Pages 1--56 from MVP Healthcare

Serving: Upstate New York and Vermont
Enrollment in this Plan is limited; see page 6 for requirements.

This Plan has Commendable accreditation from
the NCQA. See the 2002 Guide for more
information on NCQA.

Enrollment codes for this Plan:
Eastern Region

GA1 Self Only GA2 Self and FamilyCentral

Region
M91 Self Only M92 Self and FamilyMid-

Hudson Region
MX1 Self Only MX2 Self and FamilyVermont

Region
VW1 Self Only VW2 Self and Family

RI-73-465 1
1 Page 2 3
2002 MVP Health Care 2 Table of Contents
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General Advisory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Who provides my health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Your out-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . 13
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . 22
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 2
2 Page 3 4
2002 MVP Health Care 3 Table of Contents
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
After Hours MVP Unit
Services for deaf and hearing impaired
High Risk Pregnancies
Travel Benefit/ Overseas
Out-of-Area Student Benefits
( h) Dental Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
( i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 6. General exclusions --things we don t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Your medical and claims records are confidential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Long term care insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back Cover 3
3 Page 4 5
2002 MVP Health Care 4 Introduction/ Plain Language
Introduction
MVP Health Care
111 Liberty Street
Schenectady, NY 12305

This brochure describes the benefits of MVP Health Plan, Inc. under our contract ( CS 2362) 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, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and are
summarized on page 55. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans staff worked on all FEHB brochures to make them responsive, accessible,
and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, " you" means the enrollee or family member, " we" means MVP Health Plan.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first
Our brochure and other FEHB plans brochures have the same format and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve this brochure, let OPM know. Visit OPM s " Rate Us"
feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM
at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW
Washington, DC 20415-3650.

Inspector General AdvisoryStop
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 888/ 687-6277 and

explain the situation.
If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE--202/ 418-3300
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. 4
4 Page 5 6
2002 MVP Health Care 5 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
We are an Individual Practice Association ( IPA) HMO. We have over 9,000 doctors who operate in private practices
and are available to serve you as a Primary Care Physician ( PCP) or Specialist. Our PCPs may refer you to any MVP
Specialist, except in Vermont. Vermont PCPs who are part of the Vermont Managed Care ( VMC) network may only
refer you to VMC Specialists. Please refer to MVP s Provider Listing which clearly identifies all VMC physicians. If
you have any questions regarding the referral process, please call our Member Services Department at 888/ 687-6277.
You will be using the general acute hospital facilities located throughout our service area for hospital care, depending
upon where your doctors have admitting privileges. If you need a service that is medically necessary, and is covered
through MVP, and you cannot obtain that service at the community hospitals, it will be arranged for at other
appropriate facilities.

Your Rights
OPM requires that all FEHB Plans to provide certain information to their FEHB members. You may get information
about us, our networks, our 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.

MVP Health Plan is licensed in the States of New York and Vermont to operate as an HMO. MVP Health Plan has been in operation since 1983
MVP Health Plan is a not-for-profit, federally qualified HMO
If you want more information about us, call 888/ 687-6277, or write to MVP Health Care, 111 Liberty Street,
Schenectady, NY 12305. You may also contact us by fax at 518/ 356-7460 or visit our website at
http: / / www. mvphealthcare. com 5
5 Page 6 7
2002 MVP Health Care 6 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 as follows:

Eastern Region ( GA1 Self only, GA2 Self and family) : The New York counties of Albany, Fulton, Hamilton,
Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington.

Central Region ( M91 Self only, M92 Self and family) : The New York counties of Broome, Chenango, Delaware,
Herkimer, Lewis, Madison, Oneida, Onondaga, Otsego, and Tioga.

Mid-Hudson Region ( MX1 Self only, MX2 Self and family) : The New York counties of Columbia, Dutchess, Greene,
Orange, Putnam, and Ulster.

Vermont ( VW1 Self only, VW2 Self and family) : The Vermont counties of Addison, Bennington, Caledonia,
Chittenden, Essex, Franklin, Grand Isle, Lamoille, Orange, Orleans, Rutland, Washington, Windham, and Windsor.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care benefits. We will not pay for any other health care services outside of our
service area unless the services have prior plan approval.

If you or a covered family member moves outside of our service area, you can enroll in another plan. You do not have
to wait until Open Season to change plans. If your dependents live out of the area you should consider enrolling in a
fee-for-service plan or an HMO that has agreements with affiliates in other areas. Contact your employing or
retirement office. 6
6 Page 7 8
2002 MVP Health Care 7 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure, any language change not shown here is a
clarification that does not change benefits.

Program-wide change
We no longer limit total blood cholesterol tests to certain age groups. ( Section 5( a) )
We now cover routine screening for chlamydial infection. ( Section 5( a) )
We increased speech therapy benefits by removing the requirement that services must be required to restore functional speech. ( Section 5( a) )

We clarified the brochure to show why we think you should use generic drugs whenever possible. We moved other language around within the Prescription drugs section but didn t change its meaning. ( Section
5( f) )
We changed the address for sending disputed claims to OPM. ( Section 8)

Changes to this Plan
If you are in Enrollment Code GA, your share of the non-Postal premium will increase by 12.6 % for Self Only and decrease by 10.8% for Self and Family

If you are in Enrollment Code M9, your share of the non-Postal premium will increase by 16.8% for Self Only and decrease by 25.3% for Self and Family.
If you are in Enrollment Code MX, your share of the non-Postal premium will decrease by 13.9 % for Self Only and increase by 14.1% for Self and Family.
If you are in Enrollment Code VW, your share of the non-Postal premium will increase by 109.7% for Self Only and increase by 89.3% for Self and Family.
We have removed the quantity ( 100 unit/ 300 unit) limit on prescription drugs.
Members only pay one $ 10.00 copay per surgery. This copay is usually paid to the facility. ( Section 5( b) and Section 5( c) )

Members pay the lesser of a $ 10.00 copay or 20 % of the cost of diabetes treatment services. ( Section 5 ( a) ) 7
7 Page 8 9
2002 MVP Health Care 8 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 obtain 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 888/ 687-
6277.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments, deductibles, 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
( http: / / www. mvphealthcare. com) .

