Document Outline

• Who provides my health care
• To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:
  • • Diagnostic and treatment services
      • • Lab, X-ray and other diagnostic tests
          • • • Maternity care
      • Educational classes and programs
  • Not covered:
  • Limitation We may limit your benefits if you do not follow your treatment plan.
    • Service
    • Service
      • • • (
          • Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,

Pages 1--59 from Health Maintenance Plan

Health Maintenance Plan http:// www. anthem. com 2001
A Health Maintenance Organization

Serving: Most Of Ohio
Enrollment in this Plan is limited; see page 3 for requirements.

Enrollment codes for this Plan:
R51 Self Only R52 Self and Family

RI 73-031

For changes in benefits,
see page 4. 1
1 Page 2 3

2001 Health Maintenance Plan i Table of Contents
Table of Contents
Introduction…………………………………………………………………................................................................ 1
Plain Language……………………………………………………………….............................................................. 1
Section 1. Facts about this HMO plan…………………………….............................................................................. 2
How we pay providers……………………................................................................................................. 2
Who provides my health care?……………………………………………………………………………. 2
Patients' Bill of Rights……………………................................................................................................. 2
Service Area………………………………................................................................................................ 3
Section 2. How we change for 2001………………………………………................................................................. 4
Program-wide changes…………………………………………………………………………………….. 4
Changes to this Plan……………………………. ....................................................................................... 4
Section 3. How you get care ………………………………........................................................................................ 5
Identification cards……………………….. ................................................................................................ 5
Where you get covered care………………........................................................................................... …. 5
Plan providers…………………………............................................................................................... 5
Plan facilities…………………………………..................................................................................... 5
What you must do to get covered care……………. ................................................................................... 5
Primary care………………………….. ................................................................................................ 6
Specialty care……………………………………................................................................................ 6
Hospital care…………………………………..................................................................................... 7
Circumstances beyond our control………………….................................................................................. 7
Services requiring our prior approval……………...................................................................................... 8
Section 4. Your costs for covered services……………………................................................................................... 9
Copayments…………………………………....................................................................................... 9
Deductible……………………………………..................................................................................... 9
Coinsurance…………………………………....................................................................................... 9
Your out-of-pocket maximum………………………................................................................................. 9
Section 5. Benefits …………………………………………………………............................................................. 10
Overview…………………………………. .............................................................................................. 10
(a) Medical services and supplies provided by physicians and other health care professionals............ 11
(b) Surgical and anesthesia services provided by physicians and other health care professionals ........ 19
(c) Services provided by a hospital or other facility, and ambulance services ...................................... 23
(d) Emergency services… …………………. ....................................................................................... 25
(e) Mental health and substance abuse benefits..................................................................................... 27
(f) Prescription drug benefits……………………................................................................................. 30
(g) Special features…………………………….................................................................................... 33
(h) Dental benefits………………………………................................................................................. 35
Section 6. General exclusions --things we don't cover.............................................................................................. 38 2
2 Page 3 4

2001 Health Maintenance Plan ii Table of Contents
Table of Contents (Continued)
Section 7. Filing a claim for covered services………………..................................................................................... 39
Section 8. The disputed claims process………………............................................................................................... 41
Section 9. Coordinating benefits with other coverage. ............................................................................................... 43
When you have…
Other health coverage…………………............................................................................................... 43
Original Medicare……………………………..................................................................................... 43
Medicare managed care plan…………………................................................................................... 45
TRICARE/ Workers' Compensation/ Medicaid........................................................................................... 45
Other Government agencies……………………....................................................................................... 46
When others are responsible for injuries…………. ................................................................................... 46
Section 10. Definitions of terms we use in this brochure............................................................................................ 47
Section 11. FEHB facts……………………………………. ...................................................................................... 49

Coverage information
No pre-existing condition limitation ……………………………………………………….……… 49
Where you get information about enrolling in the FEHB Program………………………….…….. 49
Types of coverage available for you and your family……………………………………….…….. 49
When benefits and premiums start………………………………………………………………… 50
Your medical and claims records are confidential………………………………………………… 50
When you retire…………………………………………………………………………………… 50
When you lose benefits
When FEHB coverage ends……………………………………………………………………….. 50
Spouse equity coverage…………………………………………………………………………… 50
Temporary Continuation of Coverage (TCC).………………….………………………………… 50
Converting to individual coverage ……………………………………………………………….. 51
Getting a Certificate of Group Health Plan Coverage……………………………………………. 51
Inspector General Advisory ……………………………………………………………………….……. 51
Index….………………………………………………................................................................................................ 52
Summary of benefits………………………………………….................................................................................... 54
Rates……………………………………………………………………………….………………………….. Back cover 3
3 Page 4 5

2001 Health Maintenance Plan 1 Introduction/ Plain Language
Introduction
Health Maintenance Plan 1351 William Howard Taft Road
Cincinnati, Ohio 45206-1775
This brochure describes the benefits of Community Insurance Company, dba Anthem Blue Cross and Blue Shield*, under our contract (CS 1659) with the Office of Personnel Management (OPM), as authorized by the Federal

Employees Health Benefits law. This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are 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. You do not have a right to
benefits that were available before January 1, 2001, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are summarized on page 4. Rates are shown at the end of this brochure.

*An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company.
Registered marks Blue Cross and Blue Shield Association.

