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Intergroup of Arizona Inc 2000
A Health Maintenance Organization

For changes Enrollment in this Plan is limited see page 6 for requirements
in benefits 5
see page

Enrollment code
A71 Self Only
A72 Self and Family

This plan received commendable accreditation
from the NCQA See the FEHB Guide
for more information on NCQA

Visit the OPM website at http www opm gove insure
and
this Plan's website at http www INTERGROUPOFARIZONA com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service
RI 73 283 1
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Intergroup of Arizona Inc HMO 2000
Table of Contents
Table of Contents 1
Introduction 2
Plain Language 2
How to Use This Brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How We Change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 10
Section 5 Benefits 12
Section 6 General Exclusions Things we don't cover 22
Section 7 Limitations Rules that affect your benefits 23
Section 8 FEHB Facts 25
Inspector General Advisory Stop Health Care Fraud 29
Summary of Benefits for Intergroup of Arizona Inc HMO 2000 30
Premiums Back Cover

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Intergroup of Arizona Inc HMO 2000
Introduction
Intergroup of Arizona Inc 930 North Finance Center Drive Tucson AZ 85710 1362
This brochure describes the benefits you can receive from Intergroup of Arizona Inc HMO under its contract
CS2121 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 5 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 Intergroup of Arizona 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 rewritten the Benefits section of this brochure You will find new benefits language next year

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Intergroup of Arizona Inc HMO 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

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Intergroup of Arizona Inc HMO 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

You will not have to submit claim forms or pay bills However when you receive services 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

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Intergroup of Arizona Inc HMO 2000
Section 2 How We Change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for
changes all primary care office visits

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

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 8 6 for Self Only or 8 6
Plan for Self and Family

Up to a three month supply of prescription drugs is available through the mail order
prescription program for three copayments in accordance with plan quantity limits

Prescription drugs will be dispensed as follows You pay a 5 copay for generic
formulary drugs and a 10 copay for name brand formulary drugs See pages 18
19 for details

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Intergroup of Arizona Inc HMO 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our
service area providers practice Our service area is Cochise Coconino Gila Maricopa Pima Pinal and Santa Cruz counties

You may also enroll with us if you live or work in the following places the Tucson
Phoenix Sierra Vista Flagstaff Casa Grande and Nogales City areas

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 they are preauthorized

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
for services dollar amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for

After you pay 3,395.08 in copayments or coinsurance for one family member or
9,845.16 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 prescription drugs dental
services or non FEHB 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 submit You normally won't have to submit claims to us unless you receive emergency
claims services from a 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 There are multiple locations throughout Maricopa County Pima County Cochise
health care County Coconino County Gila County Pinal County and Santa Cruz County serving Intergroup members When you enroll you must select a primary care

doctor for yourself and eligible family members Each member may choose a
different primary care doctor Intergroup of Arizona contracts with Medical
Groups to provide medical care The Medical Group determines the group of
specialist s and hospital s that are available

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Intergroup of Arizona Inc HMO 2000
How to get benefits continued
The first and most important decision each member must make is the selection of a
primary care doctor The decision is important since it is through this doctor that
all other health services particularly those of specialists are obtained It is the
responsibility of your primary care doctor to obtain any necessary authorizations
from the Plan before referring you to a specialist or making arrangements for
hospitalization Services of other providers are covered only when there has been a
referral by the member's primary care doctor with the following exceptions a
woman may see her Medical Group Plan obstetrician gynecologist without a
referral and a member who is diabetic may see a Medical Group Plan affiliated
opthamologist for an annual eye examination to detect eye disease without a
referral

What do I do if my Call us We will help you select a new one The Plan's provider directory lists
primary care primary care doctors generally family practitioners pediatricians internists with
physician leaves the their locations and phone numbers and notes whether or not the doctor is accepting
Plan new patients Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at

800 289 2818 or 520 721 4444 You can also find out if your doctor participates
with this Plan by calling this number If you are interested in receiving care from a
specific provider who is listed in the directory call the provider to verify that he or
she still participates with the Plan and is accepting new patients Important note
When you enroll in this Plan services except for emergency benefits are provided
through the Plan's delivery system the continued availability and or participation of
any one doctor hospital or other provider cannot be guaranteed

If you enroll you will be asked to let the Plan know which primary care doctor s
you've selected for you and each member of your family by sending a selection
form to the Plan If you need help choosing a doctor call the Plan Members may
change their doctor selection by notifying the Plan 30 days in advance

