Muskegon Area
Enrollment code
U81 Self Only
U82 Self and Family
Special Notice The Lansing area designated by Enrollment code U5 the Jackson area designated by
Enrollment code U6 and the Kalamazoo area designated by Enrollment code U7 are no longer part of the
Plan's Service Area If you do not change plans during Open Season you must travel to the Plan's
remaining service area to receive medical treatment with the exception of emergency services
Visit the OPM website at http www opm gov insure
Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 605
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Physicians Health Plan 2000
Table of Contents Page
Introduction 1
Plain Language 1
How To Use this Brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How We Change for 2000 2
Section 3 How to Get Benefits 3
Section 4 What To Do If We Deny Your Claim or Request for Service 5
Section 5 Benefits 7
Section 6 General Exclusions Things We Don't Cover 13
Section 7 Limitations Rules That Affect Your Benefits 13
Section 8 FEHB Facts 15
Inspector General Advisory Stop Healthcare Fraud 18
Summary of Benefits Inside Back Cover
Premiums Back Cover
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Physicians Health Plan 2000
Introduction
Physicians Health Plan Inc P O Box 30377 Lansing Michigan 48909 7877
This brochure describes the benefits you can receive from Physicians Health Plan under its contract CS 2668 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 2 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
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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Physicians Health Plan 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
changes office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3
How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may
add a brief statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Plan Allergy testing injections serum and venom are now covered at 100
Short term rehabilitative therapy Your copay for outpatient services changes from 20 of eligible
expenses to a 10 per visit copay
Ambulance services are now covered at 100
The Lansing Area designated by enrollment code U5 the Jackson Area designated by enrollment code
U6 and the Kalamazoo Area designated by enrollment code U7 are no longer part of the Plan's Service
area You can no longer receive services in these areas If you do not pick another Plan during Open
Season you will have to travel to the Plan's remaining Service area for medical treatment with the
exception of emergency treatment
The copay for obstetrical services provided during delivery has been increased to 100
Your share of the non postal premium will decrease by 10.9 for Self Only or 11.1 for Self and
Family
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Physicians Health Plan 2000
Section 3 How to Get Benefits
What is this Plan's To enroll with us you must live in our service area This is where our providers practice Our service
service area area is
Muskegon Area
Enrollment code
U81 Self Only
U82 Self and Family
Service Area Services from Plan providers are available only in the following area
The counties of Muskegon Oceana and Newaygo the Ottawa County townships of Allendale
Crockery Grand Haven Polkton Robinson and Spring Lake
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 I You must share the cost of some services This is called either a copayment a set dollar amount or
pay for services coinsurance a set percentage of charges
After you pay 4,760 in copayments or coinsurance for self or 11,400 for a 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 that are charged as a set dollar amount do not count toward these limits
and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that circumstances beyond your
control prevented you from filing on time
Who provides my Physicians Health Plan PHP is a state licensed Health Maintenance Organization HMO serving the
health care Greater Muskegon area and surrounding communities Founded in 1981 PHP serves over 2600 employers statewide with a current membership that exceeds 290,000
PHP offers you and your family secure comprehensive coverage with services provided in your own
personal physician's office PHP contracts with over 3,900 private practice primary care physicians
and referral specialists 43 major hospitals and over 700 pharmacies With PHP you select your own
Primary Care Physician who coordinates all of your health care and makes necessary referrals to PHP
participating specialists No claim forms or deductibles are required Simply present your PHP card
when receiving medical care PHP also provides worldwide coverage for emergency care A woman
may see her Plan obstetrician gynecologist for her annual routine examination without a referral and a
participating optometrist or ophthalmologist may provide an annual eye examination without a referral
from a primary care doctor
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Physicians Health Plan 2000
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 physician or specialist
I need to go into will make the necessary hospital arrangements and supervise your care
the hospital
What do I do First call our customer service department at 231 728 6333 or 800 323 6670 If you are new to the
if I'm in the FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and
hospital when are switching to us your former plan will pay for the hospital stay until
I join this Plan You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist
specialty care If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan and will give you a referral for this care
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a
I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when us you must receive treatment from a specialist who does Generally we will not pay for you to see a
I enroll 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 You may receive
my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue
have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy
provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
this Program 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 Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize medical recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows generally accepted medical practice
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Physicians Health Plan 2000
How do you The Plan determines that a drug biological product device medical treatment or procedure is
decide if a experimental investigative if
service is
experimental or It has not been approved by the U S Food and Drug Administration FDA to be lawfully marked for
investigational the proposed use
It is subject to review and approval by any institutional review board for the proposed use or