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. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical terms, we use common words. "You" means the enrollee or family member; "we" means Health Maintenance Plan.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan with other FEHB plans, you will find that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6

2001 Health Maintenance Plan 2 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, 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.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.
Who provides my health care
As a plan member, you will receive care from one of Health Maintenance Plan's participating primary care doctors. These doctors are under contract to HMP to provide care to HMP members. Primary care doctors practicing within a
Plan Medical Center, as well as those doctors with medical offices in the surrounding communities, are part of the Plan medical team. The Plan refers to this combination of group and private practice doctors as a mixed model
prepayment plan. The Plan has designated certain hospitals for organ transplants to be performed. These hospitals have been selected for their experience in performing transplants. In some instance, the designated hospital may not be
located in the Plan's service area and you will be responsible for your travel expenses to that facility. Contact the Plan for a list of designated organ transplant facilities.

Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.

Disenrollment rates for 1999 Compliance with State and Federal licensing or certification requirements and the dates met. If noncompliant, the
reason for noncompliance. Accreditations by recognized accrediting agencies and the dates received
Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency, confidentially and transfer of medical record
Years in existence Profit status
Medical Records Transitional Care

If you want more information about us, call 1-800/ 228-4375, or write to Mail No. CC1-014, 1351 William Howard Taft Road, Cincinnati, Ohio 45206-1775. You may also contact us by fax at 513/ 872-3929 or visit our website at
www. anthem. com. 5
5 Page 6 7
2001 Health Maintenance Plan 3 Section 1
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:

Cincinnati Area: In Ohio --Brown, Butler, Clermont, Clinton, Hamilton, and Warren counties, and ZIP codes 45110 and 45142 in Highland County
Cleveland Area: In Ohio --Cuyahoga, Geauga, Lake, Lorain, Medina, and Summit counties, and ZIP codes 44032, 44033, 44066, 44076, 44084, 44085, 440093 and 44099 in Ashtabula County
Dayton Area: In Ohio --Butler, Champaign, Clark, Clinton, Greene, Miami, Montgomery, Preble, Shelby, and Warren counties, ZIP codes 45304, 453113, 45328, 45329, 45331, 45332, 45336, 45352, 45358 and 45380 in Darke
County, 43128 and 43142 in Fayette County, and 43310, 43311, 43318, 43319, 43324, 43331, 43333, 43343 and 43357 in Logan County

Akron-Canton Area: In Ohio --Ashland, Carroll, Harrison, Holmes, Medina, Portage, Stark, Summit, Tuscarawas, and Wayne counties
Warren-Youngstown Area: In Ohio --Columbiana, Jefferson, Mahoning, and Trumbull counties
Columbus Area: In Ohio --Coshocton, Delaware, Fairfield, Franklin, Licking, Pickaway, and Union counties, and ZIP codes 43029, 43064, 43140, 43143, 443151, 43153 and 43162 in Madison County

Toledo-Defiance Area: In Ohio --Allen, Defiance, Erie, Fulton, Hancock, Henry, Huron, Lucas, Ottawa, Paulding, Putnam, Seneca, Williams, and Wood counties, ZIP codes 43407, 43410, 43420, 43431, 43435, 43442, 43448, 43469
and 44841 in Sandusky County, and 45832, 45863, 45886 and 45891 in Van Wert County
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 or urgent 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. Refer to Section 5( g), Special Features on page 33 for details regarding the Plan's reciprocity benefits. 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. 6
6 Page 7 8
2001 Health Maintenance Plan 4 Section 2
Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and day and visit limitations when you follow a treatment plan that we approve. Previously, we placed higher patient
cost sharing and shorter day or visit limitations on mental health and substance abuse services than we did on services to treat physical illness, injury, or disease.

Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our
patient safety activities by calling 800/ 228-4375. You can find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take these five steps:

Speak up if you have questions or concerns.
Keep a list of all the medicines you take.
Make sure you get the results of any test or procedure.
Talk with your doctor and health care team about your options if you need hospital care.
Make sure you understand what will happen if you need surgery.

We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the language referenced only women.

Changes to this Plan
Your share of the non-Postal premium will increase by 15% for Self Only or 15% for Self and Family.

The office visit copay for specialty providers will increase from $0 to $10 per visit.
Outpatient mental health and substance abuse services will now be covered with a $10 office visit copayment
with no day or visit limitations.

Inpatient mental health and substance abuse services will now be covered in full with no day limitations. 7
7 Page 8 9
2001 Health Maintenance Plan 5 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800/ 228-
4375.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. The list is also on our website.

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician (PCP). This decision is
important since your primary care physician provides or arranges for most of your health care.

How you choose a PCP
1. Ask family and friends about their doctors. While you're at it, ask health care practitioners you respect, too. Personal
recommendations can mean a lot.
2. Consider a get-acquainted visit if the doctor is accepting new patients. (Many doctors do not charge for such an appointment, but
make sure.) Use this time to ask questions, not to get advice about specific medical complaints.

Here are some questions you might ask:
What are your office hours?
Who will handle my care when you aren't available?
3. Pay attention. Does the physician explain things so you can understand? Are you comfortable talking with him or her? Is the
tone of the conversation friendly and respectful? Is the physician listening carefully to you? 8
8 Page 9 10
2001 Health Maintenance Plan 6 Section 3
Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see optometrists and OB/ GYNS without a referral.
How do I get specialty care?
Except in a medical emergency or when a primary care doctor has designated another doctor to see patients when he or she is unavailable,
you must contact your primary care doctor for a referral before seeing any other doctor or before you obtain special services. Referral to a
participating specialist is given at the primary care doctor's discretion; if specialists or consultants are required beyond those participating in the
Plan, your primary care doctor will make arrangements for appropriate referrals.

