Pages 1--28 from RI73-583

Serving Northern Indiana
Enrollment in this Plan is limited see page 6 for requirements
Enrollment Code
DQ1 Self Only
DQ2 Self and Family

Visit the OPM Website at http www opm gov insure
Authorized for distribution by the
United States Office of Personnel Management

RI 73 583 1
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Physicians Health Plan of Northern Indiana 2000
Table of Contents Page
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6 8
Section 4 What to do if we deny your claim or request for service 8 10
Section 5 Benefits 10 17
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 18 19
Section 8 FEHB FACTS 19 22
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits 27
Premiums Back cover

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Physicians Health Plan of Northern Indiana 2000
Introduction
Physicians Health Plan of Northern Indiana Inc
8101 West Jefferson Boulevard Fort Wayne Indiana 46804 4163
Telephone 219 432 6690 Ext 11 or outside local calling area 800 982 6257 Ext 11 or
219 459 2600 for the Hearing Impaired

This brochure describes the benefits you can receive from Physicians Health Plan under its contract CS2648 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 Physicians Health Plan as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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Physicians Health Plan of Northern Indiana 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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Physicians Health Plan of Northern Indiana 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventative care
such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office
changes 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 don 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 premium will decrease by 9.4 for Self Only or 9.8 for Self and Family
There will be a 25 copay for non formulary drugs obtained at a pharmacy and a 50 non formulary copay
for drugs obtained by mail order

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Physicians Health Plan of Northern Indiana 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 The service area for this plan where Plan
service area providers and facilities are located are described as the counties below

Adams Allen Dekalb Jay Huntington Kosciusko LaGrange Noble Steuben Wabash Wells and Whitley

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
rendered outside the service area unless there is a Plan authorization made in advance

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

After You pay 500 in copayments or coinsurance for one family member or 1,500 per family 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 or durable medical equipment do not
count towards 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 services from a provider who
claims 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 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 Physicians Health Plan of Northern Indiana does not require you to choose one primary care doctor What
health care makes Physicians Health Plan of Northern Indiana special is that as a Plan member you will have the freedom to receive your medical care from any of the more than 777 private practice doctors in all specialties at more

than 291 locations In addition there are over 129 neighborhood participating pharmacies 17 participating
hospitals and over 9 urgent care facilities

What do I do if my Call us We will help you select a new one
primary care
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 specialist will
to go into the make the necessary hospital arrangements and supervise your care
hospital

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Physicians Health Plan of Northern Indiana 2000
What do I do if I'm in First call our Customer Service Department at 219 432 6690 Extension 11 If you are new to the FEHB
the hospital when I Program we will arrange for you to receive care If you are currently in the FEHB Program and are switching
join this Plan to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get specialty A wide range of specialty care doctors is available among the Plan's more than 777 participating doctors
care You do not need a referral from a primary care doctor to see a specialty care doctor under the Plan Consult the Plan Participating Directory or call the Customer Service Department at 219 432 6690 Extension 11

for a specialist near you

The Plan will approve referrals to non Plan providers for health services that are otherwise covered by this
Plan and are recommended by a Plan physician but are not available from Plan providers The member must
obtain all other related health services including prescription drugs from Plan providers according to the
terms of this brochure

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 specialist
seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us you must
when receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does
I enroll not participate with our Plan

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

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
serious illness and my your provider for up to 90 days after we notify you that we are terminating our contract with the provider
provider leaves the unless the termination is for cause If you are in the second or third trimester of pregnancy you may
Plan or this Plan continue to see your OB GYN until the end of your postpartum care
leaves the Program 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 for an inpatient stay referring you to a
medical services non participating physician or facility Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice

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Physicians Health Plan of Northern Indiana 2000
How do you decide if The Plan uses a variety of authoritative sources including governmental regulatory agencies scientific
a service is literature medical experts and other recognized authorities in the medical field to determine whether medical
experimental or procedures are experimental and or investigational
investigational