It is the subject of an ongoing clinical trial that meets the definition of a Phase I II or III clinical trial
set forth by the FDA
It is not demonstrated through prevailing peer reviewed medical literature to be safe and effective for
treating or diagnosing the condition
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 denial or refusal
OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim or
denial request for service
What if I have Call us In Muskegon 231 728 6333 or 800 323 6670 and we will expedite our review
a serious or life
threatening condition
and you haven't
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening
condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are
or life threatening not treated as soon as possible
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Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits 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 Your request must be complete or OPM will return it to you You must send the following
to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which
claim
Who can make Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the
review request
Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs
mail my disputed Contracts Division IV P O Box 436 Washington D C 20044
claim to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the your only recourse is to sue
Plan's 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
the Privacy Act 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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Physicians Health Plan 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and
covered 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 you pay nothing for home visits by nurses and health aides
Plan doctors also provide all necessary medical or surgical care in a hospital or extended care facility at
no additional cost to you except as noted
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as recommended by your doctor and at a minimum for women age 35
through age 39 one mammogram during these five years for women age 40 through 49 one
mammogram every one or two years for women age 50 through 64 one mammogram every year
and for women age 65 and above one mammogram every two years In addition to routine
screening mammograms are covered when prescribed by the doctor as medically necessary to
diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures including 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 copayments are waived for obstetrical care you pay a
100 copay for obstetrical services provided during delivery The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean
delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is
terminated during pregnancy benefits will not be provided after coverage under the Plan has ended
Ordinary nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and Family enrollment
other care of the infant requiring definitive treatment will be covered only if the infant is covered
under a Self and Family enrollment
Voluntary sterilization and family planning services
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Diagnosis and treatment of diseases of the eye
Cornea heart 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 Treatment for breast cancer multiple myeloma and
epithelial ovarian cancer may be limited to non randomized clinical trials at an approved transplant
facility subject to medical necessity as determined by the Plan's Medical Director Related medical
and hospital expenses of the donor are covered when the recipient is covered by the Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity if medically necessary
Home health services of nurses and health aides including intravenous fluids and medications for
home use when prescribed by your Plan doctor who will periodically review the program for
continuing appropriateness and need
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Health Plan 2000
Medical and Surgical Benefits continued
What is Implantable drugs such as Norplant and some injectable drugs
covered All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
continued other Plan providers Allergy testing injections serum and venom are covered at 100
Limited Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for
benefits congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and
excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding the
teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ
pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition that has resulted in a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and the condition
can reasonably be expected to be corrected by such surgery A patient and her attending physician may
decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the
other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis for up to 62 consecutive calendar days per condition if significant improvement can be
expected within two months you pay a 10 copay per visit for outpatient services 20 of eligible
expenses for rehabilitation services rendered on an inpatient basis 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 including artificial insemination is covered you pay 40 of
eligible expenses the following types of artificial insemination are covered intravaginal insemination
IVI intracervical insemination ICI and intrauterine insemination IUI cost of donor 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 Infertility treatment following surgical sterilization is
not covered Fertility drugs are covered under the Prescription Drug benefit
Durable medical equipment such as wheelchairs and hospital beds orthopedic devices such as braces
and prosthetic devices such as artificial limbs are covered Coverage is provided for breast prostheses
and surgical bras and replacements following mastectomy You pay 20 of eligible expenses
The insertion of prosthetic devices and related inpatient or outpatient health services are covered when
medically necessary you pay nothing Elective implants including cochlear implants penile implants
and implants for the purpose of contraception or for the delivery of medication are covered when
approved in advance by the Plan you pay 40 of covered charges
Growth Hormone Therapy provided by or under the direction of the primary care physician for
treatment of children or adolescents appropriately diagnosed in the Plan's judgment with Growth
Hormone Deficiency or Turner's Syndrome is covered when medically necessary you pay 40 of
eligible expenses
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining
covered or continuing employment or insurance attending school or camp or travel Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Medical and Surgical Benefits continued