Before going to the specialist, for the initial consultation or for follow-up care, make sure your primary care doctor has written a referral for you to
take with you to the specialist's office and has indicated the referral information in your medical records. Your primary care doctor will also
notify the Plan of the referral by telephone, fax or mail. On referrals, the primary care doctor will give specific instructions to the specialist as to
what services are to be performed. If additional services or visits are suggested by the specialist, you must first check with your primary care
doctor. If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you

for you to be seen by another participating doctor.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will work with you and the Plan to develop a treatment plan that

allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to

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

If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist

until we can make arrangements for you to see someone else. 9
9 Page 10 11
2001 Health Maintenance Plan 7 Section 3
If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800/ 228-4375. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the necessary care. 10
10 Page 11 12
2001 Health Maintenance Plan 8 Section 3
Services requiring our prior approval Your primary care physician has authority to refer you for most services.
For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice. We call this review and approval process precertification. Your
Physician must obtain precertification for services such as:
all inpatient admissions (except maternity)
hysterectomy
cardiac rehabilitation
OB ultrasounds (second and subsequent)
Precertification is a procedure which requires that an approval be obtained from us before incurring expenses for certain Covered Services.
When care is evaluated, the Medical Necessity will be determined. For admissions, the appropriate length of stay will also be determined. For
certain services you will be required to use the Provider designated by our Health Care Management staff. Medical Necessity includes a review
of both the service and the setting. When approved, a copy of the approval will be provided to you, the Physician, and the Hospital or
facility. The care will be covered according to your benefits for the number of days approved unless our Concurrent Review determines that
the number of days should be revised. As a result of Concurrent Review, additional days of Inpatient care may be approved which exceed the
number of days originally authorized by our Health Care Management staff. With prior notice by us, the number of days originally authorized
by Precertification may be reduced when it is determined that continued Inpatient care is no longer Medically Necessary.

Your PCP and other Network Providers know which services require Precertification and will obtain any required Precertification. If a
request is denied, the Provider may request a reconsideration to be completed within 3 days of the request. An expedited reconsideration
may be requested when the Member's health requires an earlier decision.

For Emergency admissions, Precertification is not required; however, you must notify your Primary Care Physician of your admission within
24 hours or as soon as possible within a reasonable period or services after 24 hours could be denied. 11
11 Page 12 13
2001 Health Maintenance Plan 9 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayment A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 20% of our allowance for infertility and family planning services.

Your out-of-pocket maximum for coinsurance and copayments
After your copayments and/ or coinsurance total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay
any more for covered services. However, copayments and/ or coinsurance for the following services do not count toward your out-of-pocket
maximum, and you must continue to pay copayments and/ or coinsurance for these services:

Dental services
Prescription drugs
Be sure to keep accurate records of your copayments and/ or coinsurance since you are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Health Maintenance Plan 10 Section 5
Section 5. Benefits --OVERVIEW
(See page 4 for how our benefits changed this year and page 54 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 800/ 228-4375.

(a) Medical services and supplies provided by physicians and other health care professionals………………… 11-18
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies

Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 19-22
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 23-24
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services ........................................................................................................................................ 25-26 Medical emergency Ambulance
(e) Mental health and substance abuse benefits ................................................................................................... 27-29
(f) Prescription drug benefits ............................................................................................................................... 30-32
(g) Special features............................................................................................................................................... 33-34 24 hour nurse line

Reciprocity benefit
Centers of Excellence for Transplants/ heart surgery
Discount programs
(h) Dental benefits................................................................................................................................................ 35-37

Summary of benefits.................................................................................................................................................... 54 13
13 Page 14 15
2001 Health Maintenance Plan 11 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In a primary care physician's office

In a specialty physician's office

$10 per office visit

Professional services of physicians
In an urgent care center
$5 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Initial examination of a newborn child covered under a family enrollment

At home

Nothing 14
14 Page 15 16
2001 Health Maintenance Plan 12 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Preventive care, adults
Routine screenings, such as:
Blood lead level
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test

Nothing

Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing
Routine pap test
Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine Immunizations, such as:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines

Nothing. 15
15 Page 16 17
2001 Health Maintenance Plan 13 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)
Well-child care charges for routine examinations, immunizations and care (through age 22)

Nothing if you receive these services during your office visit,
otherwise , $10 per office visit.

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
One routine sonogram
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 8 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b)

Nothing 16
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2001 Health Maintenance Plan 14 Section 5( a)
Family planning You pay
Voluntary sterilization 20% of our allowance

Surgically implanted contraceptives
Injectable contraceptive drugs
Nothing

Not covered:
reversal of voluntary surgical sterilization
voluntary abortion 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

All charges.

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

20% of our allowance

Diagnosis and treatment of infertility, such as:
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

50% of our allowance

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded ART procedures

Cost of donor sperm

All charges. 17
17 Page 18 19
2001 Health Maintenance Plan 15 Section 5( a)
Allergy care You pay
Testing and treatment

Allergy serum
20% of our allowance

Allergy injection 20% of our allowance when performed in an allergy
specialist's office; otherwise, $10 per office visit at a Primary Care
Physician's office

Not covered: provocative food testing and sublingual allergy desensitization. All charges.

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

Nothing

Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is

medically necessary. We will ask you or your physician to submit the following:

a letter of medical necessity
laboratory results, and
a growth chart
We will not cover the GHT or related services and supplies if you do not request preauthorization from us.

50% of our allowance 18
18 Page 19 20
2001 Health Maintenance Plan 16 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
Two consecutive months per condition, beginning with the first treatment, for the services of each of the following:

qualified physical therapists;
speech therapists; and
occupational therapists.
Note: We only cover therapy to restore bodily function or speech when there has been a total or partial loss of bodily function or

functional speech due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to two consecutive months beginning with the first treatment.

Nothing

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit

Not covered: all other hearing testing
hearing aids, testing and examinations for them
All charges.