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
to get covered care member must choose a primary care physician ( PCP) . This decision is important since your PCP provides or arranges for most of your health

care. Please use our provider directory or our website to choose your
PCP.

Primary care Your PCP can be a doctor in Family or General Practice, Internal Medicine, OB/ GYN, or Pediatrics. 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. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize any follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you
may see any Plan gynecologist for routine office visits, or care related to
pregnancy without a referral. 8
8 Page 9 10
2002 MVP Health Care 9 Section 3
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 develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
and must obtain authorization from a Plan Medical Director. Your
PCP will submit his/ her recommendation to our Medical Director and
then the Medical Director will notify both you and your PCP in
writing as to our decision. Please contact our Member Services
Department at 1-888-687-6277 if you have any questions about this
process.

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.

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 FEHB 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 Member Services Department immediately at 1-888-687-6277. If
you are new to the FEHB Program, we will arrange for you to receive
care. 9
9 Page 10 11
2002 MVP Health Care 10 Section 3
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

You are dis harged, not merely moved to an alternative are enter; 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 hospital benefit 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.

Services requiring our Your primary care physician has authority to refer you for most services.
prior approval 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:

Inpatient Hospital Admissions Organ/ Tissue Transplants
Cardiac rehabilitation programs Pulmonary rehabilitation programs
Skilled nursing facility care Home health care
Health education and nutritional counseling Sexual dysfunction services and prescriptions
Elective inpatient, and certain outpatient procedures
Your physician will contact our medical review staff in order to obtain
our approval. We may contact you and ask you some questions about
your condition and the treatment you have received in the past.

If our Medical Director does not approve this procedure, you may follow
the disputed claims process detailed in Section 7. 10
10 Page 11 12
2002 MVP Health Care 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay when you receive services.

Example: When you see your primary care physician you pay a
copayment of $ 10 per office visit and when you go in the hospital, you
pay nothing per admission.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for those services.
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 50% of our allowance for advanced
infertility services and 20% for durable medical equipment.

Your out-of-pocket maximum After you make copayments equal to or greater than two times the cost of the total, annual plan premium for two or more family members, you do
not have to make any additional payments for certain services for the rest
of the year. This amount is called your out-of-pocket maximum.
However, copayments for your prescription drugs do NOT count toward
this maximum and you must continue to make these copayments.

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 11
11 Page 12 13
2002 MVP Health Care 12 Section 5
Section 5. Benefits --OVERVIEW
( See page 7 for how our benefits changed this year and page 55 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; as 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
888/ 687-6277 or at our web site at http: / / www. mvphealthcare. com

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-21
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 Physical and occupational therapies
Speech therapy

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
Chiropractic Alternative treatments
Educational classes and programs

( b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . 22-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-28
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30
Medical emergency Ambulance

( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-32
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-34
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

After Hours MVP Unit Services for the deaf and hearing impaired
High risk pregnancies
Travel benefit/ Overseas Out-of-area student coverage ( to age 22)

( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-37
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 12
12 Page 13 14
2002 MVP Health Care 13 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 do not have a 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 physician s office, including office medical consultations and second surgical opinions

Initial examination of a newborn child covered under a family enrollment

$ 10 per office visi

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

Nothing

At home $ 10 per visit
Not covered:
Dental treatment of temporomandibular joint( TMJ) syndrome
Costs for which a member fails to keep an appointment
All charges. 13
13 Page 14 15
2002 MVP Health Care 14 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 if you receive these
services during your office visit;
otherwise, $ 10 per visit

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years, , ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test

$ 10 per office visit

Sigmoidoscopy, screening every five years s ar ing a age 50
Prostate Specific Antigen ( PSA es ) one annually for men age 40 and older $ 10 per office visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment , above.

$ 10 per office visit

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 49, one every one or two calendar years
From age 50 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, limited to:
Tetanus-diphtheria ( Td) booster once every 10 years, , ages 19 and over ( except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

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

Not covered: Immunizations or vaccinations for employment,
educational, insurance, or travel purposes
All Charges 14
14 Page 15 16
2002 MVP Health Care 15 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Examinations, such as:
-Well-child care charges for routine examinations, immunizations
and care ( through age 22)

-Examinations done on the day of immunizations ( through age 22)

Nothing

-Eye exams through age 17 to determine the need for vision
correction.

-Ear exams through age 17 to determine the need for hearing
correction ( exams for screening only)

$ 10 per office visit ( for refraction
only)

$ 10 per office visit ( for screening
only)

Maternity care
Complete maternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
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) .

$ 10 copay for the initial office
visit only and nothing thereafter

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A broad rage of family planning services, such as:
Voluntary sterilization
Surgically implanted contraceptives ( such as Norplant)
Injectable contraceptive drugs ( such as Depo provera)
Intrauterine devices ( IUDs)
Diaphrams
NOTE: We cover oral contraceptives under the prescription drug
benefit.

$ 10 per office visit 15
15 Page 16 17
2002 MVP Health Care 16 Section 5( a)
Family planning ( Continued) You pay
Not covered:

reversal of voluntary surgical sterilization,
genetic counseling, voluntary abortions, embryo transfer, GIFT, ZIFT, in-vitro fertilization

All charges.

Infertility services
Basic infertility services include those services provided for the initial
evaluation and testing for infertility.
$ 10 per office visit for Basic
services

Advanced infertility services such as:
Semen analysis
Post-coital examinations
Hysterosalpingograms
Varicocele surgery
Artificial insemination ( up to six cycles) :
-intravaginal insemination ( IVI)

-intracervical insemination ( ICI)
-intrauterine insemination ( IUI)
Note: You and your spouse must have already received basic infertility
services before you are eligible for advanced infertility services. You
must obtain a referral from your PCP in order to see a Plan specialist for
infertility services.