What is not Transplants not listed as covered
covered Hearing aids continued Long term rehabilitative therapy
Chiropractic services
Homemaker services
Cardiac rehabilitation
Corrective lenses frames contact lenses including contact lenses following cataract surgery used as
prosthesis
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 100 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
service nothing
Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
Inpatient for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
dental hospitalization but not the cost of the professional dental services Conditions for which hospitalization
procedures would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
inpatient treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 11 for nonmedical Substance Abuse Benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Health Plan 2000
Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
medical endangers your life or could result in serious injury or disability and requires immediate medical or
emergency 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 If you are in an emergency situation please call your primary care doctor In extreme emergencies if
within the service you are unable to contact your doctor contact the local emergency system e g the 911 telephone
area 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 care services to the extent the services would have been covered if received from Plan providers
You pay 25 per emergency room visit or 15 per urgent care center visit for emergency care services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care
copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required because of
outside the service injury or unforeseen illness To be covered by this Plan any follow up care recommended by non Plan
area 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 25 per emergency room visit or 15 per urgent care center visit for emergency care services that are covered benefits of this Plan
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service if approved by the Plan You pay nothing
What is not Elective care or nonemergency care
covered Emergency care provided outside the Service Area if the need for care could have been foreseen before departing the Service Area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the Service Area
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Physicians Health Plan 2000
Emergency Benefits continued
Filing claims With your authorization the Plan will pay emergency benefits directly to the providers of your
for non Plan emergency care upon receipt of their claims submitted on the HCFA 1500 claim form If you are
providers 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 A 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 You may request reconsideration in accordance with the disputed claims
procedure set forth on page 5
Mental Conditions Substance Abuse Benefits
Mental conditions
What is To the extent shown below the Plan provides the following services necessary for the diagnosis and
covered treatment of acute psychiatric conditions including treatment of mental illness or disorders
The medical management of mental conditions will be covered under this Plan's Medical and Surgical
benefits provisions Related drug costs will be covered under this Plan's Prescription Drug Benefits and
any costs for psychological testing or psychotherapy will be covered under this Plan's Mental
Conditions Benefits Office visits for the medical aspects of treatment do not count toward the 20
outpatient Mental Conditions visit limit
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year
care you pay a 20 copay for each covered visit all charges thereafter
Inpatient Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges
care thereafter Inpatient mental health days can be exchanged for outpatient day treatment at the rate of two day treatments for one inpatient day
What is not Care for psychiatric conditions that in the professional judgment of Plan psychiatric designees are
covered 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 Plan psychiatric designees 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 This Plan provides medical and hospital services such as acute detoxification services for the medical
covered 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 Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for
care each covered visit all charges thereafter
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Health Plan 2000
Mental Conditions Substance Abuse Benefits continued
Inpatient Up to 28 days per calendar year in a substance abuse rehabilitation intermediate care program in an
care alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the benefit period all charges thereafter Inpatient days can be exchanged for outpatient day treatment at the rate
of two day treatments for each inpatient day
What is not Treatment that is not authorized by a Plan psychiatric designee
covered
Prescription Drug Benefits
What is Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be
covered dispensed for up to a 34 day supply or 100 unit supply whichever is less You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not
permissible When generic substitution is permissible i e a generic drug is available and the
prescribing doctor does not require the use of a name brand drug but you request the name brand drug
you pay the price difference between the generic and name brand drug as well as the 5 copay per
prescription unit or refill
Drugs must be prescribed by Plan doctors and dispensed in accordance with the Plan's Preferred Drug
List The Preferred Drug List is a list of commonly prescribed medications that have been chosen by the
Pharmacy and Therapeutic Committee based on a drug's effectiveness and cost The Pharmacy and
Therapeutics Committee will evaluate any needed additions or deletions to the Preferred Drug Listing
Upon your doctor's request specific medications not on the Preferred Drug Listing can be evaluated on
a case by case basis to be covered
Non formulary drugs will be covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive diaphragms
Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles and glucose test strips
Disposable needles and syringes needed for injecting covered prescribed medication
Limited Benefits Drugs for the treatment of infertility are covered you pay 40 per prescription or refill Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay the drug copayment up to the
dosage limit and all charges above that
Intravenous fluids and medication for home use implantable drugs such as Norplant and some
injectable drugs are covered under Medical and Surgical Benefits
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available