Vision services (testing, treatment, and supplies)
One eye refraction per year $10 per office visit

Not covered:
Eyeglass frames and lenses or contact lenses
Eye exercises and vision training
Radial keratotomy

All charges. 19
19 Page 20 21
2001 Health Maintenance Plan 17 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges.

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints and pacemakers
Note: See 5( b) for coverage of the surgery to insert the device.

50% of our allowance up to a $1,500 maximum, all charges
thereafter.

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors;
insulin pumps; and
first pair of lenses following cataract removal
medical supplies, such as surgical dressings and colostomy bags

50% of our allowance up to a $1,500 maximum, all charges
thereafter.

Not covered: Devices and equipment used for environmental control or to enhance
the environmental setting, such as: air conditioners, humidifiers or air filters.
All charges. 20
20 Page 21 22
2001 Health Maintenance Plan 18 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.) or home

health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered: nursing care requested by, or for the convenience of, the patient or
the patient's family; nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.

All charges.

Educational classes and programs
Coverage is limited to:

Diabetes self-management
$10 per office visit 21
21 Page 22 23
2001 Health Maintenance Plan 19 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( C ) for charges associated with the facility (i. e. hospital,

surgical center, etc).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require

precertification and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
Treatment of fractures, including casting Treatment of burns

Normal pre-and post-operative care by the surgeon Endoscopy procedure
Biopsy procedure Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery) Surgical treatment of morbid obesity --a condition that has persisted
for a duration of at least five years, and for which non-surgical treatment has been unsuccessful for at least twelve to eighteen
consecutive months. Insertion of internal prosthetic devices, such as pacemakers and
artificial joints. See 5( a) – Orthopedic braces and prosthetic devices for device coverage information.
Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs)

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing

Surgical procedures continued on next page. 22
22 Page 23 24
2001 Health Maintenance Plan 20 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization 20% of our allowance

Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care in Section 5( a).
All charges.

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: cleft lip; cleft palate; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;

Nothing

breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital
up to 48 hours after the procedure.

50% of our allowance up to a $1,500 maximum, all charges
thereafter.

Not covered: Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges 23
23 Page 24 25
2001 Health Maintenance Plan 21 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures, and

Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

Medical treatment related to temporomandibular joint disease Nothing up to $200; All charges thereafter.
Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Dental care involved in the treatment of temporomandibular joint (TMJ) pain dysfunction or syndrome

All charges. 24
24 Page 25 26
2001 Health Maintenance Plan 22 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas

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
Blue Quality Centers for Transplant (BQCT)
Limited Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved

clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Nothing in a Plan designated organ transplant facility, or 20%
of our allowance in a participating, non-designated organ transplant
facility.

Not covered: Implants of artificial organs
Transplants not listed as covered
Travel expenses related to transplant benefits

All charges

Anesthesia
Professional services provided in – Hospital (inpatient)

Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office

Nothing 25
25 Page 26 27
2001 Health Maintenance Plan 23 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I M
P O
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as ward, semiprivate, or intensive care accommodations;

general nursing care; meals and special diets; and
nursery charges.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services

Nothing

Not covered: Custodial care
Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges. 26
26 Page 27 28
2001 Health Maintenance Plan 24 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Extended care benefits/ skilled nursing care facility benefits
Extended care/ skilled nursing facility benefits:

Up to 180 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
necessary as determined by a Plan doctor and approved by the Plan.
Days 0 -30

Nothing

Days 31 – 180 50% of our allowance
Not covered: custodial care All charges

Hospice care
Home Health Care provided by Hospice nurses Nothing

Not covered: Independent nursing, homemaker services and hospice services provided in a hospice facility All charges

Ambulance
Local professional ambulance service when medically appropriate 20% of our allowance 27
27 Page 28 29
2001 Health Maintenance Plan 25 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
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A N
T
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 we may determine are medical emergencies – what
they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, you must contact 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 you may notify the Plan. You or
a family member must notify your primary care doctor within 24 hours, unless it was not reasonably possible to do so. It is your responsibility to ensure that your primary care doctor has been timely notified.

If you need to be hospitalized, the Plan must be notified within 24 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 you believe 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.

Emergencies outside our 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.

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. 28
28 Page 29 30
2001 Health Maintenance Plan 26 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center $5 per office visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $25 per visit; if visit results in an admission,
you pay nothing

Not covered: Elective care or non-emergency care All charges.

Emergency outside our service area
Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center $5 per office visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $25 per visit; if visit results in an admission,
you pay nothing

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.

All charges.

Ambulance
Professional land and air ambulance service when medically appropriate.

See 5( c) for non-emergency service.
20% of our allowance 29
29 Page 30 31
2001 Health Maintenance Plan 27 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve "parity" with other benefits. This means that we will provide mental health and substance abuse

benefits differently than in the past.
When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for

similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
We have no deductible.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no
greater than for other illness or conditions.

Professional services, including medication management, individual therapy or group therapy by providers such as psychiatrists,
psychologists, or clinical social workers provided in -

Office

$10 per office visit

Professional services, including medication management, individual therapy or group therapy by providers such as psychiatrists,
psychologists, or clinical social workers provided in -
Hospital (inpatient)
Hospital outpatient department

Nothing

Mental health and substance abuse benefits -Continued on next page 30
30 Page 31 32

2001 Health Maintenance Plan 28 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Not covered:
Services we have not approved.

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

Psychiatric evaluation or therapy on court order or as a condition of
parole or probation, unless determined by a Plan doctor to be necessary and appropriate.

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

The same exclusions contained in this brochure that apply to other benefits apply to these mental health and substance abuse benefits, unless the
services are included in a treatment plan that we approve.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
If you feel you need mental health or substance abuse services, you
may call Magellan Behavioral Health at 800/ 788-4003. Magellan will work with you to determine your needs and begin the treatment

planning process. Referrals for any necessary services will also be handled by Magellan Behavioral Health.