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

What if I have a Call us Physicians Health Plan at 800 982 6257 Extension 11 219 432 6690 Extension 11 or 219
serious or life 459 2600 for the Hearing Impaired and we will expedite our review
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 we will inform OPM so
denied my request for that they can give your claim expedited treatment too Alternatively you can call OPM's Health Benefits
care and my condition Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or life threatening conditions are
is serious or life ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
threatening

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Physicians Health Plan of Northern Indiana 2000
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial
limits 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 did not answer within 30 days In this
case OPM must receive your request within 120 days of the date we asked you for additional
information

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

brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical
records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make 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 mail Send your request for review to Office of Personnel Management Office of Insurance Programs Contract
my disputed claim to Division IV P O Box 436 Washington DC 20044
OPM

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your
the Plan's denial 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 court will base its review
file a lawsuit 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

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Physicians Health Plan of Northern Indiana 2000
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
Privacy Act determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of

Information Act and the Privacy Act OPM may disclose this information to support the disputed claim
decision If you file a lawsuit this information will become part of the court record

Section 5 BENEFITS
MEDICAL and SURGICAL BENEFITS

A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and
other Plan providers This includes all necessary office visits You pay a 10 office visit copay but no
additional copay for laboratory tests and X rays Within the service area house calls will be provided if in
the judgment of the Plan doctor such care is necessary and appropriate You pay nothing for a doctors
house call or for home visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 49 one mammogram every one or two years for women age 50 through 64
one mammogram every year and for women 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 office visit copays for prenatal and postnatal care are waived The mother at her
option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated
during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery
care of the newborn child during the covered portion of the mother's hospital confinement for maternity will
be covered under either a Self Only or Self and Family enrollment other care of an infant who requires
definitive treatment will be covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung single and double kidney 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 Plan's Medical Director Related medical and hospital expenses
of the donor are covered when the recipient is covered by this Plan

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Physicians Health Plan of Northern Indiana 2000
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness
and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers

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 except for dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction
syndrome as shown below

Temporomandibular joint syndrome TMJ services are covered up to a maximum Plan payment of
750 per lifetime You pay 40 of charges

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 participant and her attending physician may
decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the
other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis for up to two months per condition if significant improvement can be expected within two
months You pay a 10 copay 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 pay 40 of charges The following types of
artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI You pay 40 cost of donor sperm is not covered Fertility drugs are
covered up to a consecutive 14 day supply of medication unless limited by drug manufacturer's packaging
per prescription order or refill You pay 40 Other assisted reproductive technology ART procedures
such as in vitro fertilization and embryo transfer are not covered

Outpatient surgery and related services are covered You pay 20 of charges
Durable medical equipment such as wheelchairs and hospital beds prosthetic devices such as artificial
limbs nonexperimental implants and orthopedic devices such as braces and foot orthotics are covered
Breast prostheses and surgical bras as well as their replacements are covered You pay 20 of charges

Cardiac rehabilitation for Phase I and Phase II treatment is covered You pay 10 copay per visit

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Physicians Health Plan of Northern Indiana 2000
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining or
covered continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility

Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives no charge if replacement is arranged by member
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services

HOSPITAL EXTENDED CARE BENEFITS
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized
Hospital care under the care of a Plan doctor You pay 20 of the first 2,500 up to the annual out of pocket maximum of 500 per member or 1,500 per family per calendar year All necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended Care The Plan provides a comprehensive range of benefits for up to 60 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered
including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

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

Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay 20 of
Service charges

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Physicians Health Plan of Northern Indiana 2000
Limited benefits Hospitalization for certain dental procedures is covered when a Plan determines there is a need for
Inpatient dental hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
procedures 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 15 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
Blood and blood derivatives no charge if replacement is arranged by member

EMERGENCY BENEFITS
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious

examples include deep cuts and broken bones Others are emergencies because they are potentially
life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe
There are many other acute conditions that the Plan may determine are medical emergencies what they all
have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are
the service area 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 should 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 Plan doctors believe care can be better provided in a
Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

