Pages 1--23 from 4329 FEHB 2000 READ

Enrollment code 7P1 Self Only
7P2 Self and Family

HMO POS
This plan was awarded a Commendable Accreditation for its HMO POS

products from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure and
our website at http www pplusic com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service RI73 559 1
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Physicians Plus HMO 2000
Table of Contents

Page
Introduction 2

Plain language 2
How to use this brochure 2
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 8
Section 6 General exclusions Things we don't cover 15
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

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Physicians Plus HMO 2000
Introduction
Physicians Plus Insurance Corporation 22 E Mifflin Street Suite 200
Madison WI 53703
This brochure describes the benefits you can receive from Physicians Plus HMO under its contract CS 2622 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 Physicians Plus 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

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
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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Physicians Plus 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 preventive
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

Any treatment services supplies provided by a physician hospital or other healthcare provider without precertification except as specifically stated in the benefits provision will not be covered Benefits for treatment services supplies not specifically addressed
in this brochure will be administered according to the terms and conditions of our plan's Medical Plan Certificate

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for 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 Plan Your share of the non postal premium will increase by 12.7 for Self Only or 19.1 for Self and Family
The primary care and specialty care office visit copay will increase from 0 to 10 children ages 0 17 are covered in full except for hearing and vision office visits see page 8
The copayment for prescription drugs will increase from 5 to 6 for generic and from 10 to 12 for brand name drugs See page 14

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Physicians Plus HMO 2000
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 consists of the following Wisconsin counties Columbia Dane Dodge Iowa
Jefferson Juneau Lafayette Marquette Milwaukee Ozaukee Richland Rock Sauk Walworth Washington and Waukesha

Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care benefits We will not pay for any other
health care services out of area unless you receive Plan approval
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area 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 20 coinsurance up to 1,000 per member per calendar year for durable medical equipment prosthetic and orthopedic devices and medical supplies you do not have to make any
further payments for these services for the rest of the year This is called a catastrophic limit Additional copayments or coinsurance for your prescription drugs emergency room visits mental
conditions substance abuse and hearing aids 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 claims You normally won't have to submit claims to us unless you receive emergency 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 within 120 days of the date you received the service Either OPM or we can extend this deadline up to an additional year if you show that
circumstances beyond your control prevented you from filing on time
Who provides Physicians Plus HMO is made up of over 1900 Primary and Specialty physicians in southeastern my health care and southcentral Wisconsin communities As a member of Physicians Plus HMO you will be
required to select a primary care physician PCP The services of physicians other than those designated as the member's primary care doctor require a referral from the member's primary care
physician However a woman may see her gynecologist for a yearly routine visit without having to obtain a referral as long as the provider is in the same medical group or IPA as her PCP If there is
a situation where Physicians Plus HMO's physicians cannot provide the appropriate specialty services your Physicians Plus HMO physicians will refer you outside the network of providers These
services are covered only with an approved written precertification in advance of your appointment to a specialist outside of the network

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Physicians Plus HMO 2000
Any treatment services supplies provided by a physician hospital or other healthcare provider without precertification except as specifically stated in the benefits provision will not be covered
Benefits for treatment services supplies not specifically addressed in this brochure will be administered according to the terms and conditions of our plan's Medical Plan Certificate

What do I do if Call us You may be able to receive services from your current PCP for a limited period of time my primary care If not we will help you select a new PCP within our network
physician leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or to go into the hospital specialist will make the necessary hospital arrangements and supervise your care The plan may
use hospitals for outpatient services Some services such as inpatient hospitalization and outpatient surgery require precertification