Your mental health and substance abuse services must be provided by Plan providers. You may obtain a provider directory by calling us at
800/ 228-4375 or visit our website at www. anthem. com.

Mental health and substance abuse benefits -Continued on next page 31
31 Page 32 33
2001 Health Maintenance Plan 29 Section 5( e)
Mental health and substance abuse benefits (Continued)
Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued
coverage with your provider for up to 90 days under the following conditions:

If your mental health or substance abuse professional provider with
whom you are currently in treatment leaves the plan at our request for other than cause.

If these conditions apply to you, we will allow you reasonable time to transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day period ends before January 1 and this transitional benefit does not apply.

Limitation We may limit your benefits if you do not follow your treatment plan. 32
32 Page 33 34
2001 Health Maintenance Plan 30 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Prior authorization is the process required to dispense certain drugs when the use of a drug is defined or limited by your medical condition.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

I M
P O
R T
A N
T

There are important features you should be aware of. These include:
Who can write your prescription? A Plan physician or licensed dentist must write the prescription.

Where you can obtain them. You may fill the prescription at a Community Rx National Network pharmacy or by mail. You may fill the prescription at a Plan pharmacy, or by mail for a
maintenance medication.
We use a formulary. Prescription drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's prescription drug formulary. All prescription drugs on the formulary have been

approved by the Food and Drug Administration (FDA). The formulary consists of medications that have been rigorously reviewed and selected by a committee of practicing doctors and clinical
pharmacists for their safety, quality and effectiveness. Coverage will be provided for both formulary and non-formulary medications when prescribed by a Plan doctor. However, when non-formulary
drugs are dispensed a higher copay will apply.
These are the dispensing limitations. Prescriptions filled by a pharmacy or through a mail order pharmacy have a limitation on days supply and different levels of copayments based on the days

supply. You may obtain a 30-day supply at a Plan pharmacy or up to a 90-day supply through our mail order program. Remind your doctor to write for the maximum days supply. Any continuous
therapy medication presently covered by this Plan within the limits of applicable State and Federal laws, can be dispensed through the mail order program. Your prescriptions will be filled using FDA
dispensing guidelines.
Your prescription claims' history and patient profile information will be used by the Plan to administer your pharmacy program and to identify possible drug interactions, duplications or other

adverse events that may occur. This profile allows the Plan to determine if you are trying to refill your prescription too soon, which could cause your claim to be rejected and could require you to file
again at a later date.
If you receive a name-brand drug, whether by mail order or from a Plan pharmacy, the copayment for the name brand applies regardless of whether:

a generic equivalent is unavailable, the prescription order specifies "Dispense as Written," or
you choose the name-brand drug instead of a generic drug.
When you have to file a claim. Typically you will not have to file a claim for prescription drugs; however, if you have had to pay for a prescription due to some unforeseen circumstance, you will

have to submit the original prescription receipt to : Health Maintenance Plan, Mail No. CC1-014, 1351 William Howard Taft Road, Cincinnati, OH 45206-1775.

Prescription drug benefits begin on the next page. 33
33 Page 34 35
2001 Health Maintenance Plan 31 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Drugs for which a prescription is required by Federal law
FDA-approved prescription drugs and devices for birth control
Insulin
Disposable needles and syringes needed to inject covered prescribed medications are covered at the name brand copayment.

Diabetic supplies including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, glucose monitors and
acetone test tablets are covered at the name brand copayment.
Drugs for the treatment of impotence, such as Viagra: HMP requires proof of medical necessity prior to approving benefits. Then, this Plan will cover

a maximum of six tablets per month, subject to the following guidelines. The patient:

– must be a male over age 18,
– is being treated for erectile dysfunction (ED) regardless of the cause, and

is not on medication containing nitrates.
Intravenous fluids and medications for home use, implantable drugs, and some injectable drugs, such as Depo Provera, are covered under Medical

and Surgical Benefits.

30-day supply at a Plan pharmacy
$ 5 copay for generic drugs
$12 copay for formulary name brand drugs

$24 copay for non-formulary name brand drugs

Up to a 90-day supply through the mail order program
$10 copay for generic drugs
$24 copay for formulary name brand drugs

$36 copay for non-formulary name brand drugs

Note: If there is no generic equivalent available, you will still
have to pay the brand name copay.

Immuno-Suppressive Agent
Infertility drugs
Human growth hormones
Smoking cessation drugs and medications. The drugs and medications are limited to one 12-week treatment per lifetime, upon proof of

enrollment in a smoking cessation program.

50% of our allowance

Covered medications and supplies – Continued on next page 34
34 Page 35 36

2001 Health Maintenance Plan 32 Section 5( f)
Covered medications and supplies (Continued) You pay
Here are some things to keep in mind about our prescription drug program:

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written
for the name brand drug, you will still have to pay the name brand copay.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. To order a prescription drug listing, call 800/ 228-4375 or visit our website at
www. anthemprescription. com.

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a Non-network pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
The cost of smoking cessation programs
Drugs for weight loss purposes (except when authorized by the Plan doctor for treatment of morbid obesity)

Replacement prescriptions such as lost, stolen or spilled

All Charges 35
35 Page 36 37

2001 Health Maintenance Plan 33 Section 5( g)
Section 5 (g). Special Features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse line You have access to Personal Health Advisor (PHA), a health information service, 24 hours a day, seven days a week. All calls are completely
confidential. You can:
Speak with a registered nurse for help with everyday health decisions and for health counseling on chronic conditions.

