Pages 1--41 from 100FED.PDF

A Health Maintenance Organization
Serving South Central Kansas Area
Enrollment in this Plan is limited see page 6 for requirements

SPECIAL NOTE This Plan has terminated Brown Jefferson Pottawatomie and Shawnee Counties
from it's service area Members who live or work in these counties must change health plans

Enrollment Code
VA 1 Self Only
VA 2 Self and Family

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www phsystems com 1
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Authorized for distribution by the

United States
Office of
Personnel
Management RI 73 604

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Table of Contents
Page
Introduction 1

Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 10
Section 5 Benefits 13
Section 6 General exclusions Things we don't cover 25
Section 7 Limitations Rules that affect your benefits 26
Section 8 FEHB facts 29
Inspector General Advisory Stop Healthcare Fraud 34
Summary of benefits Inside back cover
Premiums Back cover 3
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Preferred Plus of Kansas
Introduction
Preferred Plus of Kansas
8535 E 21 st Street North
Wichita KS 67206

This brochure describes the benefits you can receive from Preferred Plus of Kansas Inc HMO under its
contract 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 pages 4 and 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 Preferred Plus of Kansas HMO as this Plan throughout this brochure even though in other
legal documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to
make it more understandable

We have not re written the Benefits section of this brochure You will find new benefits language next
year

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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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Preferred Plus of Kansas
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

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Preferred Plus of Kansas
Section 2 How we change for 2000
Program wide To keep your premiums as low as possible OPM has set a minimum copay of 10
changes 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 with your records call us and we will
assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy
every five years This screening is for colorectal cancer

Changes to this Your share of the premium will increase by 11.9 for Self Only or 16 for Self
Plan and Family

The plan has reduced its service area by deleting the following counties in
Kansas Brown Jefferson Pottawatomie and Shawnee

A member who attends Lamaze childbirth classes from a participating hospital or
a participating OB Gyn will be reimbursed by the Plan for 50 of the cost not to
exceed a maximum benefit of 30 Proof of payment and class completion must
be submitted to Preferred Plus of Kansas Member Services Department

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Preferred Plus of Kansas
Durable Medical Equipment coverage has increased to covered in full
when used for life sustaining equipment and supplies such as oxygen
tube feedings IV infusion pumps and associated supplies as deemed
medically necessary and ordered by your primary care doctor See page
16

Coverage is provided for outpatient diabetic self management training
and education Coverage for Durable Medical Equipment for diabetic
self management training is limited to 1,000 per member per calendar
year Coverage for supplies used in conjunction with Durable Medical
Equipment are limited to the 500 per member per calendar year under
the Disposable Medical Supply benefit See page 16

Biofeedback is covered under Mental Conditions Benefits See page 21

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Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our
Plan's service providers practice Our service area is the following counties in Kansas Marion
area Harvey Kingman Sedgwick Butler Sumner Cowley or Chautauqa

You may also enroll with us if you live or work in the following places
The Kansas counties of Saline Dickson Morris McPherson Chase Reno Harper
Greenwood or Elk

Ordinarily you must get your care from providers who contract with us If you receive
care outside our service area we will pay only for emergency care We will not pay for
any other health care services

If you or a covered family member move outside of our service area you can enroll in
another plan If your dependents live out of the area for example if your child goes to
college in another state you should consider enrolling in a fee for service plan or an
HMO that has agreements with affiliates in other areas If you or a family member
move you do not have to wait until Open Season to change plans Contact your
employing or retirement office

How much do You must share the cost of some services This is called either a copayment a set
I pay for dollar amount or coinsurance a set percentage of charges Please remember you
services must pay this amount when you receive services except for emergency care

Your out of pocket expenses for benefits under this Plan are limited to the stated
copayments required for a few benefits

Do I have to You normally won't have to submit claims to us unless you receive emergency services
submit claims from a provider who doesn't contract with us If you file a claim please send us all of
the documents for your claim as soon as possible You must submit claims by
December 31 of the year after the year you received the service
Either OPM or we can extend this deadline if you show that circumstances beyond your
control prevented you from filing on time

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Preferred Plus of Kansas
Who provides Preferred Plus of Kansas is an individual practice prepayment IPP model HMO As a
my health member of Preferred Plus you will select a primary care doctor for yourself and each
care member of your family Each member may designate his or her own primary care
doctor You will be able to choose from a list of doctors located throughout the
enrollment area Preferred Plus has more than 270 primary care doctors in its Kansas
service area and more than 1,100 referral specialists

What do I do if Call us We will help you select a new one
my primary
care physician
leaves the
Plan