What do I do if I'm in the First call our customer service department at 800 545 5015 or 608 282 8900 If you are new to the hospital when I join FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program
this 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 Your primary care physician will arrange your referral to a specialist specialty care
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan Referral to a participating specialist is
given at the primary care doctor's discretion if non Plan specialists or consultants are required the primary care doctor will arrange appropriate precertification that must be approved by the
Plan's Medical Director
When you receive a referral from your primary care doctor you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits All follow up care
must be provided or authorized by the primary care doctor Do not go to the specialist for a second visit unless your primary care doctor has arranged for and the Plan has issued an authorization for
the referral in advance
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll 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 us You may be able to receive services from your current specialist for a limited period of specialist leaves the Plan time If not call your primary care physician who will arrange for you to see another specialist in
our network

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Physicians Plus HMO 2000
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to a serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating
provider leaves the Plan our contract with the provider unless the termination is for cause If you are in the second or this Plan leaves or third trimester of pregnancy you may continue to see your OB GYN until the end of your
the Program 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 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 If authorization is not obtained you will be responsible for all costs It is important to talk with your PCP about the
authorization to understand what care you will receive and why
How do you decide if a The criteria that Physicians Plus HMO uses for determining whether or not drugs devices service is experimental treatment or procedures are experimental or investigational is based upon the judgment of the
or investigational medical director and must meet one of the following criteria
A Full and final approval has not been granted by the US Food and Drug Administration for the treatment of the patient's medical condition

B Specific Evidence shows that the drug device treatment or procedure is being provided subject to
1 A phase I or phase II clinical trial or the experimental arm of a phase III clinical trial
2 A protocol to determine the safety toxicity maximum tolerated dose efficacy or efficacy in comparison to the standard means of treatment or diagnosis or

3 A protocol approved by and under the supervision of an Institutional Review Board
C The published authoritative medical and scientific literature
1 Has not defined or supports further research to define the safety toxicity maximum tolerated dose efficacy or efficacy in comparison to the standard means of treatment or

diagnosis
2 Does not demonstrate clinically significant improvement in the efficacy or outcomes for the drug device treatment or procedure compared to standard drugs devices treatments

or procedures

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

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Physicians Plus HMO 2000
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 OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to 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 800 545 5015 or 608 282 8900 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 inform my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious health benefits Contract's Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or lifeor life threatening 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 You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We did 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 do 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

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

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Physicians Plus HMO 2000
Who can make the request Those who have a legal right to file a disputed claim with OPM are
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 mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contracts Division 3 P O Box 436 Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure

described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act 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 is provided by Plan doctors and other Plan Providers This includes all necessary office visits you pay a 10 office visit
copay but no additional copay for laboratory test and X rays You pay nothing for children's ages 0 17 office visits excluding vision and hearing exams 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 you pay nothing for children age's 0 17 or home visits
by nurses and health aides Physicians Plus HMO must approve home health visits You have up to 100 medically necessary home health visits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
Medical and The following services are included Surgical Benefits Preventive care including well baby care and periodic check ups
continued Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 through 49 one mammogram every one or two years for women age 50 through 64 one mammogram every year and for women age 65 and above

one mammogram every two years In addition to routine screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness

Routine immunizations and boosters
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 Copays are waived for maternity care The mother at her option

may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarian 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
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support

for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast
cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical Director
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
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics You pay 20 of charges up to a maximum of member out of pocket expenses of 1,000 per calendar year no coinsurance for these

charges will apply for the remainder of the calendar year once the out of pocket expense limit has been reached

Prosthetic devices such as artificial limbs and lenses following cataract removal and breast prostheses including the surgical bra for external prosthesis following a mastectomy and
including the necessary replacement prostheses and bra You pay 20 of charges up to a maximum of member out of pocket expenses of 1,000 per calendar year no coinsurance for
these charges will apply for the remainder of the calendar year once the out of pocket expense limit has been reached

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
Durable medical equipment such as wheelchairs and hospital beds and durable medical supplies You pay 20 of charges up to a maximum of member out of pocket expenses of 1,000 per
calendar year no coinsurance for these charges will apply for the remainder of the calendar year once the out of pocket expense limit has been reached