If you are receiving services from a doctor who leaves the Plan the Plan will pay
for covered services until the Plan can arrange with you for you to be seen by
another participating doctor

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

What do I do if I'm First call our customer service department at 800 289 2818 If you are new to the
in the hospital when FEHB Program we will arrange for you to receive care If you are currently in the
I join this Plan FEHB Program 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 Your primary care physician will arrange your referral to a specialist with the
specialty care following exceptions A woman may see her Medical Group Plan obstetrician gynecologist without a referral and a member who is diabetic may see

a Medical Group Plan affiliated ophthalmologist for an annual eye examination to
detect eye disease without a referral

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Intergroup of Arizona Inc HMO 2000
How to get benefits continued
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 The physician may have to get an authorization or approval
beforehand

What do I do if I am Your primary care physician will decide what treatment you need If they decide to
seeing a specialist refer you to a specialist ask if you can see your current specialist If your current
when I enroll 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 my Call your primary care physician who will arrange for you to see another specialist
specialist leaves the You may receive services from your current specialist until we can make
Plan 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
serious illness and able to continue seeing your provider for up to 90 days after we notify you that we
my provider leaves are terminating our contract with the provider unless the termination is for cause
the Plan or this Plan If you are in the second or third trimester of pregnancy you may continue to see
leaves the Program your OB GYN until the end of your postpartum 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
medical services you to a 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

Usually your primary care physician PCP can perform the medical care you
require but from time to time your PCP may want you to see a specialist or
undergo tests or procedures that can't be performed in his or her office These are
considered specialized services and may require prior approval from Intergroup

There are two types of prior approvals They are called either an authorization or a
referral

Certain tests or procedures require an authorization These are usually services that
a PCP can't do in his or her office Some examples would be surgeries MRIs or
other specialized tests When your PCP feels that you may need such a test or
procedure he or she will submit a request for an authorization

If you need to see a doctor or provider other than your PCP a referral is required
This is usually when you need to consult a specialist in a particular field such as
cardiology When your PCP feels that you may need to see a specialist he or she
will submit a request for a referral

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Intergroup of Arizona Inc HMO 2000
How to get benefits continued
Most PCPs will submit the request for an authorization or referral directly to
Intergroup

Note visits to ob gyn doctors never require a referral

Easy access rapid access program Because we want your healthcare to be easy
and convenient we have developed an easy access rapid access request program
PCPs who are part of this program can give you a direct writing referral or
authorization This allows you to see certain specialist or get certain tests without
any prior approval This could include an initial consultation or evaluation
diagnostic tests and same day treatment

If the specialist you need to see or the test or procedure you need done is not
eligible for an easy access rapid access referral or authorization as described
above the following process will occur

Your PCP will submit the request to Intergroup Once we receive the request our medical staff will review it They review the treatment plan
covered benefits medical history and national treatment standards
If a request is denied it will automatically proceed to one of our doctors for review he or she will either support the decision for denial or approve the

care requested
If the case or treatment is complex we may ask for an outside review from non Intergroup doctors who are experts in the field of care requested If

these doctors recommend the care it will be approved
If a case involves new medical technology our doctors may review current medical literature and or consult with medical experts Our doctors will use

this information to decide if the care requested is appropriate
Remember your PCP must coordinate all your medical care except for
emergencies If you need specialty care your PCP will determine the most
appropriate specialists based on your medical condition If you go to a specialist
or receive a service without prior authorization the services you receive will not be
covered by your Intergroup health plan

How do you decide if Our parent company Foundation Health Systems FHS has a technology
a service is assessment policy committee whose sole function is to evaluate if a drug device
experimental or medical treatment or procedure is experimental or investigational FHS bases its
investigational determination on one or more of the following

Is it broadly accepted in the medical community as standard safe and effective for the illness or injury being treated

Is it approved for use by the appropriate governmental regulatory bodies including the FDA
Is it attainable in the U S outside of a research institution program or protocol Does it clearly improve the net health outcome as evaluated against
non experimental or non investigation health care services using credible and
accepted medical evidence

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

What if I have a Call us at 800 289 2818 and we will expedite our review
serious of life
threatening condition
and you haven't
responded to my
request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim
denied my request we will inform OPM so that they can give your claim expedited treatment too
for care and my Alternatively you can call OPM's health benefits Contract Division 3 at 202 606
condition is serious 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that
or life threatening may cause permanent loss of bodily functions or death if they are not treated as soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after
limits we uphold our initial denial or refusal of service You may also ask OPM to review your claim if