Listen to pre-recorded health care topics in the Audio Health Library.
Locate doctors and hospitals in your area.

You can access Personal Health Advisor by calling 1-888-474-2258 or through the internet website: www. pha-online. com/ anthem.

Centers of excellence for transplants/ heart
surgery

We use the Blue Quality Centers for Transplant Network (BQCT) as our transplant network. The network consists of leading medical
facilities throughout the nation. For a list of transplant hospitals near you, call 800/ 824-0581.

We utilize a network of institutions that have met stringent clinical standards for the following heart services:
coronary artery bypass graft (CABG) percutaneous transluminal coronary angioplasty (PTCA)
heart valve procedures other major cardiovascular procedures

You can refer to our provider directory for further information concerning our transplant and heart surgery centers of excellence.

Special features – Continued on next page 36
36 Page 37 38
2001 Health Maintenance Plan 34 Section 5( g)
Section 5 (g). Special Features (Continued)
Feature Description

Reciprocity benefit BluesCONNECT Away from Home Care Program
HMP participates in BluesCONNECT Away from Home Care Program, the national HMO network sponsored by the Blue Cross and

Blue Shield Association. It provides for you and your family to receive urgent care at other Blue Cross and Blue Shield HMO Plans
while traveling outside the service area of HMP.
You have the option of obtaining care under HMP's out-of-area guidelines or under BluesCONNECT Away from Home Care
Program. Simply call 1-800-446-6872. You'll be given the location and phone number of the participating HMO covering that location
and the name of the away from home care coordinator who will schedule an appointment for you. Your membership with HMP will
be verified and you will receive services. You will pay nothing at the time you receive services. Applicable HMP copayments will be billed
by HMP after you return home.
HMP offers guest memberships at affiliated HMO plans through BluesCONNECT Away from Home Care Program. Whenever you or
a family member is away from the HMP service area for more than 90 days, you may become a guest member at an affiliated HMO near your
destination. Reasons to consider a guest membership include extended out-of-town business, children away at school, dependent children in
another state, or a winter "snowbird" residency in the South. To determine if a guest membership is available at your destination,
call 1-800-446-6872.

Discount programs Anthem Advantage
You can receive negotiated savings on selected health and wellness services and programs simply by being an eligible Anthem Blue Cross

and Blue Shield Health Maintenance Plan member. Companies participating in the Anthem Advantage program include:

Beltone " – free hearing exams and discounts on hearing aids Mature Mart " – discounts on life enhancing products for mature
adults Priorities " – discounts on asthma and allergy relief products
Revive-A-Lens " – mail order contact lens cleaning Safe Beginnings " – discounts on child-proofing and family safety
products Vision One – discounts on frames, contacts, bifocals
Weight Watchers – preferred pricing on weight management programs
SafeTech (a div. of Troxel) preferred pricing on bicycle and in-line skating helmets
Quality Books and Audio – discounts on health education books and cassettes 37
37 Page 38 39
2001 Health Maintenance Plan 35 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not

cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair within three days of an accident (but not replace) sound natural teeth.

The need for these services must result from an accidental injury.
Nothing

Dental benefits
See benefit chart on the following page. 38
38 Page 39 40
2001 Health Maintenance Plan 36 Section 5( h)
The following dental services are covered when provided by participating Plan dentists; and indicates copayments where they apply: This benefit description does not list exclusions. Contact the Plan for specific
exclusions at 800/ 228-4375 or 513/ 872-8242 ( in the local dialing area).

Dental Benefits
Service You pay

DIAGNOSTIC
X-rays including bite wings and panoramic; oral examinations and treatment plan; vitality test; and

oral cancer exam

Nothing

RESTORATIVE (Fillings)
Amalgam – one surface
Amalgam – two surfaces
Amalgam – three surfaces (Build up per tooth)
Plastic or composite – single surface
Plastic or composite – two surfaces

80% of our allowance

ORAL SURGERY (including preoperative and postoperative treatments under local anesthetics)
Extraction (simple)
Alveolectomy per quadrant
Impaction (soft tissue)
Impaction (complete bony)

80% of our allowance

PROSTHODONTICS
Complete upper or lower denture
Cast chrome partial – upper or lower
Acrylic partial – upper or lower (with clasps)
Repair broken denture
Denture adjustment
Reline upper or lower complete denture or partial (office)

Reline upper or lower complete denture or partial (laboratory)

80% of our allowance

PREVENTIVE
Prophylaxis; annual topical application of fluoride to children age 12, preventive dental instructions
Nothing

Dental Benefits – Continued on next page 39
39 Page 40 41
2001 Health Maintenance Plan 37 Section 5( h)
Dental Benefits (Continued)
Service You pay

PREVENTIVE
Space maintainers (for primary teeth)
Stainless steel crown (for primary teeth)
Bridge abutments or pontics

80% of our allowance

PERIODONTICS (Under local anesthetics)
Examination, treatment plan
Periodontal, root planing and curettage
Hemisection
Gingivectomy or gingivoplasty
Osseous surgery (per quadrant)
Equilibration (entire mouth)

80% of our allowance

ENDODONTICS (under local anesthetics)
Pulpotomy (including restoration)
Root canal filling – one canal
Each additional canal
Apicoectomy, performed as separate surgical procedure

80% of our allowance

ORTHODONTICS (braces)
Initial Consultation
Diagnosis and treatment plan
Limited to one two-year course of phase II
treatment per eligible child up to age 19.

80% of our allowance

Missed appointments without 24 hours prior notification $10.00
ACCIDENTAL INJURY BENEFIT
Restorative services and supplies necessary to promptly repair within three days of accident (but not

replace) sound natural teeth.
(The need for these services must result from an accidental injury.)

