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 Physicians 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 the structure of 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 Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a Plan doctor, 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 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired, or

contact us through our Web site at www. phpni. com 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 Physicians Health Plan Section 1 5
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific Plan 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 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.

Your Rights
Physicians Health Plan of Northern Indiana does not require you to choose one primary care doctor. What makes Physicians Health Plan of Northern Indiana special is that as a Plan member you will have the freedom to receive your medical care from
any of the more than 926 private practice doctors in all specialties at more than 291 locations. In addition, there are over 129 neighborhood participating pharmacies, 17 participating hospitals and over 9 urgent care facilities.

OPM requires 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.
We are licensed by the State of Indiana and in compliance with all applicable state laws and regulations. We were founded by a group of local doctors in 1983.
We are a not-for-profit managed care insurance company.
If you want more information about us, call 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired, or write to Physicians Health Plan of Northern Indiana, Inc., 8101 West Jefferson Boulevard, Fort Wayne,
Indiana 46804-4163. You may also contact us by fax at 260/ 432-0493 or visit our Web site at www. phpni. com. 5
5 Page 6 7

2002 Physicians Health Plan Section 2 6
Service Area
To enroll in this Plan, you must live or work in our Service Area. This is where our providers practice. Our service area is where you will find Plan providers and facilities. Our service area includes the following Indiana counties:

Adams, Allen, Dekalb, Jay, Huntington, Kosciusko, LaGrange, Noble, Steuben, Wabash, Wells, and Whitley.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the
services have prior Plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

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 changes
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will decrease by 17.1% for Self Only or 16.4% for Self and Family.

We clarified that the limit of 62 visits for physical and occupational therapies does not apply to cardiac rehabilitation services. (Section 5( a))

We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))
Your copays under the Prescription Drug Benefits have changed to $5 generic; $15 brand name formulary; $40 brand name non-formulary. The mail-order copays are $10 generic; $30 brand name formulary; $80 brand name non-formulary.
Prescriptions may be written by a participating or non-participating provider but must be filled at a participating pharmacy.
We now cover certain intestinal transplants. (Section 5( b))
We clarified the Preventive care, adult benefits by removing the entry for blood lead level testing for adults because it is a test more typically done for children. (Section 5( a))

Our telephone area code has changed from 219 to 260 effective January 1, 2002. 6
6 Page 7 8

2002 Physicians Health Plan Section 3 7
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809,
your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired or contact us through our Web site at
www. phpni. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and you will not have to file claims. Please remember you may be
required to pay this amount when you receive services. Ordinarily, you must get your care from providers who contract with us. If you receive care outside our
service area, we will pay only for emergency care. We will not pay for any other health care services rendered outside the service area unless there is a Plan
authorization made in advance.
Plan physicians Plan providers are doctors and other health care professionals in our service area that we contract with to provide covered services to our members. We credential
Plan doctors according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our Web site: www. phpni. 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 Web site.

What you must do PHP is an "open access" Health Maintenance Organization. We do not to get covered care require you to choose one primary care doctor and a referral is not necessary to
see a participating specialist. You have the freedom to receive medical care from any of our Plan providers or facilities.

Primary care We recommend that you choose a Primary Care Physician to oversee your health care for the best overall quality of care. The person you select may specialize in
Family and General Practice, Internal Medicine, Pediatrics, or Obstetrics/ Gynecology.

If your primary care physician leaves the Plan, call us. We will help you select a new one. 7
7 Page 8 9

2002 Physicians Health Plan Section 3 8
Specialty care A wide range of specialty care doctors is available among the Plan's more than 926 participating doctors. You do not need a referral from a primary care doctor
to see a specialty care doctor under the Plan. Consult the Plan Provider Directory or call the Customer Service Department at 260/ 432-6690, Extension 11; 800/ 982-
6257, Extension 11; or 260/ 459-2600 for the hearing impaired, for a specialist near you.

Here are other things you should know about specialty care:
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 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.

We may approve referrals to non-Plan providers for covered health services when your physician recommends such care and it is not available from Plan providers.
You must obtain all other related health services from Plan providers, including prescription drugs. 8
8 Page 9 10

2002 Physicians Health Plan Section 3 9
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 260/ 432-6690, Extension 11;
800/ 982-6257, Extension 11; or 260/ 459-2600 for the hearing impaired. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.

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

Services requiring our Your Plan physician must get our approval before sending you to a hospital prior approval for an inpatient stay, or referring you to a non-participating physician or facility.
Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.
Your doctor must obtain our approval for the following services:

Inpatient Services
Durable Medical Equipment
Growth Hormone Therapy
Transplants
Out-of-area Doctors
Maternity
Sleep Studies
Sclerotherapy
Feta Fibronectin
Immune Globulin
Penile Implants
Reconstructive Surgeries
Behavioral Health or Substance Abuse
Non-Emergency Ambulance Transportation 9
9 Page 10 11

2002 Physicians Health Plan Section 4 10
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 to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.
Coinsurance Coinsurance is the percentage of covered charges that you must pay for your care.
Example: You pay 40% of the charges for infertility treatment and 20% of hospital charges up to your out-of-pocket maximum.

Deductible We do not have a deductible.