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

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Intergroup of Arizona Inc HMO 2000
What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the
OPM following information

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 the Those who have a legal right to file a disputed claim with OPM are
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 Send your request for review to Office of Personnel Management Office of
my disputed claim to Insurance Programs Contract Division 3 P O Box 436 Washington D C 20044
OPM

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees
the Plan's denial with our 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 Federal law governs your lawsuit benefits and payment of benefits The Federal
file a lawsuit court will base 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
Privacy Act collects from 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

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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits
you pay a 10 office visit copay 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 10 copay for a doctor's house call nothing for home visits
by nurses and health aides

The following services Preventive care including well baby care and periodic check ups
are included 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 and above one
mammogram every year 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 including laboratory tests and X rays Complete obstetrical maternity care for all covered females including
prenatal delivery and postnatal care by a Plan doctor Female members who
have tested positive for pregnancy may self refer to an obstetrician within
their Medical Group 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 who requires definitive
treatment will be covered only if the infant is covered under a Self and
Family enrollment

Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye

Vision screening and examinations Allergy testing and treatment including testing and treatment materials such
as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints

Non experimental transplants including cornea heart heart lung lung single and double kidney kidney pancreas and liver 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 Donor searches for bone
marrow transplants will be covered Coverage for donor searches is provided
for up to 5,000 per organ per lifetime Related medical and hospital
expenses of the donor are covered when the recipient is covered by this Plan

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
Dialysis to include a maximum of six 6 out of area dialysis treatments per Plan Year are covered provided the Member has preauthorization by the
Medical Group and an Intergroup Medical Director
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity

Prosthetic devices which include artificial limbs and eyes breast prostheses and surgical bras as well as their replacement The first pair of contact
lenses or corrective lenses following cataract surgery treatment of
keratoconus aphacia or corneal transplantation the plan will also pay up to
75 towards the cost of a frame

Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically

review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from
Plan doctors and other Plan providers at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate
and for medical or surgical procedures occurring within or adjacent to the oral
cavity or sinuses including but not limited to treatment of fractures and excision of
tumors and cysts All other procedures involving the teeth or intra oral areas
surrounding the teeth are not covered including any dental care involved in the
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

Orthopedic devices such as braces and durable medical equipment such as
manual wheelchairs and hospital beds are covered for the initial device Repair and
replacement are not covered You pay nothing

Short term rehabilitative therapy physical speech and occupational 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 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

Cardiac rehabilitation following a heart transplant bypass surgery or a
myocardial infarction is provided as medically appropriate you pay a 10
copayment per outpatient session

Surgical implantation of time released hormonal drugs such as Norplant is
covered you pay 50 for all services The benefit is limited to one 1 implant in
any three 3 year period There will be no refund of this copayment if the
implanted time release hormonal drug is removed before the end of its expected
life One 1 non medically necessary time release hormonal implant removal in
any three 3 year period you pay nothing

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
Diagnosis and treatment of infertility is covered you pay 50 The following
types of artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI you pay 50
Cost of donor sperm is not covered Fertility drugs are not covered Other assisted
reproductive technology ART procedures such as in vitro fertilization and
embryo transfer are not covered

What is not covered Physical examinations immunizations or medications that are not necessary for medical reasons such as those required for obtaining or continuing
employment or insurance attending school or camp or travel
Forms of holistic treatment or alternative therapies Reversal of voluntary surgically induced sterility

Surgery primarily for cosmetic purposes Hearing aids
Chiropractic services Homemaker services
Long term rehabilitative therapy Foot orthotics
Repairs to or replacement of initial prosthetic devices except for replacement due to a change in physical condition

Hospital Extended Care Benefits
What is covered

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

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

Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit 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 a 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor
procedures determines there is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the

professional dental services Conditions for which hospitalization would be
covered include hemophilia and heart disease the need for anesthesia by itself is
not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency
detoxification care diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that

outpatient management is not medically appropriate See page 17 for nonmedical
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
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability and requires immediate medical or surgical care Some problems
are emergencies because if not treated promptly they might become more serious examples include deep cuts and
broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes
poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action Emergency services
include an initial medical screening examination and any immediate necessary stabilization treatment or services