Nothing

Not covered:
All other dental services not shown as covered
All charges 40
40 Page 41 42
2001 Health Maintenance Plan 38 Section 6
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, disease, injury, or condition..
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits); Services, drugs, or supplies you receive while you are not enrolled in this Plan;

Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or 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;
Services, drugs, or supplies related to sex transformations; or
Chiropractic services; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 41
41 Page 42 43
2001 Health Maintenance Plan 39 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 800/ 228-4375.

When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Health Maintenance Plan PO Box 37180
Louisville, KY 40233-7180

Prescription drugs When you must file a claim,---such as prescription drugs that you had to pay for,---submit the original itemized Pharmacy receipt that comes
with the prescription.
Submit your claims to: Health Maintenance Plan Mail No. CC1-014
1351 William Howard Taft Road Cincinnati, OH 45206-1775

Other supplies or services When you must file a dental claim,---such as out-of-network care,---submit a completed Standard ADA (American Dental Association )
Claim Form.
Submit your claims to: Dental Network of America Ohio Claims
Two Transam Plaza Drive Oakbrook Terrace, IL 60181 42
42 Page 43 44
2001 Health Maintenance Plan 40 Section 7
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 43
43 Page 44 45
2001 Health Maintenance Plan 41 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Health Maintenance Plan, Mail No. CC1-014,
1351 William Howard Taft Road, Cincinnati, OH 45206-1775; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or (c) Ask you or your provider for more information. If we ask your provider, we will send you a copy
of our request— go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division II, P. O. Box 436, Washington, D. C. 20044-0436. 44
44 Page 45 46
2001 Health Maintenance Plan 42 Section 8
Section 8. The disputed claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 800/ 228-4375 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 45
45 Page 46 47
2001 Health Maintenance Plan 43 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly for Part B.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare managed care plan is the term used to describe the various health
plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B benefits.
You may go to any doctor, specialist, or hospital that accepts Medicare. Medicare pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.
When you are enrolled in this Plan and Original Medicare, you still need to follow the rules in this brochure for us to cover your care. Your care
must continue to be authorized by your Plan PCP, or precertified as required.

We will not waive any of our copayments and/ or coinsurance.

(Primary payer chart begins on next page.) 46
46 Page 47 48
2001 Health Maintenance Plan 44 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
A. When either you --or your covered spouse --are age 65 or over and … Then the primary payer is…

Original Medicare This Plan
1) Areanactiveemployee withthe Federalgovernment(includingwhen you or afamilymemberare eligibleforMedicaresolely becauseofadisability),

2) Are an annuitant,

3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or…………………………… ………..

b) The position is not excluded from FEHB…………………………….
Ask your employing office which of these applies to you.
……………………..………

1) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),




2) Are enrolled in Part B only, regardless of your employment status,
(for Part B
services)

(for other services)

3) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

(except for claims related to Workers'

Compensation.)
B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and…

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or………………………………………… ..…..…

b) Are an active employee…………………………………….. ………………… ………

Please note, if your Plan physician does not participate in Medicare, you may have to file a claim with Medicare on occasion. 47
47 Page 48 49

2001 Health Maintenance Plan 45 Section 9
Claims process You probably will never have to file a claim when you have both our Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated
automatically. You will not need to do anything. To find out if you need to do something about filing your claims, call us at 800/ 228-
4375.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans cover all Medicare Part A and B benefits. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1- 800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan, the following options are available to you:

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments and/ or coinsurance for your FEHB coverage.

This Plan and another Plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers), but we will not waive any of our copayments and/ or coinsurance.

Suspended FEHB coverage and a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed
care plan premium.) For information on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.
Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage. 48
48 Page 49 50
2001 Health Maintenance Plan 46 Section 9
Workers' Compensation We do not cover services that:
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 determines they must provide; or
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 OWCP or similar agency pays its maximum benefits for your treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies are responsible for your care We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.

When others are responsible for injuries When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for
any expenses we paid. However, 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. 49
49 Page 50 51
2001 Health Maintenance Plan 47 Section 10
Section 10. Definitionsof terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 9.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 9.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a
person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include, but are not

limited to:
personal care such as help in walking, getting in and out of bed, bathing, eating by spoon, tube or gastrostomy, exercising or
dressing
homemaking such as preparing meals or special diets
moving the patient
acting as a companion or sitter
supervising medication that can usually be self administered
treatment services that any person may be able to perform with minimal instruction, including, but not limited to, recording
temperature, pulse and respirations or administration and monitoring of feeding systems

The Plan determines which services are custodial.
Experimental or investigational services A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed
without approval of the U. S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished.

Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of
ongoing phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its
efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among
experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are
necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means
of treatment or diagnosis. 50
50 Page 51 52
2001 Health Maintenance Plan 48 Section 10
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol( s) of another facility studying substantially the same drug, device, or medical
treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same
drug, device, or medical treatment or procedure.

Group health coverage Health care coverage that a member is eligible for because of employment, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or other health care services or supplies, or that pays a specific amount for

each day or period of hospitalization.

Medical necessity Services, drugs, supplies or equipment provided by a hospital or covered provider of the health care services that the Carrier determines:
are appropriate to diagnose or treat the patient's condition, illness or injury;

are consistent with standards of good medical practice in the United States;
are not primarily for the personal comfort of the patient, the family or the provider;
are not a part of or associated with the scholastic education or vocational training of the patient; and
in the case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that a covered provider has prescribed, recommended or approved a service, supply, drug or equipment does not, in itself, make
it medically necessary.

Our allowance Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as
follows:

amounts charged by other providers for the same or similar service; any unusual medical circumstances requiring additional time, skill
or experience; and other factors we determine are relevant, including, but not limited
to, a resource based relative value scale.

