all charges thereafter

What is not covered Care for psychiatric conditions that in the professional judgement 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 when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the What is covered 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 30 individual or 45 group therapy outpatient visits per calendar year to Plan providers for treatment you pay a 15 copayment for each covered visit all charges thereafter

Outpatient services from Plan providers for medically necessary detoxification are covered you
pay a 10 copayment per visit

Inpatient care Up to 30 days of hospitalization per calendar year you pay 20 of facility and supply charges for first 30 days all charges thereafter

What is not covered Treatment that is not authorized by a Plan doctor
Conversion option If a member has used the maximum number of outpatient individual or group therapy visits the member may at the discretion of the Plan exchange remaining inpatient mental health or
substance abuse days for additional outpatient individual or group visits One inpatient day equals
two outpatient visits The maximum number of inpatient days that may be converted is five 5

Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy
will be dispensed in accordance with the Plan's drug formulary for up to a 30 day supply 240
Milliliters of liquid 8 oz 60 grams of ointment creams topical preparation or one
commercially prepared unit e g one inhaler one vial of ophthalmic medication or insulin You
pay a 5 copayment or 25 of the cost of the drug whichever is greater per prescription unit or
refill for generic drugs or for name brand drugs when generic substitution is not permissible
When generic substitution is permissible i e a generic drug is available and the prescribing
doctor does not require the use of a name brand drug but you request the name brand drug you
pay the price difference between the generic and name brand drug as well as the 5 copayment
or 25 of the cost of the drug whichever is greater per prescription unit or refill Nonformulary
drugs will be covered when prescribed by a Plan doctor Covered medications and accessories
include

Drugs for which a prescription is required by law
FDA approved prescription drugs and devices for birth control You pay 40 of charges for Norplant implantation and removal when authorized by the Plan

Insulin with a copayment charge applied to each vial
Maintenance drugs one copayment per 30 day supply

Smoking cessation drugs limited to Prostep Habitrol and Nicoderm patches Contact Plan for benefit restrictions and guidelines

Fertility drugs you pay 50 of charges
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin syringes needles glucose test tablets and test tape
Benedict's solution or equivalent and acetone test tablets

Intravenous fluids and medication for home use implantable drugs and some injectable
drugs such as Depo Provera are covered under Medical and Surgical Benefits

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Principal Health Care of Iowa Inc 2000
Section 5 Benefits continued
Limited Benefits Drugs to treat sexual dysfunction are limited You pay 5 copayment up to the dosage limits and all charges above that Covered dosage will be limited to 4 tablets per month

What is not covered Drugs available without a prescription or for which a non prescription equivalent is 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
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Nicorette Gum and Nicotrol 16
Appetite suppressants and other drugs to assist in weight control except for the treatment of morbid obesity when authorized by the Plan and primary care physician

Other Benefits
Dental Care The following preventive and diagnostic dental services are covered when provided by What is covered participating Plan dentists You pay a 25 deductible per member per calendar year

Oral examinations
X rays
Pulp vitality tests
Diagnostic casts
Prophylaxis cleaning
Flouride treatments

Accidential injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury Before services
are rendered for accidental dental benefits prior authorization must be obtained through
your primary care doctor and the Plan You pay 20 of reasonable and customary charges

What is not covered Dental services not shown above
Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases What is covered of the eye annual eye refractions which include the written lens prescription may be obtained
from Plan providers You pay nothing for services performed by an optometrist you pay a 15
copayment for services performed by an ophthalmologist

Coverage is provided for the first pair of glasses or the first pair of contact lenses following
cataract surgery No coverage is provided for replacements You pay 20 of eligible expenses

What is not covered Corrective eyeglasses and contact lenses including the fitting of contact lenses except following cataract surgery
Eye exercises

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Principal Health Care of Iowa Inc 2000
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 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
deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedure

1 Discounts on eyeglasses and contacts Principal Health Care of Iowa Inc members receive a discount on their
contacts or eyeglasses at the following participating optometric locations J C Penney Optical Sears Optical
Montgomery Ward Optical Target and Pearl Vision

2 The Baby Beeper Program During the last four weeks of pregnancy Principal Health Care of Iowa members
in the Des Moines area are provided a free baby beeper so that husbands or birthing coaches can be contacted
immediately when labor begins

3 Health Club Discount Program Fitness World West waives enrollment fees and offers a reduced monthly rate to
Principal Health Care of Iowa members