Emergencies within If you are in an emergency situation please contact your doctor the local
the service area 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 should notify the
Plan within 48 hours unless it was not reasonably possible to do so Coverage for
emergency care includes an immediate screening examination and any initial
stabilization services These services do not require precertification or
preauthorization in order to be covered 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
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 health

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 visit or non Plan urgent care center visit 10 per visit to Plan doctors or Plan urgent care centers for emergency services that are
covered benefits of this Plan

Emergencies outside Benefits are available for any medically necessary health service that is immediately
the service area required because of injury or unforeseen illness

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

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

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

You pay 50 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan
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

What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

Filing claims for nonWith your authorization the Plan will pay benefits directly to the providers of your
Plan providers emergency care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit

itemized bills and your receipts to the Plan along with an explanation of the services
and the identification information from your ID card Payment will be sent to you
or the provider if you did not pay the bill unless the claim is denied If it is
denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with
the Plan's decision you may request reconsideration in accordance with the
disputed claims procedure described on pages 10 11

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
Mental conditions

What is covered Mental Health Benefits must be preauthorized by Catalina Behavioral Health Services in order to be covered To access available benefits you must contact
Catalina Behavioral Health Services at 800 977 0281 To the extent shown below
the Plan provides the following services necessary for the diagnosis and treatment
of acute psychiatric conditions including the treatment of mental illness or
disorders

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

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 15 copay for each individual therapy
session a 7.50 copay for each group therapy session all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year this may include partial hospitalization If partial hospitalization is provided the benefit will be exchanged
as two partial hospitalization days equal to one inpatient day you pay nothing for
the first 30 days all charges thereafter

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

appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including
alcoholism and drug addiction the same as for any other illness or condition and to
the extent shown below the services necessary for diagnosis and treatment

Outpatient care All necessary visits to Plan providers for treatment you pay nothing

Inpatient care Lifetime maximum of two substance abuse rehabilitation intermediate care programs in an Alcohol Detoxification or Rehabilitation Center approved by the
Plan you pay nothing during the benefit period all charges thereafter

What is not covered Treatment that is not authorized by a Plan doctor Substance Abuse services on court order or as a condition of parole or
probation unless determined by a Plan doctor to be necessary and
appropriate

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply or commercially prepared
unit You pay a 5 copay per prescription unit or refill for generic medications and
a 10 copay for name brand medications when a generic equivalent is not available
When a generic equivalent is available but your Plan doctor prescribes a name
brand drug and the Plan determines the name brand drug is medically indicated
you pay a 10 copay per prescription unit or refill When a generic equivalent is
available but you request the name brand drug you may be responsible for the price
difference between the generic and name brand medications in addition to your
brand name copay

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's
drug formulary The Plan's formulary offers a variety of drug choices in each
therapeutic category However due to individual patient variability a nonformulary
drug may be required When non formulary drugs are required a simple
process exists whereby a physician may request a patient specific authorization
Each request for a non formulary drug is evaluated to determine if it meets standard
approval criteria established by the Intergroup Pharmacy and Therapeutics
Committee

Covered medications Drugs for which a prescription is required by Federal law
and accessories Oral contraceptive drugs contraceptive diaphragms
include Contraceptive devices for time release hormonal drugs such as Norplant please refer to Medical Surgical Benefits on page 13

Inhalers 2 per copay Holding chambers 1 per 6 months

Insulin 2 vials per copay Disposable needles and syringes needed to inject covered prescribed
medication are covered up to a one hundred 100 unit supply per copay
Diabetic supplies including lancets 100 unit supply and glucose test strips 100 unit supply when submitted on a written prescription

Self indictable drugs other than insulin when preauthorized by plan Intravenous fluids provided please refer to medical surgical benefit on page
13

Mail Order Order up to a three month supply at one time for three copayments in accordance
Prescription Drug with plan quantity limits Convenient refills by phone All eligible FEHB members
Program and dependents are covered Formulary medications dispensed through the Plan's Mail Order Prescription Provider To request a Registration and Prescription order

form or to receive additional assistance call Intergroup Member Services at
800 289 2818

Limited benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies Anorexiants appetite suppressants diet aids weight loss medications and
drugs used to treat obesity