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

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

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Physicians Health Plan of Northern Indiana 2000
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 at participating hospitals 30 at a participating urgent care center for emergency services that are covered benefits of this Plan
Emergencies Benefits are available for any medically necessary health service that is immediately required because of
Outside the injury or unforeseen illness
Service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following

your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor
believes care can be better provided in a Plan hospital you will be transferred when medically feasible with
any ambulance charges covered in full

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

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

You pay 20 of the first 2,500 of eligible expenses for emergency services received from non Plan providers nothing thereafter
What is covered Emergency care at a doctor's office or a participating urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services

Ambulance service approved by the Plan You pay 20 of charges

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 nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
providers 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 8

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Physicians Health Plan of Northern Indiana 2000
MENTAL CONDITIONS SUBSTANCE ABUSE BENEFITS
Mental conditions
What is Covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

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

Outpatient care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay a 20 copay per individual visit or 10 per group therapy visit all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year If you have not met your annual copayment maximum You pay 20 of the first 2,500 up to the annual copayment maximum of 500 per member or 1,500 per
family per calendar year

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 when 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 Services for the psychiatric aspects of substance abuse are provided as shown
below

Outpatient care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay a 20 copay per individual visit or 10 per group therapy visit all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year If you have not met your annual copayment maximum You pay 20 of the first 2,500 up to the annual copayment maximum of 500 per member or 1,500 per
family per calendar year

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

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Physicians Health Plan of Northern Indiana 2000
PRESCRIPTION DRUG BENEFIT
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply 240 milliliter of liquid 8 oz 60 grams of ointment creams or topical
preparation or one commercially prepared unit i e one inhaler one vial ophthalmic medication or insulin
You pay a 10 copay per formulary prescription or 25 copay per non formulary prescription When
generic substitution is permissible i e a generic drug is available and the prescribing doctor does not
require the use of a name brand drug but you request the brand named drug You pay the price difference
between the generic and the brand name drug as well as your 10 or 25 copay per prescription unit or
refill Covered medications and accessories include

Drugs for which a prescription is required by law
Oral contraceptive drugs contraceptive diaphragms
Insulin with a copay charge applied to each vial
Diabetic supplies
Disposable needles and syringes needed to inject covered prescribed Medication

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

Mail Order If you use certain Prescription Drugs on an extended basis you may wish to obtain larger quantities through
Prescriptions the Plan's mail order benefit You pay a 20 formulary copay or 50 per non formulary copay prescription unit up to a 90 day supply Please contact the Plan for more information regarding this benefit

Limited benefit For Norplant and other internally implanted time release medications You pay 40 of charges per implantation There will be no refund of any portion of these charges if the implanted time release
medication is removed before the end of its expected life

Fertility drugs are covered under Infertility benefits see page 11
Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay a 10 formulary copay or 25 non formulary copay for up to the dosage limit and all charges above that

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
Smoking cessation drugs and medication including nicotine patches

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Physicians Health Plan of Northern Indiana 2000
OTHER BENEFITS

Dental care
Accidental injury Restorative services and supplies necessary to promptly repair sound natural teeth are covered The need
benefit for these services must result from an accidental injury not chewing or biting and services must be provided within 12 months of the accident You pay 20 of charges

What is not covered Other dental services not shown as covered

Vision care
What is In addition to the medical and surgical benefits provided for diagnosis and treatment of disease of the eye
Covered annual eye refractions which includes the written lens prescription may be obtained from Plan providers Refractions for members age 18 and older are limited to one 1 per twelve months members 17 years of

age and under are not limited to one per twelve months You pay a 20 copay per visit

Contact lenses following cataract surgery are covered when medically
necessary and authorized by your doctor You pay nothing per visit

What is not Eye exercises
Covered Replacements for any lenses during the same calendar year the lenses were provided

Eye glasses

Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your
Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

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

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Physicians Health Plan of Northern Indiana 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 reenroll
in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in
the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA office
or request it from SSA at 1 800 638 6833

Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage You
coverage must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the first
plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is less
We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to
receive payment from your primary plan

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

Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to provide
our control 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 another
responsible for injuries person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must

agree to let us try This is called subrogation If you need more information contact us for our subrogation
procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

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Physicians Health Plan of Northern Indiana 2000
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 or
Agencies 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 right to
information about your information about your health plan its networks providers and facilities You can also find out about care
HMO management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the

specific types of information that we must make available to you

If you want specific information about us call 219 432 6690 Extension 11 or write to Physicians Health
Plan of Northern Indiana 8101 West Jefferson Boulevard Fort Wayne Indiana 46804 4163 You may also
contact us by fax at 219 432 0493

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 an
enrolling in the FEHB informed decision about
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 your coverage and
and premiums premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
effective premiums begin January 1

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

later in this section

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Physicians Health Plan of Northern Indiana 2000
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried
coverage are available dependent children under age 22 including any foster or step children your employing or retirement office
for my family and me 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 access to it
claims records
confidential OPM this Plan and subcontractors when they administer this contract This Plan and appropriate third parties such as other insurance plans and the Office of Workers

Compensation Programs OWCP when 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 We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809
cards 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 We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled

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Physicians Health Plan of Northern Indiana 2000
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my 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 under your
spouse coverage 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 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

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Physicians Health Plan of Northern Indiana 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You
TCC 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

How can I convert You may convert to an individual 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 If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving
Coverage 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

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Physicians Health Plan of Northern Indiana 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 800 982 6257 Extension 11 219 432 6690 Extension 11 or 219 459 2600 for the Hearing Impaired 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 Health Plan of Northern Indiana 2000
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Physicians Health Plan of Northern Indiana 2000
Summary of Benefits for PHP of Northern Indiana 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth
in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this
brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page Inpatient hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital
care 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 20 of the first 2,500 up to the copayment maximum of 500 per member or
1,500 per family per calendar year 12

Extended care All necessary services up to 60 days per member per calendar year You pay nothing 12
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year If you conditions
have not met your annual copayment maximum You pay 20 of the first 2,500 up to a maximum of
500 per member or 1,500 per family per calendar year 15

Substance Treatment of substance abuse for up to 30 days of inpatient care per year If you have not met your annual abuse
copayment maximum You pay 20 of the first 2,500 up to a maximum of 500 per member or 1,500
per family per calendar year 15

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness 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 a 10 copay per office visit copays for maternity care are
waived nothing per house call by a doctor 10 11

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental Up to 30 outpatient visits per year You pay a 20 copay per individual visit or a 10 copay for group therapy conditions
visit 15

Substance Up to 30 outpatient visits per year You pay a 20 copay per individual visit or a 10 copay for group therapy abuse
visit 15

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 per
hospital emergency room visit at participating hospitals 30 at participating urgent care centers or 20 of the
first 2,500 of eligible expenses for emergency services received from non Plan Providers and any charges for
services that are not covered by this Plan 13 14
Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 10 copay for formulary and Prescription
25 copay for nonformulary medications per prescription unit or refill Certain drugs are available by mail Drugs
You pay a 20 formulary or 50 non formulary copay for up to a 90 day supply 16

Dental care Accidental injury benefit You pay 20 of charges 17
Vision care Refractions eye examination You pay a 20 copay per visit Person 18 years and older are maximumed to
one examination per calendar year There is no maximum for children 17

Out of Pocket Copayments and coinsurance are required for a few benefits however after your out of pocket expenses reach
a maximum of 500 per member or 1,500 per family per calendar year covered benefits will be provided at
100 This copayment maximum does not include amounts you paid for prescription drugs and durable
medical equipment 6

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2000 Rate Information for
Physicians Health Plan of Northern Indiana

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 DQ1 78.83 26.50 170.80 57.42 93.06 12.27 93.26 12.07
Self and DQ2 175.97 61.44 381.27 133.12 207.74 29.67 201.02 36.39
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