Benefits on this page are not part of the FEHB contract
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Principal Health Care of Iowa Inc 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 or eligible self referred services
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

Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage coverage You must tell us if you or a family member has double coverage You must also send us
documents about other 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 Association 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 beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary
care

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Principal Health Care of Iowa Inc 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures

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 primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers compensation We do not cover services that
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 Government We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for

If you have a If you have a malpractice claim because of services you did or did not receive from a plan malpractice claim provider it must go to binding arbitration Contact us about how to begin our binding arbitration
process

Section 8 FEHB Facts
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out about care 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 800 257 4692 or write to Principal Health Care of Iowa Inc 4600 Westown
Parkway Suite 200 West Des Moines IA 50266 1099 You may also contact us by fax at 515 223 0097 or visit our website at
http www phcia cvty com or www cvty com

Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal about enrolling in the FEHB Employees Health Benefits Plans brochures for other plans and other materials you need to
Program make an informed decision about
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

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Principal Health Care of Iowa Inc 2000
Section 8 FEHB Facts continued
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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan your and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1

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

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

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after 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 claims We will keep your medical and claims information confidential Only the following will have records confidential access to it
OPM this Plan and subcontractors when they administer this contract 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

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 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 paid a Your old plan's deductible continues until our coverage begins deductible under my
old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

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Principal Health Care of Iowa Inc 2000
Section 8 FEHB Facts continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this Your enrollment ends unless you cancel your enrollment or

Plan ends You or a family member are no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

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

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage 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 32nd 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

How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
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

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Principal Health Care of Iowa Inc 2000
Section 8 FEHB Facts
How can I convert to You may convert to an individual policy if individual coverage Your coverage under TCC or the spouse equity law ends
If you canceled your coverage or did not pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law
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 get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when
Health Plan Coverage getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
limitations or exclusions for health related conditions based on the information in the certificate
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

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 800 257 4692 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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Principal Health Care of Iowa Inc 2000
Notes

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Principal Health Care of Iowa Inc 2000
Notes

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Principal Health Care of Iowa Inc 2000
Summary of Benefits for Principal Health Care of Iowa Inc 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 nothing .10
Extended care All necessary services for up to 62 days per calendar year You pay nothing .10
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of conditions inpatient care per calendar year You pay 20 of the facility and supply charges .12

Substance Treatment of alcoholism drug addiction and drug abuse for up to 30 days of abuse inpatient care per calendar year You pay 20 of the facility and supply charges .13
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 checkups
and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay for a primary care physician visit a 15 copay for a specialist's
office visit and a 10 copay per house call by a primary care physician .7
Home health All necessary visits by nurses and health aides You pay nothing .7 care

Mental Up to 30 individual or 45 group outpatient visits per year You pay a 15 copay per conditions visit .12
Substance Up to 30 individual or 45 group outpatient visits per calendar year You pay a 15 abuse copay per visit For medically necessary outpatient detoxification you pay a 10
copay per visit .13
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay or 50 of the charges whichever is less to the
hospital for each emergency room visit or a 30 copay for an urgent care center visit within the Services Area and any charges for services that are not covered benefits
of this Plan Outside the Service Area you pay 50 or 50 of charges whichever is less for both emergency room and urgent care center visits .10

Prescription drugs Generic drugs prescribed by a Plan doctor are dispensed according to the Plan's formulary Non formulary drugs will be dispensed when approved in advance by the
Plan You pay a 5 copay or 25 of the cost whichever is greater per prescription unit or refill plus the difference in cost for name brand drugs you request For
fertility drugs you pay 50 of the charges .13
Dental care Accidental injury benefit you pay 20 of reasonable and customary charges Preventive dental care you pay a 25 deductible per member per calendar year .14

Vision care One refraction annually You pay nothing to optometrist a 15 copay for an ophthalmologist visit .14
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 750 per Self Only or 1,500 per Self and Family
enrollment per calendar year covered benefits will be provided at 100 .4

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Authorized for distribution by the
United States Office of Personnel Management

2000 Rate Information for
Principal Health Care of Iowa 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 determine 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

Wichita Salinas Central Kansas areas
Self Only SV1 62.99 20.99 136.47 45.49 74.53 9.45 74.53 9.45

Self and Family SV2 170.09 56.70 368.54 122.84 201.28 25.51 201.02 25.77

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