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
18 19
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Intergroup of Arizona Inc HMO 2000
Section 5 Benefits continued
Medical supplies such as dressings and antiseptics Fertility drugs
Vitamins except Prenatal Nutritional replacements and dietary supplements
Drugs for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medications Any drug consumed at the place where it is dispensed or that is dispensed or
administered by the physician
Drugs prescribed for non covered services Take home drugs drugs prescribed for use after discharge from a hospital

nursing home skilled nursing facility or other inpatient facility must be
obtained from a participating pharmacy

Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace
benefit sound natural teeth the jawbone and supporting tissues are covered does not include injury caused by the act of chewing The need for these services must

result from an accidental injury You pay nothing

What is not covered Other dental services not shown as covered including dental splints and dental prosthesis

Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye

A comprehensive vision examination once every 12 months you pay nothing One pair of standard single vision bifocal or trifocal lenses once every 24
months one frame within Plan allowance once every 24 months you pay a
10 copayment for materials The Plan contains a limit on the cost of frames
If the wholesale price of the frame exceeds the Plan's frame allowance you
will pay a designated amount based on the difference between the wholesale
price and the Plan's frame allowance

Elective contact lenses once every 24 months you receive a 100 allowance toward the cost of fitting evaluation and the contacts lenses contact lenses

are in lieu of an examination spectacle lenses and a frame

What is not covered Orthoptics or vision training Subnormal vision aids
Plano non prescription lenses Two pair of lenses in lieu of bifocals
Replacement of lenses or frames which are lost or broken is not covered except when the member is normally eligible for services

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
ALL VISION SERVICES ADMINISTERED BY IVS PLEASE CALL 800 443 4994 x 410

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Intergroup of Arizona Inc HMO 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 Program
but are made available to all enrollees and family members of this Plan The cost of the benefits described on this
page is not included in the FEHB premium and any charges for these services do not count toward any FEHB
deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure

Available in all Intergroup has added The WellRewards Program a discount program offered to
service areas all Intergroup members Intergroup has been able to negotiate reduced prices and excellent values on a number of products and services including

Eyewear Discounts Massage Therapy Health Club Discounts Chiropractic Care
Home Fitness Products Hearing Aids Member Classes and Seminars Home Medical Equipment Supplies
Mom Baby Basics Program Vitamins Herbs and Supplements Routine Podiatry Emergency Medical Record Service
Home Protection Service
Sports Helmet Rebates Heads up Intergroup will rebate 25 for sports helmets
of all kinds Now bicyclists rock climbers motorcyclists horseback riders and
other avid sports enthusiasts can buy industry approved protective helmets and
receive an Intergroup rebate
Car Seat Rebates Helping you keep your child safe while riding in the car is our
concern as well as yours Intergroup offers a rebate of up to 25 on the purchase of
a child car seat for each child UNDER AGE 5 covered by your Intergroup plan
Baby Beepers If you're an expectant parent Intergroup offers you the free use
of a digital pager during the last month of pregnancy Our Baby Beeper makes it
easy to keep in touch with important people during this special time

Available in Eyewear Discounts Now you can see even more savings As an Intergroup
participating service member you'll receive discounts on frames lenses and contacts Call Member
areas Services for optical shops in your area that offer an Intergroup discount

As an Intergroup member you'll automatically be eligible for Intergroup's Dental
Program which is administered by Protective Dental As a member of Protective
Dental you choose a general dentist from the Protective Dental participating
provider listing See the Protective Dental pamphlet for benefit details

If you have any questions or would like more information on the extra benefits listed please call an Intergroup
Member Service representative at 800 289 2818 or 520 721 4444

Medicare Prepaid Plan Enrollment
This Plan offers Medicare recipients the opportunity to enroll in the plan through Medicare As indicated on page
23 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage
and enroll in a Medicare prepaid plan when one is available in their area They may then later re enroll in the FEHB
Program Contact your retirement system for information on dropping your FEHB enrollment and changing to a
Medicare prepaid plan Contact us at 1 800 289 2818 or 520 721 4444 for information on the Medicare prepaid
plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without
dropping your enrollment in this Plan's FEHB plan call the numbers above for information on the benefits available
under the Medicare HMO

Benefits on this page are not part of the FEHB contract

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Intergroup of Arizona Inc HMO 2000
Notes

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Intergroup of Arizona Inc HMO 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 Services drugs or supplies that are not medically necessary
following 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

22 23
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Intergroup of Arizona Inc HMO 2000
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 800 638 6833 For
information on the Medicare Choice plan offered by this Plan see page 20