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 non dental 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 In accordance with Wisconsin Statutes we will pay benefits for medically indicated treatment of temporomandibular disorders including prescribed
intraoral splint therapy devices Covered diagnostic procedures and non surgical treatments are limited to 1,250 per Participant per calendar year We must precertify most services Plan
providers must provide services
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 their attending physician will decide whether or not to have breast reconstruction surgery following
a mastectomy including whether or not to have surgery on the other breast in order to produce a symmetrical appearance

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

Diagnosis and treatment of infertility is covered you 10 pay per office visit The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI are covered you pay 10 per office visit cost of donor sperm is not covered Fertility drugs are covered under the Prescription Drug Benefit Other
assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for up to 36 sessions per covered illness in a 12 consecutive week period if begun within
21 days of hospital confinement you pay nothing Benefits are not payable for behavioral or vocational counseling and maintenance cardiac rehabilitation No other benefits for outpatient cardiac
rehabilitation services are available from this Plan
Hearing aids One pair of the standard model is covered every 36 months You pay 50 of the charges

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
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
Surgery primarily for cosmetic purposes
Homemaker services
Transplants not listed as covered
Long term rehabilitative therapy

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 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 for up to 100 days per confinement
Prescription 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

Ambulance service Emergency use of ambulance transport is covered Non emergency ambulance transportation must be precertified by us

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover

the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care 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 14 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that requires medical emergency immediate medical or surgical care Some problems are emergencies because if not treated

promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings
gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for
quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies the service area 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 Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized in a non Plan facility 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 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
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan No urgent care center copay for children ages 0 17 If the
emergency results in admission to a hospital within 24 hours the 50 hospital copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan doctor believes care can be better provided in a Plan hospital you would 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 10 per urgent care center visit for emergency services that are covered benefits of this Plan No urgent care center copay for children ages 0 17 If the
emergency results in admission to a hospital within 24 hours the 50 hospital copay is waived

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
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 non emergency care including follow up 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 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
page 7

Mental Conditions Substance Abuse
Benefits
Mental conditions For referral you must call the appropriate Physicians Plus HMO mental health vendor For Southeastern Wisconsin call CNR Health Inc at 800 989 2792 or 414 327 0381 For Southcentral

Wisconsin call Mental Health Case Management and Consultation System at 800 683 2300 or 608 282 8960 Care must be obtained through referral prior to services being rendered This plan
will determine and authorize the appropriate number of visits A referral from your primary care physician is not required

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

Outpatient care Up to 30 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay nothing for the first 1,800 in charges per calendar year thereafter you pay 50 of charges for

the remainder of the calendar year or until the 30 visits limit has been reached You pay all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days You pay 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 relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the

same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Outpatient care Up to 30 combined mental conditions and substance abuse outpatient visits to Plan providers for treatment each calendar year you pay nothing for the first 1,800 in charges per calendar year
Thereafter you pay 50 of charges for the remainder of the calendar year until the 30 visit limit has been reached You pay all charges thereafter

Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the benefit
period You pay all charges thereafter
What is not covered Treatment that is not authorized by the Plan

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 30 day supply You pay a 6 copay per prescription unit or refill for generic

drugs and a 12 copay per prescription unit or refill for name brand drugs for up to a 30 day supply Inhalers are limited to two per copayment

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary A drug formulary is a list of approved drugs that are covered by the Plan You pay a 6 copayment
for generic or a 12 copayment for brand name drugs A panel of participating physicians and pharmacists selects drugs included on the formulary In the event the formulary alternative
is not appropriate for you your Plan doctor may request an exception to the formulary Once approved by our Medical Director non formulary FDA approved prescription drugs are available

Covered medications and accessories include
Drugs for which Federal Law requires a prescription
Oral contraceptive drugs contraceptive diaphragms
Fertility drugs you pay 50 of charges
Insulin you pay nothing for insulin Insulin is limited to two vials or a 30 day supply whichever is less per transaction