50% per visit for Advanced
services

Fertility drugs ( including drugs taken orally) such as: HCG, Progesterone injections, Menotropins, Urofollitropins, Serophene
( Clomid)
50% copay per cycle of fertility
drugs

Not covered:
Assisted reproductive technology ( ART) procedures, such as:

-in-vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer

Services and supplies related to excluded ART procedures
Cost of donor sperm or sperm banking
Cost of donor egg
Gender Selection
External pump for administration of infertility drugs
Reversal of vasectomy or tubal ligation

All charges. 16
16 Page 17 18
2002 MVP Health Care 17 Section 5( a)
Allergy care You pay
Testing and treatment
Allergy injection
$ 10 per office visit

Allergy serum Nothing
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 is limited to those transplants listed under
Organ/ Tissue Transplants on page xx.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy ( GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. .
Call 1-888-687-6277 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask OR if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

$ 10 per office visit

Not covered: treatment that is not authorized or provided by a Plan
doctor
All charges.

Physical and occupational therapies
Two consecutive months per acute condition for the services of each of the following:

-qualified physical therapists and;
-occupational therapists.
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or
injury. Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 36 sessions

$ 10 per outpatient visit
Nothing per visit during covered
inpatient admission

Not covered:
long-term rehabilitative therapy exercise programs
All charges. 17
17 Page 18 19
2002 MVP Health Care 18 Section 5( a)
Speech Therapy You pay
Two consecutive months per acute condition $ 10 per office visit

Hearing services ( testing, treatment, and supplies)
Hearing testing for children through age 17 ( see Preventive care, children ) . Exams for screening purposes only. $ 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)
Routine eye refractions, covered once every 24 months
Note: You do not need a referral for the refraction exam. You will
need a referral from your Primary Care Physician for any eye exams
involving a diagnosed or suspected illness.

$ 10 per office visit

Not covered:
Eyeglasses or contact lenses
Eye exercises
Radial keratotomy and other refractive surgery

All charges.

Foot care
Non-routine foot care such as care that you receive when you are under
active treatment for a metabolic or peripheral vascular disease, such as
diabetes. You are limited to ten visits per year.

$ 10 per office visit

Not covered:
Routine foot care such as 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)
Foot orthotic devices such as arch supports and shoe inserts

All charges. 18
18 Page 19 20
2002 MVP Health Care 19 Section 5( a)
Orthopedic and prosthetic devices You pay
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, pacemakers, and surgically implanted breast implant following mastectomy. Note:
We pay internal prosthetic devices as hospital benefits; see Section
5 ( c) for payment information. See 5( b) for coverage of the surgery
to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint ( TMJ) pain dysfunction syndrome

20% of charges

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic repair or replacements unless authorized by MVP
Wigs and other hair prostheses

All charges. 19
19 Page 20 21
2002 MVP Health Care 20 Section 5( a)
Durable medical equipment ( DME) You pay
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:

Wheelchairs;
Crutches;
Walkers;
Braces

20% of charges

Blood glucose monitors; and
Insulin pumps. 20% of the cost or a $ 10 copay ( whichever is less) for services and equipment necessary for the treatment

of diabetes

Note: Call us at 888/ 687-6277 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Note: Services and equipment necessary for the treatment of diabetes is
limited to a 31-day supply per each copay.

Not covered:
Motorized wheel chairs
Exercise Equipment
Car or Van Lifts
Hearing aids
Personal comfort items

All charges.

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

$ 10 per visit

Not covered:
nursing care requested by, or for the convenience of, the patient or the patient s family;

home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.

All charges. 20
20 Page 21 22
2002 MVP Health Care 21 Section 5( a)
Chiropractic You pay
For spinal manipulation only.
Note: You must obtain a referral from your primary car physician
$ 10 per office visit

Alternative treatments
Not covered:
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback

All charges

Educational classes and programs
Coverage is limited to:

Diabetes self-management
You may attend educational classes in most participating Plan hospitals
please contact the hospital directly for details. . You need a referral
from your PCP to attend a class.

$ 10 copay 21
21 Page 22 23
2002 MVP Health Care 22 Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and other
health care professionals

I M
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Here are some important thing to keep in mind about these benefit :
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 mus provide or arrange your care.
We do no have a calendar year deduc ible.
Be sure o read Sec ion 4, Your costs for covered services for valuable informa ion about how cos sharing works. Also read Section 9 about coordina ing benefi s wi h other coverage, including wi h

Medicare.
The amoun s listed below are for the charges billed by a physician or o her heal h care professional for your surgical care. Look in Sec ion 5 ( c) for charges associa ed wi h he facility charge ( i. e.

hospi al, surgical cen er, e c. ) .
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precer ification information shown in Section 3 to be sure

which services require precer ification and identify which surgeries require precer ification.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible
members must be age 18 or over. Will only be covered with Plan
preauthorization and when medically necessary.

Insertion of internal prostethic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

$ 10 per office visit

Surgical procedures continued on next page. 22
22 Page 23 24
2002 MVP Health Care 23 Section 5( b)
Surgical procedures ( Continued) You pay
Voluntary sterilization
Treatment of burns

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.

$ 10 per office visit

Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.

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: protruding ear deformities; cleft lip; cleft
palate; birth marks; 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;
-breast prostheses and surgical bras and replacements ( see
Prosthetic devices)

Note: If you need a mastectomy, you may choose to have this procedure
performed on an inpatient basis and remain in the hospital up to
48 hours after the procedure.

Note: See Orthopedic and Prosthetic Devices for information on the
actual breast prostheses. You pay 20% of charges for breast protheses.

$ 10 per office visit

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
2002 MVP Health Care 24 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to the nondental:
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.

$ 10 per office visit

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures ( such as the periodontal membrane, gingiva, and alveolar bone)

Any dental care involved in the treatment of temporomandibular joint ( TMJ) pain dysfunction syndrome

All charges.