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care
I need to go physician or specialist will make the necessary hospital arrangements and supervise
into the your care Should you need hospitalization for mental health or substance abuse
hospital services please contact Mental Health Network Inc at 1 800 456 5641

What do I do if First call our Member Services department at 316 609 2390 If you are new to the
I'm in the FEHB Program we will arrange for you to receive care If you are currently in the
hospital when I FEHB Program and are switching to us your former plan will pay for the hospital stay
join this Plan 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

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How do I get Your primary care physician will arrange your referral to a specialist with the following
specialty care exceptions women may self refer to see their contracting OB GYN for their annual
wellness exams and should you require mental health or substance abuse services please
contact Mental Health Network Inc at 1 800 456 5641

If you need to see a specialist frequently because of a chronic complex or serious
medical condition your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals Your primary care physician will use our criteria when creating your
treatment plan

What do I do if Your primary care physician will decide what treatment you need If they decide to
I am seeing a refer you to a specialist ask if you can see your current specialist If your current
specialist when specialist does not participate with us you must receive treatment from a specialist
I enroll who does Generally we will not pay for you to see a specialist who does not
participate with our Plan

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

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

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How do you Your physician must get our approval before sending you to a hospital referring you to
authorize a specialist or recommending follow up care Before giving approval we consider if
medical the service is medically necessary and if it follows generally accepted medical practice
services All mental health or substance abuse services must be prior authorized by Mental
Health Network 800 456 5641

How do you If a service has not been approved by the Federal Drug Administration FDA or is
decide if a labeled experimental or investigational on the protocol the Plan considers the service
service is experimental or investigational
experimental or
investigational

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Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request
must

1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time
limit if you show that you were unable to make a timely request due to reasons beyond your
control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must
make a decision within 30 days after we receive the additional information If we do not receive the
requested information within 60 days we will make our decision based on the information we already
have

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

What if I have a Call us at 316 609 2390 or outside Segdwick County at 1 800 660 8114 and we
serious or life expedite our review
threatening
condition and your
haven't responded
to my request for
services

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What if you have If we expedite your review due to a serious medical condition and deny your
denied my request claim we will inform OPM so that they can give your claim expedited treatment
for care and my too Alternatively you can call OPM's health benefit Contract Division IV at
condition is serious 202 606 0737 between 8 a m and 5 p m Serious or life threatening conditions
of life threating 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
time limits we uphold our initial denial or refusal of service You may also ask OPM to
review your claim if

1 We do not answer your request within 30 days In this case OPM must
receive your request within 120 days of the date you asked us to reconsider
your claim

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

What do I send to Your request must be complete or OPM will return it to you You must send
OPM 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

What address Send your request for review to Office of Personnel Management Office of
should I send my insurance programs Contracts Division IV P O Box 436 Washington D C
disputed claim to 20044

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What if OPM OPM's decision is final There are no other administrative appeals If OPM
upholds the Plan's agrees with our decision your only recourse is to sue
denial
If you decide to sue you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received the disputed
services or supplies

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal
I file a lawsuit court will base its review on the record that was before OPM when OPM made
its decision on your claim You may recover only the amount of benefits in
dispute

You or a person acting on your behalf may not sue to recover benefits on a
claim for treatment services supplies or drugs covered by us until you have
completed the OPM review procedure described above

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

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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 tests and X rays Within the Service Area
house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 10 copay for a doctor's house call or for home visits by nurses and health
aides

The following services are included
Preventive care including well baby care and periodic check ups including routine immunizations and boosters you pay nothing for children up to age 72 months

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 year 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

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 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

Prospective parents may receive authorization from the Plan to select a primary care doctor for their unborn child and receive coverage for one visit to that doctor prior to the
birth of the child
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A member who attends Lamaze childbirth classes from a participating hospital or a participating OB GYN will be reimbursed by the Plan for 50 of the cost to exceed a maximum benefit
of 30 Proof of payment and class completion should be submitted to this Plan's Member
Services Department

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 heart lung single and double lung pancreas 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 Related
medical and hospital expenses of the donor are covered when the recipient is covered by
this Plan Organ procurement costs have no dollar limitation

Transportation costs for the Member and a companion will be provided if the transplant is
performed outside the Plan service area when the Member resides more than fifty 50
miles from the transplant site Travel expenses shall be defined as commercial
transportation of the Member receiving the transplant and a companion to and from the
site of the transplant Reasonable and necessary lodging and meal costs incurred by the
Member and a companion for a period beginning 24 hours prior to the Member's
hospitalization and 48 hours after the Member's discharge from the Hospital are also
covered Transportation lodging and meal costs are subject to a 125 day limitation not
to exceed maximum benefit of 2,000