Us/ We Us and we refer to Health Maintenance Plan.
You You refers to the enrollee and each covered family member. 51
51 Page 52 53
2001 Health Maintenance Plan 49 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

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
When the next open season for enrollment begins.
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.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue 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 that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
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, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan. 52
52 Page 53 54
2001 Health Maintenance Plan 50 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when

coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you 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 (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue 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 RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices.

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 Temporary
Continuation of Coverage (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 53
53 Page 54 55
2001 Health Maintenance Plan 51 Section 11
retirement office or from www. opm. gov/ insure.
Converting to You may convert to a non-FEHB individual policy if: individual coverage Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot convert;

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. 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.

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled with us. You
can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions
for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 848-9276
and explain the situation. If we do not resolve the issue, call THE HEALTH CARE FRAUD
HOTLINE--202/ 418-3300 or write to: The United States Office of Personnel Management, Office of the Inspector General Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 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 the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take administrative action against you. 54
54 Page 55 56
2001 Health Maintenance Plan 52 Index
Index Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Abortion, 14 Allergy care, 15
Ambulance, 24, 26 Anesthesia, 22

Blood or blood plasma, 23-24
Cardiac rehabilitation, 16 Changes for 2001, 4
Chemotherapy, 15 Claims filing, 30, 39, 45
Coinsurance, 9, 47 Contraceptive devices and drugs, 31
Coordination of benefits, 43 Copayments, 9

Definitions, 47 Dental, 35
Diabetic supplies, 31 Diagnostic services, 11
Dialysis, 15 Disputed claims review , 41
Durable medical equipment (DME), 17
Educational classes and programs, 18 Emergency, 25-26
Experimental or investigational, 47 Extended care, 24

Family planning, 14 Fertility drugs, 14
Foot care, 17 Formulary drugs, 30-32

General Exclusions, 38 Growth hormone services, 15, 31
Hearing services, 16 Home health services, 18
Hospice care, 24
Immunizations, 12-13 Infertility, 14, 31
Inpatient hospital, 23 Insulin, 31
Intravenous (IV)/ infusion therapy, 15

Lab, 12
Mammogram, 12 Maternity, 13
Medicaid, 46 Medical necessity, 48
Medicare, 43-45 Medical supplies, 17
Mental health, 27

Morbid obesity, 19
Newborn care, 11 Nursery charges, 23

Occupational therapy, 16 Office visit, 11, 13, 16-18,
26-27 Oral and maxillofacial surgery, 21
Orthopedic devices, 17, 19 Out-of-pocket maximum, 9
Outpatient hospital, 24
Pap test, 12 Pathology, 12
Patients' Bill of Rights, 2 Physical therapy, 16
Preauthorization, 28 Pre-existing condition, 49
Prescription drugs, 30 Presurgical testing, 24
Preventive care, adults, 12 Preventive care, children, 13
Primary care, 6 Prior approval, 8
Prostate Specific Antigen (PSA) test, 12 Prosthetic devices, 17, 19
Providers, 5
Radiation therapy, 15 Reconstructive surgery, 20

Rehabilitation therapies, 16 Respiratory and inhalation therapy, 15
Room and board, 23
Service area, 3 Skilled nursing care, 24
Smoking cessation, 31 Special features, 33
Specialty care, 7 Speech therapy, 16
Subrogation, 46 Substance abuse, 27
Surgical procedures, 19 Syringes, 31

Temporary continuation of coverage, 50-51 Transplants, 22
Treatment therapies, 15
Urgent Care, 11, 26
Vision services, 16
Workers' compensation, 46
X-ray, 12 55
55 Page 56 57
2001 Health Maintenance Plan 53
NOTES: 56
56 Page 57 58
2001 Health Maintenance Plan 54 Summary
Summary of benefits for Health Maintenance Plan -2001
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ............ Office visit copay: $10 primary care; $10 specialist 11

Services provided by a hospital:
Inpatient .......................................................................................
Outpatient ....................................................................................
Nothing
Nothing
23
24

Emergency benefits:
In-area .........................................................................................
Out-of-area..................................................................................
$25 per visit
$25 per visit
26
26

Mental health and substance abuse treatment...................................... Regular cost sharing 27
Prescription drugs:
Network pharmacy……………………………………………..

Mail order……………………………………………………….
$5 generic copay; $12 formulary name brand copay;
$24 non-formulary name brand copay

$10 generic copay; $24 formulary name brand copay;
$36 non-formulary name brand copay

31

Dental Care
Preventive care……………………………………………………
Other services……………………………………………………
Nothing
80% of our allowance
36

Vision Care
One annual refraction……………………………….…………… $10 per visit 16
Summary of benefits for Health Maintenance Plan -2001 -continued on next page 57
57 Page 58 59
2001 Health Maintenance Plan 55 Summary
Summary of benefits for Health Maintenance Plan – 2001 (Continued) Benefits You Pay Page
Special features:
Flexible benefits option
24-hour nurse line
Centers of excellence for transplants/ heart surgery
Reciprocity benefit
Discount programs

33

Protection against catastrophic costs (your out-of-pocket maximum)......................................................... Nothing after $1,500/ Self Only or $3,000/ Family enrollment per year
Some costs do not count toward this protection.
9 58
58 Page 59
2001 Health Maintenance Plan 56
2001 Rate Information for Health Maintenance Plan (HMP)
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 career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

Most of Ohio
Self Only R51 $86.11 $28.70 $186.57 $62.19 $101.89 $12.92
Self and Family R52 $194.59 $64.86 $421.61 $140.53 $230.26 $29.19 59

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