Organ/ tissue transplants
Non-experimental transplants are limited to:
Cornea Heart

Kidney Liver
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
Intestinal transplants ( small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach and pancreas

Nothing

Organ/ tissue transplants continued on next page 24
24 Page 25 26
2002 MVP Health Care 25 Section 5( b)
Organ/ tissue transplants ( Continued) You pay
Note: You must receive prior approval from the MVP Medical
Director.

Note: National Transplant Program ( NTP) We contract with aCenters
of Excellence network for all transplant services. The network we use
is the United Resource Network ( URN) . URN selects facilities for
participation in their network by using criteria such as: transplant
experience, transplant volume, survival rates, geographic location, and
medical education of the center and its staff.

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

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in
Hospital ( inpatient)
Hospital outpatient department
Ambulatory surgical center

Nothing

Professional services provided in
Skilled nursing facility
Office

$ 10 per visit 25
25 Page 26 27
2002 MVP Health Care 26 Section 5( c)
Section 5 ( c) . Services provided by a hospital or other facility, and
ambulance services

I M
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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.

We do not have a 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 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 Sections 5( a) or
( b) .

YOUR PHYSICIAN MUST RECEIVE OUR APPROVAL FOR ALL HOSPITAL STAYS . Please refer to Section 3 for a list of services that require

preauthorization.

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

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

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
Take-home items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges. 26
26 Page 27 28
2002 MVP Health Care 27 Section 5( c)
Outpatient hospital or ambulatory urgical 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 certain
dental procedures when a Plan doctor believes that there is a need for
hospitalization for reasons totally unrelated to the dental procedure.
This would include conditions such as hemophilia and heart disease.
The need for anesthesia, by itself, is not such a condition. We do not
cover the dental procedures.

$ 10 per outpatient surgery or
procedure

Not covered:
Blood and blood derivatives not replaced by the member
Personal comfort items such as telephone and television

All charges

Extended care benefits/ skilled nur ing care facility benefits
Extended care benefits/ skilled nursing care facility benefits: We cover up
to 45 days per calendar year when full-time skilled nursing care is
necessary. All necessary services are covered including:

Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan
doctor.
Note: In certain situations, we may approve skilled nursing care in a
hospital. This happens when there are no skilled nursing facilities that are
near you. y ( for example, when there is no skilled nursing facility near
you) . In these instances, the Please remember that the inpatient hospital
days will count toward your 45-day skilled nursing facility annual
maximum benefit.

Nothing

Not covered: custodial care, rest cures, domiciliary or convalescent
care
All charges 27
27 Page 28 29
2002 MVP Health Care 28 Section 5( c)
Hospice care You pay
We cover up to 210 days of hospice care for a terminally ill member in the
home or a hospice facility. Services are provided under the direction of a Plan
doctor who certifies that the patient is in the terminal stages of illness, with a
life expectancy of approximately six months or less. Covered services must be
billed by the hospice and include:

Inpatient hospice care
Outpatient care, including drugs and medical supplies
Five visits for bereavement counseling of the immediate family

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance services when appropriate, medically necessary, and ordered or authorized by a Plan doctor Nothing 28
28 Page 29 30
2002 MVP Health Care 29 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
I M
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Here are some impor an hings o keep in mind abou hese benefi s:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information abou how cos sharing works. Also read Sec ion 9 about coordina ing benefits wi h other

coverage, including with Medicare.

I M
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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:
Please call your primary care doctor when you are in an emergency situation. In extreme emergencies, if you
are unable to contact your doctor, contact the local emergency system ( e. g. , the 911 telephone system) or go to
the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan
member so they can notify us. You or a family member should notify us within 48 hours by calling 1-888-
687-6277. It is your responsibility to ensure that the Plan has been timely notified. If you need to be
hospitalized, we must be notified within 48 hours or on the first working day following your admission, unless
it was not reasonably possible to notify the Plan within that time.

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

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition. However, follow-up
care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers. 29
29 Page 30 31
2002 MVP Health Care 30 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
Emergency care as an outpatient or inpatient at a hospital, including doctors services

$ 35 per urgent care center
visit or hospital
emergency room visit
Note: We waive this
copay if you are
admitted to the hospital

Not covered:
Elective care or non-emergency care
Prescriptions written by non-Plan doctors

All charges.

Emergency outside our service area
Emergency care at a doctor s office Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors services
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

Prescriptions written by non-Plan doctors

All charges.

Ambulance
Professional ambulance service when medically appropriate and
ordered or authorized by a Plan doctor

See 5( c) for non-emergency service.

Nothing

Not covered: air ambulance if not medically necessary All charges. 30
30 Page 31 32
2002 MVP Health Care 31 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
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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 do not have a 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.
YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Call us at 1-888-687-6277 before seeking mental health and substance abuse care. See the instructions after

the benefits description below.

I M
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T

Benefit Description You pay
Mental health and substance abuse benefits
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 individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

$ 10 per visi

Mental health and substance abuse benefits -Continued on next page 31
31 Page 32 33
2002 MVP Health Care 32 Section 5( e)
Mental health and substance abuse benefits ( Continued) You pay
Diagnostic tests Nothing if you receive these
services during your office
visit; otherwise, $ 10 per visit

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.
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 obtain a treatment plan and follow all of the following authorization processes:
Call our Member Services Department at 1-888-687-6277 before seeking treatment.
Limitation We may limit your benefits if you do not obtain a treatment plan. 32
32 Page 33 34
2002 MVP Health Care 33 Section 5( f)
Section 5 ( f) . Prescription drug benefits
I
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T

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

All benefits are subjec o the definitions, limita ions and exclusions in his brochure and are payable only when we de ermine hey are medically necessary.
We do no have a calendar year deduc ible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Sec ion 9 about coordina ing benefits wi h

other coverage, including with Medicare.

We administer an open prescription drug formulary. If your physician believes a name brand produc is necessary or here is no generic available, your physician may
prescribe a name brand drug from a formulary lis . This lis of name brand drugs is a
preferred lis of drugs ha we selec ed o mee pa ient needs at a lower cos . To order a
copy of our prescrip ion drug formulary please call us a 1-888-687-6277.