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 Incidental
to a mastectomy the Member will be provided surgical services for breast reconstruction
An initial bra immediately following the mastectomy will also be covered if purchased at a
contracting provider

Dialysis
Chemotherapy radiation therapy and inhalation therapy

Surgical treatment of morbid obesity
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Chiropractic services
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 procedure
involving the teeth or intra oral areas surrounding the teeth are not covered including any
dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction
syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance
and if the condition can reasonably be expected to be corrected by such surgery A patient
and her attending physician may decide whether to have breast reconstructive surgery
following a mastectomy and whether surgery on the other breast is needed to produce a
symmetrical appearance

Rehabilitation services physical speech occupational respiratory physical medicine modalities cardiac pulmonary and neuropsychological testing is provided on an inpatient
basis for up to 60 consecutive days per condition if significant improvement can be
expected within 60 days you pay nothing Outpatient visits are limited to sixty 60 visits
per condition per calendar year 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

Developmental Therapy which includes physical speech and occupational therapy is covered for children under the age of 6 years Such services must be referred and precertified by
the primary care doctor The Plan will cover these benefit sup to a maximum of 1,000
for each of the therapies listed in this section per calendar year you pay nothing

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Diagnosis and treatment of infertility is covered you pay a 10 copay The following types of artificial insemination are covered at procedure cost only for three 3 attempts
intravaginal insemination IVI intracervial insemination ICI and intrauterine
insemination IUI you pay a 10 copay Other covered services in which you pay a
10 copay include diagnostic services to establish the cause or reason for infertility these
are medical evaluation limited to sperm counts hysterosalpingography and endometrial
biopsy counseling surgical correction of physiological abnormalities causing infertility
Cost of donor sperm is not covered Collection or storage of sperm is not covered Other
assisted reproductive technology ART procedures that enable a woman with otherwise
untreatable infertility to become pregnant through other artificial conception procedures
such as in vitro fertilization and embryo transfer are not covered Fertility drugs and
surrogate parenting are not covered

Durable medical equipment such as wheelchairs and hospital beds is covered up to a maximum Plan payment of 1,000 per member per calendar year

Durable medical equipment used for life sustaining equipment and supplies such as
oxygen tube feedings IV infusion pumps and associated supplies will be covered without
dollar limitations as deemed medically necessary and ordered by your primary care
doctor

Dietitian services diabetic education Dietitian services are covered for up to 4 visits per member per calendar year as recommended by the Member's primary care doctor
Outpatient self management training and education for diabetics are covered if treated at
an approved program and such treatment is rendered by a person certified by the National
Certification Board of Diabetic Educators Equipment and supplies for the self
management treatment of diabetics are covered as specified under the durable medical
equipment and disposable medical supplies section in this brochure

Prosthetic devices such as breast prostheses surgical bras artificial limbs and lenses following cataract removal and pacemakers are covered for one standard appliance device per
lifetime unless repair replacement is medically necessary as a result of normal usage or
changes in condition

Orthopedic devices such as braces and foot orthotics are covered for one standard appliance device per lifetime unless repair replacement is medically necessary as a result of
normal usage or changes in condition
Disposable medical supplies including supplies related to care of ostomy appliance pouches skin care agents support belt supplies for care of open wounds gauze pads wound
packing strips ABD pads or supplies relating to care of venous access catheter alcohol
pads benzoin OP site supplies used in conjunction with covered durable medical
equipment urinary supplies are limited to catheters catheters supplies bags and related
ostomy supplies tracheostomy supplies and diabetic hypodermic needles and associated
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supplies are covered when prescribed by the primary care physician and with proof of
purchase for up to a 500 Plan payment per calendar year

Lenses and Frames are covered immediately following cataract surgery under the following payment schedule The Plan will pay for two 2 lenses and one 1 set of frames at 41
for single lenses 62 for bifocal 76 for trifocal or seamless 140 for lenticular 30 for
frames and 80 for contacts in lieu of lenses and frames

What is not covered
Physical examinations that are not necessary for medical reasons such as those required for 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 not replaced by the member
Long term rehabilitation therapy convalescent care or custodial maintenance care vocational rehabilitation or cognitive therapy

Radial keratotomy
Acupuncture
Hearing aids
Homemaker services
Refractions including lens prescriptions
Corrective eyeglasses and frames or contact lenses including the fitting of contact lenses except following cataract surgery

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Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary
services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing
care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility
is medically appropriate as determined by a Plan doctor and approved by the Plan You
pay nothing All necessary services are covered including