Other group When anyone has coverage with us and with another group health plan it is called
insurance double 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
coverage 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
our control be unable to provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for
responsible for injuries or illness that another person caused you must reimburse us for whatever
injuries 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

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Intergroup of Arizona Inc HMO 2000
Section 7 Limitations Rules that affect your benefits continued
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 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 Government Agencies

Other We do not cover services and supplies that a local State or Federal Government
Government agency directly or indirectly pays for
agencies

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Intergroup of Arizona Inc HMO 2000
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which
information about gives you the right to information about your health plan its networks providers
your HMO 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 800 289 2818 or write to Intergroup
of Arizona 930 North Finance Center Drive Tucson AZ 85710 1362 You may
also contact us by fax at 1 520 733 5541 or visit our website at
www intergroupofarizona com

Where do I get Your employing or retirement office can answer your questions and give you a
information about Guide to Federal Employees Health Benefits Plans brochures for other plans and
enrolling in the other materials you need to make an informed 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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan
and premiums your coverage and premiums begin on the first day of your first pay period that
effective 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
retire have been enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of

coverage such as Temporary Continuation of Coverage which is described later in
this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your
coverage are available spouse and your unmarried dependent children under age 22 including any foster
for my family and or step children your employing or retirement office authorizes coverage for
me 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

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Intergroup of Arizona Inc HMO 2000
Section 8 FEHB Facts continued
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
claims records will have access to it
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 coordinating
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

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

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium
enrollment in this when
Plan ends Your enrollment ends unless you cancel your enrollment or

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

26 27
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Intergroup of Arizona Inc HMO 2000
Section 8 FEHB Facts continued
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to
coverage get benefits 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 If you leave Federal service your employing office will notify you of your right to
TCC 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

27 28
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Intergroup of Arizona Inc HMO 2000
Section 8 FEHB Facts continued
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 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 get a If you leave the FEHB Program we will give you a Certificate of Group Health
Certificate of Group Plan Coverage that indicates how long you have been enrolled with us You can
Health Plan use this certificate when getting health insurance or other health care coverage
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

28 29
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Intergroup of Arizona Inc HMO 2000
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 800 289 2818 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

29 30
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Intergroup of Arizona Inc HMO 2000
Summary of Benefits for Intergroup of Arizona Inc HMO 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 PHYSICIANS

Benefits Plan pays provides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or
day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operation room
intensive care and complete maternity care You pay nothing 14 15

Extended Care All necessary services no dollar or day limit You pay nothing 14
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days if
Conditions inpatient care per year this may include partial hospitalization If partial
hospitalization is provided the benefit will be exchanged as two partial
hospitalization equal to one inpatient day You pay nothing 17

Substance Abuse Up to a maximum of two substance abuse treatment programs per lifetime
You pay nothing 17

Outpatient Comprehensive range of services such as diagnosis and treatment of illness
care or injury 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 10 per office visit 10 per
house call by a doctor 12

Home health All necessary visits by nurses and health aides You pay nothing 13
care

Mental Up to 20 outpatient visits per year You pay a 15 copay per visit for
conditions individual therapy sessions a 7.50 copay for group therapy sessions 17

Substance abuse All necessary outpatient visits You pay nothing 17
Emergency Reasonable charges for services and supplies required because of a
Care medical emergency You pay a 50 copay to the hospital for each emergency room visit and any charges for services that are not covered by

this Plan 15 16
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You
drugs pay a 5 copay per generic prescription unit or refill 10 copay per name brand prescription unit or refill 18 19

Dental care Accidental injury benefit you pay nothing 19
Vision care Comprehensive examination once every 12 months you pay nothing Lenses and or frames once every 24 months you pay 10 copay for

materials Elective contact lenses once every 24 months 100 allowance
provided toward cost of contacts evaluation and fitting 19

Out of pocket Copayments are required for a few benefits however after your out of
maximum pocket expenses reach a maximum of 3,395.08 per Self Only or 9,845.16 per Self and Family enrollment per calendar year covered

benefits will be provided at 100 The copay maximum does not include
charges for prescription 6
drugs

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Intergroup of Arizona Inc HMO 2000
2000 Rate Information for
Intergroup of Arizona 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 Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

Self Only A71 59.93 19.98 129.86 43.28 70.92 8.99 70.92 8.99
Self and Family A72 161.77 53.92 350.50 116.83 191.42 24.27 191.42 24.27

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