I
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There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician must write the prescription. Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail for a

covered maintenance medication. Please call our Member Services Department at 1-888-687-6277
or visit our website at http: / / www. mvphealthcare. com to determine whether or not a maintenance
medication is available through our mail order program.
We use a formulary. Our formulary is a list of medications that we approved for your use. Our Plan doctors prescribe drugs and Plan pharmacies dispense them in accordance with our formulary.

A committee of primary care and specialty physicians, pharmacists and other healthcare
professionals used clinical data to develop our formulary. They periodically review it and choose
the most effective drugs for treating illness and disease. We will cover non-formulary drugs when
prescribed by a Plan doctor. If you have questions about our formulary, please visit our website at
http: / / www. mvphealthcare. com or call our Member Services Department at 1-888-687-6277
These are the dispensing limitations.

-You may obtain up to a 30-day supply per copay from a participating Retail pharmacy.
-Under our mail-order program, we limit prescription drug amounts to a 90-day supply per copay.
You may contact our Member Services Department at 1-888-687-6277 or visit our website at
http: / / www. mvphealthcare. com to find out if a certain drug is covered through our mail order
program. You will also need an order form which you can download from our website to
use this benefit. Unfortunately, all drugs are not available through the mail-order program.

-Ask your doctor to write two prescriptions when your doctor prescribes a drug eligible for the mail
order program one for up to 30--days to be filled at your local pharmacy, and one to last up to
90-days which should be filled through familymeds. com. Complete and sign an order form and
attach the 90-day prescription. Then, mail everything to Familymeds. com, PO Box 150404,
Hartford, CT 06115-0404.

Why use generic drugs?
You can save money by using generic drugs. However, you and your physician have the option to
request a name-brand if a generic option is available. Using the most cost-effective medication
saves money.

Prescription drug benefits begin on the next page. 33
33 Page 34 35
2002 MVP Health Care 34 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 and medicines that by Federal law of the United States require a physician s prescription for their purchase, except as
excluded below.
Enteral formulas when medically necessary ( contact Plan for details)

Drugs for sexual dysfunction ( see note below) Contraceptive drugs

Note: Drugs to treat sexual dysfunction are limited. Please contact Plan for
dose limits and prior authorization.

$ 5 per Generic prescription unit
or refill from a participating
Retail pharmacy

$ 20 per Brand Name prescription
unit or refill from a participating
Retail pharmacy

Note: We do not waive the name
brand copay when a generic drug
is not available.

Diabetic supplies such as insulin, needles and syringes, glucose test tablets and test tape, Benedict s solution or equivalent, glucose
monitors and acetone test tablets ( 31-day supply per dispensing)
Lesser of $ 10 or 20% for the cost
of insulin and other diabetic
supplies

Disposable needles and syringes for the administration of covered medications, as well as dressings and antiseptics 20% copay for disposable needles and syringes needed to inject
covered prescription medications

Up to a 90-day supply of maintenance medication by Mail-order

Note: All prescription drugs are not available through mail.
$ 10 per Generic prescription for
up to a 90-day supply by Mail
Order

$ 40 per Brand Name prescription
for up to a 90-day supply by Mail
Order

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

Nonprescription medicines
Drugs obtained at a non-Plan pharmacy ( except for out-of-area emergencies)

Drugs to enhance athletic performance
Refills due to a lost or misused prescription drug supply
Drugs used in connection with the provision of a non-covered service or benefit

All Charges 34
34 Page 35 36
2002 MVP Health Care 35 Section 5( g)
Section 5 ( g) . Special Features
Feature Description
After Hours MVP Unit For any of your health concerns, or if you have a question concerning your benefits, from 8: 00 am Midnight, , 7 days a week, you may call
1-888-687-6277 and talk with a registered nurse or Member Services
Representative who will discuss treatment options and answer your
health questions.

Services for deaf and
hearing impaired

If you are hearing impaired and wish to speak with a Member Services
Representative please first contact a relay operator at 1-800-662-1220
and then they will call our Member Services Unit ( at 1-888-687-6277)
and help you during your conversation with our representative.

High risk pregnancies
MVP s Little Footprints is a special program for women who have had a
problem with a past pregnancy or who are at risk for having problems
during their current pregnancy. You must have at least three months left
in the pregnancy to be eligible to participate. As part of this program one
of our prenatal nurses will call you every month to discuss the progress of
your pregnancy and what can be done to help ensure a healthy pregnancy
and to answer any questions she may have.
You or your physician may contact us concerning this program. If you
feel you might benefit from this program please contact our Member
Services Department at 1-888-687-6277.

Travel benefit/ services
overseas

As an MVP member you are covered for emergency care anywhere in
the world. If you or your family member ever have a medical
emergency, either outside of our service area or outside of the United
States, please go to the nearest hospital or medical facility. Please
contact our Member Services Department as soon as possible at 1-888-
687-6277 so that we may arrange for any necessary follow-up care that
you may need.

Out-of-area student
benefit

We offer extended coverage for any of your dependent children up to
age 22 provided that your child is a full-time student at an accredited
college ( full-time means 12 or more credit hours per semester) . This
benefit covers your child for care and services outside of our service
area that he or she would normally obtain within our service area such
as sick visits, outpatient surgery, and physical therapy. This benefit
does not include coverage for routine preventive care such as physical
exams, immunizations, and elective inpatient hospital services.

This benefit is limited to $ 2,500 maximum per year. You will be
reimbursed the cost of covered services minus your applicable copay.
You will not be reimbursed if you submit claims to us one year after
the date of service. You must submit claims to us at: MVP Health
Plan, PO Box 2207, Schenectady, NY 12301. If you have any
questions about claims submission or this out-of-area benefit please
contact our Member Services Department at 1-888-687-6277. 35
35 Page 36 37
2002 MVP Health Care 36 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 the e benefits:
Please remember hat all benefits are subjec o the definitions, limita ions, and exclusions in this brochure and are payable only when we de ermine they are medically necessary.