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

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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

Limited benefits
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of medical conditions and medical management of
withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient
management is not medically appropriate See page 22 for non medical substance abuse
benefits

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What is not covered
Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care

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

Emergencies within the service area
If you are in an emergency situation please call your primary care doctor In extreme
emergencies if you are unable to contact your doctor contact the local emergency system e g
the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the
emergency room personnel that you are a Plan member so they can notify the Plan You or a
family member should notify the Plan within 48 hours It is your responsibility to ensure that the
Plan has been timely notified

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

Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers

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

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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 If the emergency results in admission to a hospital
the emergency care copay is waived

Emergencies outside the service area
Benefits are available for any medically necessary health service that is immediately required
because of injury or unforeseen illness If you need to be hospitalized the Plan must be notified
within 48 hours or on the first working day following your admission unless it was not reasonably
possible to notify the Plan within that time If a Plan doctor believes care can be better provided in
a Plan hospital you will be transferred when medically feasible with any ambulance charges
covered in full

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 If the emergency results in admission to
a hospital the emergency care copay is waived

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 if approved by the Plan
What is not covered
Elective care or non emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filings claims for non Plan providers
With your authorization the Plan will pay benefits directly to the providers of your emergency
care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
form If you are required to pay for the services submit itemized bills and your receipts to the
Plan along with an explanation of the services and the identification information from your ID
card Payment will be sent to you or the provider if you did not pay the bill unless the

claim is denied If it is denied you will receive notice of the decision including the reasons for
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the denial and the provisions of the contract on which denial was based If you disagree with the
Plan's decision you may request reconsideration in accordance with the disputed claims
procedure described on pages 10 11 and 12

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
Biofeedback
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
All services for mental conditions substance abuse benefits must be prior coordinated by Mental
Health Network Inc prior to receiving services Please contact Mental Health Network Inc at
1 800 456 5641

Outpatient care
Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each
calendar year You pay nothing for the first 3 visits you pay a 25 copay per visit for each visit
for visits 4 through 40 50 of charges thereafter

Inpatient care
Up to 60 days of hospitalization each calendar year you pay nothing for the first 60 days all
charges thereafter

What is not covered
Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment

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Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

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

Outpatient care
Up to 20 outpatient visits to Plan providers for treatment each calendar year You pay nothing
for the first 3 visits you pay a 25 copay per visit for visits 4 through 20 and 50 of charges
thereafter

Inpatient care
Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in
an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during
the benefit period all charges thereafter

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

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 34 day supply or 100 unit supply whichever is less 240 milliliters of
liquid 8 oz 60 grams of ointment creams or topical preparation or one commercially prepared
unit e g one inhaler one vial ophthalmic medication or insulin You pay a 5 copay for
generic drugs or a 15 copay for name brand drugs per prescription unit or refill You may obtain
maintenance medications through this Plan's mail order prescription drug program for up to a 90
day supply per prescription unit or refill You pay a 10 copay per prescription You may obtain
envelopes for mail order drugs by contacting the Plan at 1 800 660 8114

When generic substitution is permissible i e a generic drug is available and the prescribing
doctor does not require the use of a name brand drug but you request the name brand drug you
pay the difference between the generic and name brand drug as well as the 15 copay The
following drugs are not subject to mandatory substitution Premarin Lanoxin Coumadin
Dilantin Synthroid and Provera
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Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs up to a three cycle supply may be obtained at one time with a copay charge applied to each cycle

Contraceptive devices such as diaphragms and IUD's
Insulin with a copay charge applied to each vial
Disposable needles and syringes needed to inject covered prescribed medication including insulin

Diabetic supplies including syringes diagnostic strips and lancets A generic copayment will be charged for these supplies
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
Limited Benefits
Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits at 1 800 660 8114
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 antiseptic

Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation including nicotine patches
Fertility drugs
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Appetite suppressants except for treatment of morbid obesity
Other Benefits
Dental care
Accidental injury benefit
Restorative services and supplies necessary to promptly repair but not replace sound
natural teeth are covered The need for these services must result from an accidental injury and
not from biting or chewing Services must be received within 48 hours of the injury You pay a
10 office visit copay

What is not covered
Other dental services not shown as covered

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Section Section 6 6 General General exclusions exclusions Things Things we we dont dont cover 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 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
Charges for services not listed as covered services
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 Section 7 7 Limitations Limitations Rules Rules that that affect affect your your
benefits benefits

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

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also
remain enrolled with us