covered 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 medications including nicotine patches
Drugs for experimental or investigational purpose
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Physicians Health Plan 2000
Other Benefits
Dental care Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The
Accidental need for these services must result from an accidental injury You pay 20 of eligible expenses The
injury benefit services must be received within six 6 months of the injury
What is not Other dental services not shown as covered
covered
Vision Care
What is In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the
covered eye annual eye refractions to provide a written lens prescription for eyeglasses may be obtained from Plan providers You pay a 15 copay per visit
What is not Corrective lenses or frames
covered Eye exercises Contact lenses including contact lenses following cataract surgery used as prosthetics
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
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
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Physicians Health Plan 2000
Medicare If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits continued
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 When anyone has coverage with us and with another group health plan it is called double coverage You
insurance must tell us if you or a family member has double coverage You must also send us documents about other
coverage 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 Under certain extraordinary circumstances we may have to delay your services or be unable to provide them
beyond our In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that another
are responsible person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
for injuries 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
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 agency directly or indirectly
Government pays for
Agencies
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Physicians Health Plan 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us write or call PHP Muskegon Terrace Plaza 250
Morris Avenue Suite 550 Muskegon MI 49440 1143 231 728 6333 or 800 323 6670 You
may also contact us by fax at 231 728 5189
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
enrolling in the make an informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorizes coverage for Under certain circumstances you may also get
family and me 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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Physicians Health Plan 2000
Are my medical We will keep your medical and claims information confidential Only the following will have
and claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
The 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
cards 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 member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
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
spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
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Physicians Health Plan 2000
What is TCC Key points about TCC continued
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
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC 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
notifies 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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Physicians Health Plan 2000
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health health insurance or other health care coverage You must arrange for the other coverage within
Plan Coverage 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 231 728 6333 or 800 323 6670 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 2000
Summary of Benefits for Physicians Health Plan 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the definitions limitations
and exclusions set forth in the brochure This chart summarizes certain important expenses covered by the Plan If you wish to
enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes
appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF
EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit
care Includes in hospital doctor care room and board general nursing care private room and private nursing care if medically necessary diagnostic tests drugs
and medical supplies use of operating room intensive care and complete
maternity care You pay nothing except for a 100 copayment for obstetrical
services provided during delivery 9
Extended Care All necessary services up to 100 days per calendar year You pay nothing 9
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of
conditions inpatient care per year You pay nothing 11
Substance Up to 28 days per year in a substance abuse treatment program You pay nothing 11
abuse
Outpatient Comprehensive range of service such as diagnosis and treatment of illness or injury
care 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 10 per house call by a
doctor 7
Home health All necessary visits by nurses and health aides You pay nothing 7
care
Mental Up to 20 outpatient visits per year You pay a 20 copay per visit 11
conditions
Substance Up to 20 outpatient visits per year You pay a 20 copay per visit 11
abuse
Emergency Reasonable charges for services and supplies required because of a medical
care emergency You pay a 25 copay to the hospital for each emergency room visit and 15 for each urgent care center visit and any charges for services
that are not covered by this Plan 10
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay
drugs a 5 copay per prescription unit or refill 12
Dental care Accidental injury benefit You pay 20 of eligible expenses 13
Vision care One refraction annually You pay a 15 copay per visit 13
Out ofpocket Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 4,760.00 per Self or 11,400.00 per Family
maximum per calendar year covered benefits will be provided at 100 This copay maximum does not include the cost of prescription drugs 3
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2000 Rate Information for
Physicians Health Plan Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred
to as Category A rates and Category B rates will apply for certain career employees If you are a career postal
employee but not a member of a special postal employment class refer to the category definitions in The Guide to
Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which
rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or
associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Muskegon Western Michigan
Self Only U81 58.26 19.42 126.23 42.08 68.94 8.74 68.94 8.74
Self and Family U82 139.64 46.54 302.54 100.85 165.23 20.95 165.23 20.95
22