Our preventive den al benefits are only for children under age 19 .
You may bring your child to any den is tha you wish o receive hese covered services
We cover hospitaliza ion for den al procedures only when a non-den al physical impairment exists which makes hospitaliza ion necessary o safeguard he heal h of he pa ient; we do no cover the

dental procedure unless i is described below.
Be sure to read Section 4, Your costs for covered services, for valuable informa ion abou how cos sharing works. Also read Sec ion 9 about coordina ing benefits wi h 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
( but not replace) sound natural teeth. The need for these services must
result from an accidental injury. You pay nothing. Treatment must be
performed within 12 months of the accident.

Nothing

Not Covered:
Dental services not shown as covered Dental services that result from injury while eating All Charges

Dental Benefits
Service You pay

The following preventive and diagnostic services are covered for Plan
members under age 19:

One initial oral exam followed by periodic exams, once every six months
Bite wing x-rays, once every six months
Full mouth x-rays and panoramic x-rays, once every 36 months
Routine cleaning, scaling, and polishing of teeth, once every six months

Fluoride treatments, once every six months, to age 16
Pulp vitality testing and diagnostic casts, as needed
Space maintainers and recementation thereof, as needed
Intra-oral and periepical x-rays, as needed
Sealants once per tooth per child ( only covered to age 16)

$ 10 per office visit

Dental benefits -Continued on next page 36
36 Page 37 38
2002 MVP Health Care 37 Section 5( h)
Dental Benefits ( Continued) You pay
Note: You may see the dental provider of your choice to receive
benefits. Your dentist may require you to pay for the services at the
time they are rendered, in which case you should submit a claim to us
for full reimbursement, less your $ 10 copay. You may obtain a claim
form by calling us at 888/ 687-6277. Claim forms should be mailed to:
Dental Benefit Providers, 7200 Wisconsin Ave, Suite 800, Bethesda,
Maryland, 20814.

If you do not file your claims promptly, we will still accept them if they
are filed as soon as reasonably possible. We will neither accept nor
provide coverage for claims that are submitted later than one ( 1) year
after a service is performed.

Not covered:
Other dental services not shown as covered
Services which are not approved by the Council of Dental Therapeutics of the America Dental Association ( ADA)

Services rendered by a medical department, clinic, or similar facility of the child s employer, labor union, mutual benefits
association, or other similar group
Charges for dental appointments that are not kept
Dental implants

All charges 37
37 Page 38 39
2002 MVP Health Care 38 Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them . Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

Expanded vision care
You are entitled to various discounts on designated eyewear purchases just by being an MVP Member. Please see the
MVP Health Plan Something Extra brochure for listings of participating optical shops, and the type of discounts that
they offer.

Fitness programs
Also by being an MVP member you may receive discounts from local Health and Fitness Clubs and Weight Control
Centers on designated enrollment, membership or registration fees. Please see the MVP Health Plan Something Extra
brochure for a listing of participating Health and Fitness Clubs and Weight Control Centers.

Safety equipment
MVP Health Plan offers you discounts on safety equipment for the home and car, and for personal use when
purchased through our Something Extra program. Items such as bicycle helmets, child car seats and smoke detectors
are available by calling our Member Services Department at 888/ 687-6277 or by visiting our website at
http: / / www. mvphealthcare. com .

If you have any questions about any of these benefits, please contact the MVP Member Services Department at
888/ 687-6277. 38
38 Page 39 40
2002 MVP Health Care Section 6 39
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
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program 39
39 Page 40 41
2002 MVP Health Care 40 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,
coinsurance, or deductible.

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, hospital and In most cases, providers and facilities file claims for you. Physicians
prescription drug benefits 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 1-888-687-6277.

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 of the 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: MVP Health Care,
111 Liberty Street
Schenectady, NY 12305.

Dental services For children s preventive dental benefit, the dentist may have you pay the cost of the entire visit. If so, please call Member Services at 1-888-687-
6277 to obtain a claim form. As long as the visit was for covered care,
you will be reimbursed the cost of the visit less your $ 10 copay.

Submit your claims to: Dental Benefit Providers
7200 Wisconsin Avenue, Suite 800
Bethesda, MD 20814.

We will not accept, or provide coverage for claims that are submitted
more than one year after the date of service.

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. 40
40 Page 41 42
2002 MVP Health Care 41 Section 8
Section 8. The disputed cl ims 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: MVP Health Care, 111 Liberty Street, Schenectady, NY 12305; 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 3,
1900 E Street, NW, Washington, D. C. 20415-3630. 41
41 Page 42 43
2002 MVP Health Care 42 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 include 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 or from the year in which you were denied precertification or prior
approval. 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 1-
888-687-6277 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 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 42
42 Page 43 44
2002 MVP Health Care 43 Section 9
Section 9. Coordin ting 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 Pr gram f r:
People 65 years of age and older. S me 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 ( H spital Insurance) . M st pe ple d n t have t pay f r Part A. If y u or your spouse worked for at least 10 years in Medicare-covered employment,

you sh uld be able to qualify f r premium-free Part A insurance. ( S meone who
was a Federal empl yee on January 1, 1983 r since aut matically qualifies) .
Otherwise, if you are age 65 or lder, you may be able t buy it. Contact 1-800-
MEDICARE for more information.

Part B ( Medical Insurance) . Most people pay monthly f r Part B. Generally, Part B premiums are withheld fr m your monthly S cial Security check r your

retirement check.
If you are eligible for Medicare, you may have choices in how you get your health
care. Medicare + Choice is the term used to describe the various health plan
ch ices available t Medicare beneficiaries. The inf rmation in the next few pages
shows h w we coordinate benefits with Medicare, depending on the type f
Medicare managed care plan you have.

The Origin l Medicare Plan The Original Medicare Plan ( Original Medicare) is ( Part A or Part B) available everywhere in the United States. It is the way everyone used to get
Medicare benefits and is the way most people get their Medicare Part A and
Part B benefits now. You may go to any doctor, specialist, or hospital that
accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like
prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure and use our providers in
order for us to cover your care. We will not waive any of our
copayments or coinsurance.
( Primary payer chart begins on next page. ) 43
43 Page 44 45
2002 MVP Health Care 44 Section 9
The following chart illustrates whether the Original Medicare Plan 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.