Disposable needles and syringes needed to inject covered prescribed medication including diabetic supplies you pay 20
Some smoking cessation medications including prescription nicotine patches an approved treatment program must be in place in order to be reimbursed Benefit is limited
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets you pay 20
Drugs to treat sexual dysfunction are limited Contact the plan for dose limits You pay 50 coinsurance

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Plus HMO 2000
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance

Other Benefits
Dental Care
What is covered Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury You pay nothing

Treatment must be completed within three months of the injury
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye annual eye refraction to provide a written lens prescription may be obtained

from Plan providers You pay 10 per office visit The first lens after cataract surgery per surgical eye is covered

What is not covered Corrective lenses frames or contact lenses and the fitting of contact lenses
Procedures to correct myopia hyperopia and astigmatism including but not limited to laser photo keratotomy laser keratectomy refractive keratoplasty radial keratectomy keratotomy

radial kertectomy excimer laser photo refractive keratectomy
Eye exercises

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

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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

Other group When anyone has coverage with us and with another group health plan it is called double insurance 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 payor 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 payor 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
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for injuries 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

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Physicians Plus HMO 2000
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 payor 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 We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for

Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also find
your HMO 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 800 545 5015 or 608 282 8900 or write to us at P O Box 2078 Madison WI 53701 2078 You may also contact us by fax at 608 260 7367 or

visit our website at www pplusic com
Information that must be made available to you includes
The Plan's FEHB plan disenrollment rate for 1998 was 2.6
Primary Care Physicians
Specialty Care Providers
Physicians Plus HMO is in compliance with all State requirements from the Wisconsin Office of Commissioners Insurance

This Plan is a for profit corporation and has been in existence with FEHB since 1991
This Plan meets State Federal and accreditation requirements for fiscal solvency confidentiality and transfer of medical records

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

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Physicians Plus HMO 2000
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums effective 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 you retire you can usually stay in the FEHB Program Generally you must have been when I 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for my unmarried dependent children under age 22 including any foster or step children your employing
family and me 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 We will keep your medical and claims information confidential Only the following will have claims records 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 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 deductible Your old plan's deductible continues until our coverage begins 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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Physicians Plus HMO 2000
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 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

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse 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 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 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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Physicians Plus HMO 2000
How can I convert You may convert to an individual conversion policy if to 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 Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage of Group Health Plan that indicates how long you have been enrolled with us You can use this certificate when getting
Coverage 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 800 545 5015 or 608 282 8900 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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Physicians Plus HMO 2000
Summary of Benefits for Physicians Plus 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 DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day care limit Includes in hospital doctor care room and board general nursing care
private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete
maternity care You pay nothing 11
Extended Care All necessary services for up to 100 days per member per confinement no dollar limit You pay nothing 11

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 13
Substance Abuse Up to 30 days of inpatient care per year in a substance abuse treatment program You pay nothing 14
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or Care 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 for office visit or house call by a doctor
You pay nothing for children ages 0 17 You pay 10 per office visit for all hearing and vision exams 8 11

Home Health Care All necessary visits by nurses and health aides 100 visits You pay nothing 10
Mental Conditions Up to 30 outpatient visits per year You pay 50 of charges over 1,800 13
Substance Abuse Up to 30 outpatient visits per year You pay 50 of charges over 1,800 14
Emergency Reasonable charges for services and supplies required because of a medical care 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 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 6 copay per prescription unit or refill for generic drugs 12 per prescription
unit or refill for brand name drugs 14
Dental care Accidental injury benefit you pay nothing 15
Vision care One refraction annually You pay 10 15
Out of pocket Your maximum out of pocket expenses for benefits under this Plan are limited to maximum the stated coinsurance required for a few benefits 4 22
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2000 Rate Information for Physicians Plus HMO
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 rates 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 7P1 76.94 25.64 166.70 55.56 91.04 11.54 91.04 11.54
Only

Self and 7P2 175.97 88.65 381.27 192.07 207.74 56.88 201.02 63.60
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