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

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

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

For information on Medicare Choice plans contact your local Social Security
Administration SSA office or request it from SSA at 1 800 638 6833 For
information on the Medicare Choice plan offered by this Plan please call 316 609
2365 or 1 800 766 3777

Other group When anyone has coverage with us and with another group health plan it is called
insurance double coverage You must tell us if you or a family member has double coverage
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

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charge If we are the secondary payer we may be entitled to receive payment from
your primary plan

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

Circumstances Under certain extraordinary circumstances we may have to delay your services or be
beyond our unable to provide them In that case we will make all reasonable efforts to provide
control you with necessary care

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

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

Workers 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

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

Section Section 8 8 FEHB FEHB FACTS FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which
information about gives you the right to information about your health plan its networks providers
your HMO and facilities You can also find out about care management which includes
medical practice guidelines disease management programs and how we
determine if procedures are experimental or investigational OPM's website lists
the specific types of information that we must make available to you

If you want specific information about us call 800 660 8114 or write to 8535 E
21 st Street North Wichita Kansas 67206 You may also contact us by fax at
316 609 2327 or visit our website at www phsystems com

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

When your enrollment ends and
The next Open Season for enrollment

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

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

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

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

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

benefit payment and subrogating claims
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

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Information Information for for new new members members
Identification We will send you an Identification ID card Use your copy of the Health
cards Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until
you receive your ID card You can also use an Employee Express confirmation
letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

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

When When you you lose lose benefits benefits
What happens if You will receive an additional 31 days of coverage for no additional premium
my enrollment in when
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
spouse coverage to get benefits under your former spouse's enrollment But you may be eligible
for your own FEHB coverage under the spouse equity law If you are recently
divorced or are anticipating a divorce contact your ex spouse's employing or
retirement office to get more information about your coverage choices

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

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

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if

several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

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

Children You must notify your employing or retirement office within 60 days
after your child is no longer an eligible family member That office will send
you information about enrolling in TCC You must enroll your child within 60
days after they become eligible for TCC or receive this notice whichever is
later

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

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

Your employing or retirement office will then send your former spouse
information about enrolling in TCC Your former spouse must enroll within
60 days after the event which qualifies them for coverage or receiving the
information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your
former spouse notify your employing or retirement office within the 60 day
deadline

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

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How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health
Certificate of Plan Coverage that indicates how long you have been enrolled with us You can
Group Health use this certificate when getting health insurance or other health care coverage
Plan 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

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Inspector Inspector General General Advisory Advisory
Stop Stop Health Health Care Care Fraud 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 316 609 2390 or 1 800 660 8114 and explain the situation

If we do not resolve the issue call or write

THE THE HEALTH HEALTH CARE CARE FRAUD FRAUD HOTLINE 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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Summary of Benefits for Preferred Plus of Kansas 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 MENTAL HEALTH AND SUBSTANCE ABUSE
SERVICES MUST BE PRIOR AUTHORIZED BY MENTAL HEALTH NETWORK INC AT
800 456 5641

Benefits Plan pays provides Page
Inpatient care

Hospital Comprehensive range of medical and surgical services without dollar or
day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 18

Extended care All necessary services no dollar or day limit You pay nothing 18
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days
of inpatient care per year You pay nothing 21

Substance abuse Up to 30 days per year in a substance abuse treatment program
You pay nothing 22

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 or
house call by a doctor You pay a 10 copay per office visit or per house
call by a doctor 13

Home health care All necessary visits by nurses and health aides You pay
a 10 copay per visit 15

Mental Health Up to 40 outpatient visits per calendar year You pay nothing for the first 3
visits for visits 4 through 40 You pay a 25 copay per visit 21

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Substance Abuse Up to 20 outpatient visits per calendar year You pay nothing for the first
3 visits for visits 4 through 20 you pay a 25 copay per visit 22

Emergency care Reasonable charges for services and supplies required because of a medical
emergency You pay a 50 copay to the hospital for each emergency room
visit and any charges for services that are not covered by this Plan 19

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You
pay a 5 copay for generic drugs or a 15 copay for name brand drugs per
prescription unit or refill this Plan 22 24

Dental care Accidental injury benefit you pay a 10 copay per office visit 24
Vision care No current benefit
Your out of pocket expenses for benefits covered under this Plan are
limited to the stated copayments that may be required for a few benefits 6

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2000 Rate Information for
Preferred Plus of Kansas

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 Share Share Share
Enrollment Share Share Share Share Share

VA1 77.95 25.98 168.89 56.29 92.24 11.69 92.24 11.69
Self Only

Self and Family VA2 175.97 100.47 381.27 217.68 207.74 68.70 201.02 75.42

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