Prim ry Payer Chart
Then the prim ry p yer is A. When either you --or your covered spouse --are age 65 or over and

Origin l Medic re This Plan
1) Are anactive empl yee with theFederalgovernment( including whenyou or
afamily member areeligiblefor Medicares lely becauseof adisability) , X

2) Are an annuitant, X
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB X

b) Or, the position is not excluded from FEHB
( Ask your employing office which of these applies to you. ) X

4) 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) , X

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

X
( for other
services)

6) 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,

X
( exceptf r claims
related t 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, X

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

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

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

b) Are an active employee, or . X

c) Are a former spouse of an annuitant, or . X

d) Are a former spouse of an active employee . X

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 44
44 Page 45 46
2002 MVP Health Care 45 Section 9
Claims process when you have the Original Medicare Plan You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.

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 1-888-687-
6277.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan 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 provide all the benefits that Original
Medicare covers. 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 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 or 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, coinsurance, or
deductibles. If you enroll in a Medicare managed care plan, tell us. We
will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with
Medicare.

Suspended FEHB coverage to enroll in 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. 45
45 Page 46 47
2002 MVP Health Care 46 Section 9
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can t get premium-free Part A, we will not ask you to
enroll in it.

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.

Workers Compensation We do not cover services that:
You need because of a workplace-related illness 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 care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital
for injuries 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. 46
46 Page 47 48
2002 MVP Health Care 47 Section 10
Section 10. Definitions of 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.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Includes any service which can be learned and provided by an average individual who does not have medical training. Examples of custodial

care include: help with walking or getting out of bed, or assistance in
daily living activities such as feeding, dressing, and personal hygiene.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for

those services. See page 11.
Experimental or Services that are generally not accepted by informed health care
investigational services providers in the United States as effective in treating the condition for which their use is being recommended.

We will only provide coverage for these type of services if the proposed
treatment has: shown promising results in treating the underlying
condition through a nationally recognized program, and a group of
experts has reviewed the proposed treatment and thinks that it is
appropriate.

If an appeal agent, outside of our Plan approves coverage for
experimental or investigational services for you, and you would be part
of a scientific trial or test, than our Plan would only provide limited
benefits for these services, and you would be responsible for the rest.

Group health coverage Coverage you are eligible to receive through your employer. This Plan is offered as group health coverage to you, and all other eligible employees

of the Federal Government.
Medical necessity Covered services that we determine are necessary to prevent, detect, correct, or cure conditions that cause you or a family member acute

suffering, endanger your life, result in illness, interfere with your
capacity for normal activity or threaten you with a significant medical
handicap

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine and base our allowance

on the reasonable and customary charge that most providers would bill
you for the service, procedure or office visit in question. Our
participating providers have agreed to accept payment from us in full
you and your family members are only responsible for your copay.

Us/ We Us and we refer to MVP Health Plan
You You refers to the enrollee and each covered family member. 47
47 Page 48 49
2002 MVP Health Care 48 Section 11
Section 11. FEHB f cts
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. 48
48 Page 49 50
2002 MVP Health Care 49 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you j ined this Plan
premiums start during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. Annuitants coverage and

premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.

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 Pr gram. Generally, you must have been enr lled in the FEHB Pr gram f r the last five years f y ur
Federal service. If y u do n t meet this requirement, you may be eligible for
other forms of c verage, 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.

Temporary continuation If you leave Federal service, or if you lose coverage because you no of coverage ( TCC) 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, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct. 49
49 Page 50 51
2002 MVP Health Care 50 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees ,
from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.

Converting to individual coverage You may convert to a non-FEHB individual policy if:

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 The Health Insurance Portability and Accountability Act of 1996 is
Group Health Plan Coverage a Federal law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage.

If you leave the FEHB Program, we will give you a Certificate of Group Health
Plan C verage that indicates h w 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, r exclusions
for health related conditions based on the information in the certificate, as long as
you enr ll within 63 days f l sing 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.

For more information, get OPM pamphlet RI 79-27. Temporary
Continuation of Coverage ( TCC) under the FEHB Program. See also the
FEHB web site ( www. opm. gov/ insure/ health) ; refer to the TCC and
HIPAA frequently asked question. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 50
50 Page 51 52
2002 MVP Health Care 51 Section 11
Long Term Care Insurance Is Coming Later in 2002
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial care you may need? You should consider buying long-term care insurance.

The Office of Personnel Management ( OPM) will sponsor a high-quality long term care insurance program effective
in October 2002. As part of its educational effort, OPM asks you to consider these questions:

What is long term care
( LTC) insurance?
It s insurance to help pay for long term care services you may need if you
can t take of yourself because of an extended illness or injury, or an age-
related disease such as Alzheimer s.
LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your home, adult day care, hospice

care, and more. It can supplement care provided by family members,
reducing the burden you place on them.

I m healthy. I won t need
long term care. Or, will I?
Welcome to the club!
76% of Americans believe they will never need long term care, but the facts are that about half of them will. And it s not just the old folks. About 40%

of people needing long term care are under age 65. They may need chronic
care due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan just in case. Many people now consider long term care insurance to be

vital to their financial and retirement planning.
Is long term care expensive? Yes, it can be very expensive. A year in a nursing home can exceed
$ 50,000. Home care for only three 8-hour shifts a week can exceed $ 20,000
a year. And that s before inflation!
Long term care can easily exhaust your savings. Long term care insurance can protect your savings.

But won t my FEHB plan,
Medicare or Medicaid cover
my long term care?

Not FEHB. Look at the Not Covered blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don t cover custodial care or a stay in an
assisted living facility or a continuing need for a home health aide to help
you get in and out of bed and with other activities of daily living. Limited
stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care ( the highest level of nursing care) after a hospitalization for those who are blind, age 65 or older or fully

disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state s poverty guidelines, but has restrictions on covered services and where they can be

received. Long term care insurance can provide choices of care and
preserve your independence.

When will I get more information
on how to apply for this new
insurance coverage?

Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
How can I find out more about the
program NOW?
Our toll-free teleservice center will begin in mid-2002. In the meantime,
you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc. 51
51 Page 52 53
2002 MVP Health Care 52 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
A ccidental injury 36 Allergy tests 17
Alternative treatment 21 Ambulance 28
Anesthesia 25 Autologous bone marrow
transplant 24 B iopsies 22
Blood and blood plasma 27 Casts 22
Changes for 2001 7 Chemotherapy 17
Childbirth 15 Cholesterol tests 14
Claims 12, 35, 37 Coinsurance 11
Colorectal cancer screening 14 Congenital anomalies 22, 23
Contraceptive devices and drugs 15, 34 Coordination of benefits 43
Covered charges 11 Covered providers 8-9
Crutches 20 D eductible 11
Definitions 47 Dental care 36, 37
Diagnostic services 13 Disputed claims review 41, 42
Donor expenses ( transplants) 25 Dressings 27, 34
Durable medical equipment ( DME) 20
E ducati nal classes and programs 21 Effective date of enrollment 49
Emergency 29, 30, 36 Experimental or investigational 47
Eyeglasses 18 F amily planning 15, 16
Fecal occult blood test 14 G eneral Exclusions 39

H earing services 18 Home health services 20Hospice
care 28 Home nursing care 20Hospital
26, 27 I mmunizations 15, 35
Infertility 16 In-hospital physician care 26
Inpatient Hospital Benefits 26 Insulin 20, 34
L aboratory and pathological services 14, 26
M achine diagnostic tests 13, 14 Magnetic Resonance Imagings
( MRIs) 14 Mail Order Prescription Drugs 34
Mammograms 14 Maternity Benefits 15
Medically necessary 47 Medicaid 46
Medicare 43, 44, 45 Members 46
Mental Conditions/ Substance Abuse Benefits 31, 32
Newborn care 15 Non-FEHB Benefits 38
Nurse Licensed Practical Nurse 20
Nurse Anesthetist 26 Registered Nurse 20, 35
Nursery charges 15 O bstetrical care 15
Occupational therapy 17 Office visits 13
Oral and maxillofacial surgery 24 Orthopedic devices 19
Out-of-pocket maximum 11 Outpatient facility care 27, 32
Oxygen 20, 22, 28 P ap test 14

Physical examination 14, 35 Physical therapy 17
Pre-admission testing 22 Precertification 22
Preventive care, adult 14 Preventive care, children 15
Prescription drugs 33, 34 Preventive services 14, 15
Prior approval 22 Pr state cancer screening 14
Prosthetic devices 19 Psychologist 31
Psychotherapy 31 R adiation therapy 17
Rehabilitation therapies 17 Renal dialysis 17
Room and board 26 S econd surgical opinion 13
Skilled nursing facility care 27 Speech therapy 18
Splints 26 Sterilization procedures 15,
23 Substance abuse 31, 32
Surgery 22, 23
Anesthesia 25, 26, 27 Oral 24

Outpatient 22 Reconstructive 23
Syringes 34 T emporary continuation of
coverage 49 Transplants 24, 25
Treatment therapies 17 V ision services 18
W ell child care 15 Wheelchairs 20Workers
compensation 46 X -rays 14, 26, 36 52
52 Page 53 54
2002 MVP Health Care 53
NOTES: 53
53 Page 54 55
2002 MVP Health Care 54
NOTES: 54
54 Page 55 56
2002 MVP Health Care 55 Summary
Summary of benefits for the MVP Health Plan -2002
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. . . . . . . . . . . . . . . . . . . . $ 10 per office visit 13

Services provided by a hospital:
Inpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nothing
$ 10 per surgery
26
27

Emergency benefits:
In-area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ 10 per office visit or $ 35 per
Urgent Care Center or Hospital
Emergency Room

Nothing

3030Mental

health and substance abuse treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular cost sharing. 31
Prescription drugs:
Retail Pharmacy ( up to a 30 day supply) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mail Order ( up to a 90 day supply) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 5 Generic/ $ 20 Name Brand per
prescription unit or refill

$ 10 Generic/ $ 40 Name Brand

33

Dental Care
Preventive Care for children up to age 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 10 per office visit
Nothing

36

Vision Care ( one covered eye exam every 24 months) . . . . . . . . . . . . . . . . . . . . . . . . $ 10 per office visit 18
Special features: MVP After Hours Unit; Little Footprints; Out-area-student benefit; Travel benefit/ services
overseas
35

Protection against catastrophic costs
( your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stated copays for covered benefits 11 55
55 Page 56
2002 MVP Health Care 56
2002 Rate Information for
MVP Health Plan

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, 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 who are not career postal employees. 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

Eastern New York

Self Only GA1 $ 86.03 $ 28.68 $ 186.41 $ 62.13 $ 101.81 $ 12.90

Self and Family GA2 $ 222.21 $ 74.07 $ 481.46 $ 160.48 $ 262.95 $ 33.33
Central New York

Self Only M91 $ 88.79 $ 29.60 $ 192.38 $ 64.13 $ 105.07 $ 13.32

Self and Family M92 $ 223.41 $ 82.32 $ 484.06 $ 178.36 $ 263.75 $ 41.98
Mid-Hudson

Self Only MX1 $ 97.25 $ 32.41 $ 210.70 $ 70.23 $ 115.07 $ 14.59

Self and Family MX2 $ 223.41 $ 111.47 $ 484.06 $ 241.51 $ 263.75 $ 71.13
Vermont

Self Only VW1 $ 97.86 $ 89.24 $ 212.03 $ 193.35 $ 115.52 $ 71.58

Self and Family VW2 $ 223.41 $ 259.85 $ 484.06 $ 563.00 $ 263.75 $ 219.51 56

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