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

Prosthetic and Orthotic Devices Emergency Room Charge

Mental Health and Substance Abuse Treatment
After your copayments and/ or coinsurance for Mental Health/ Substance Abuse services total $500 per person or $1, 500 per family enrollment in any calendar
year, you do not have to pay any more for covered services. However, copayments for the following services do not count toward your out-of-pocket maximum, and
you must continue to pay copayments for these services:
Prescription Drugs
Emergency Room Charge

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum. 10
10 Page 11 12

2002 Physicians Health Plan Section 5 11
Section 5. Benefits -- OVERVIEW
(See page 6 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; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired, or through our Web site at
www. phpni. com.
(a) Medical services and supplies provided by Plan doctors and other health care professionals ........................ 12-20
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 Plan doctors and other health care professionals..................... 21-24
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 25-27
Inpatient hospital Outpatient hospital or ambulatory surgical

center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ........................................................................................................................ 28-29 Medical emergency Ambulance

(e) Mental health and substance abuse benefits ................................................................................................... 30-31
(f) Prescription drug benefits................................................................................................................................ 32-34
(g) Special features .................................................................................................................................................... 35 Flexible benefits option

Services for deaf and hearing impaired Centers of excellence for transplants/ heart
surgery/ etc.

High risk pregnancies Travel benefit/ services overseas

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

Summary of benefits .................................................................................................................................................. 55 11
11 Page 12 13

2002 Physicians Health Plan Section 5( a) 12
Section 5 (a) Medical services and supplies provided by doctors and other health care professionals
I M
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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 doctors must provide or arrange your care.
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.
After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your out-of-pocket maximum.

See Section 4, Your out-of-pocket maximum, for more information.

I M
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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical opinion

$10 per office visit

Professional services of physicians
In an urgent care center
$30 per visit

Professional services of physicians
During a hospital stay
In an extended care or skilled nursing facility
At home

Nothing

Not covered:
Physical exams & immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or

travel or examinations that are not necessary for medical reasons.
Professional services that are subject to exclusion

All Charges 12
12 Page 13 14
2002 Physicians Health Plan Section 5( a) 13
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 office visit

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol
Colorectal Cancer Screening, including
-Fecal occult test
-Sigmoidoscopy, screening

$10 per office visit

Prostate Specific Antigen (PSA test) $10 per office visit
Routine Pap Test:
Note: The office visit is covered if pap is received on the same day; see Diagnosis and Treatment above.

Routine mammogram – covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65, one every two consecutive calendar years

$10 per office visit

Routine immunizations in the doctor's office $10 per office visit
Not covered:
Physical exams & immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or

travel or examinations that are not necessary for medical reasons.

All charges

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

Preventive care, children – Continued on next page. 13
13 Page 14 15
2002 Physicians Health Plan Section 5( a) 14
Preventive care, children (continued) You pay
Well-child care charges for routine examinations, immunization and care

Examinations, such as:
-Ear exams through age 17 to determine the need for hearing correction

-Examinations done on the day of immunizations

$10 per office visit

Eye Exams for children through age 17 to determine the need for vision correction. $20 per office visit
Not covered:
Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or

travel, or examinations that are not necessary for medical reasons.
Eye glasses, contacts, or related supplies.

Eye exercises

All charges

Maternity care
Routine Maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
Your Plan doctor will need to precertify your maternity services; see page 26 for other circumstances, such as extended stays for you or

your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

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

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

$10 for initial office visit and nothing thereafter

Labs, sonograms, fetal stress tests, etc., not included in the global fee. $10 per office visit
Maternity care – Continued on next page. 14
14 Page 15 16
2002 Physicians Health Plan Section 5( a) 15
Maternity care (continued) You pay
Specialized obstetrical services such as:
Amniocentesis

Corionic Villi Sampling

$10 per office visit if performed in a doctor's office; otherwise,
nothing

Not covered: Routine sonograms to determine sex. All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization when performed in doctor's office
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Surgically implanted contraceptives (such as Norplant) 40% of charges
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling

All charges

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

Fertility drugs
Note: Fertility drugs are covered up to a 14-day supply of medicine, unless limited by drug manufacturer's packaging, per prescription or

refill. We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. (See Section
5( f))

40% of charges

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
Cost of donor egg

All charges 15
15 Page 16 17
2002 Physicians Health Plan Section 5( a) 16
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
Respiratory and inhalation therapy
Intravenous (IV)/ Infusion Therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 23-24.

$10 per office visit when performed in the doctor's office;
otherwise 20%

Dialysis – Hemodialysis and peritoneal dialysis
Note: Home intravenous (IV) therapy, Antibiotic therapy and Growth Hormone Therapy are covered as Home Health Services.
20% of charges

Not covered: Experimental, investigational or unproven services, treatments, supplies, drugs, devices, and procedures All charges
Physical and occupational therapies
62 visits per condition for the services of each of the following:
-licensed physical therapists and
-occupational therapists
Note: We only cover physical or occupational therapies to restore bodily function due to illness or injury for up to two months per

condition if significant improvement can be expected. Occupational therapy is limited to services that assist the member to achieve and
maintain self-care and improved functioning in other activities of daily living.

$10 per office or outpatient visit
20% during covered inpatient admission

Cardiac rehabilitation
Note: Cardiac rehabilitation includes Phase I and Phase II treatments.
$10 per office visit

Nothing per outpatient visit
Nothing per visit during covered inpatient admission

Not covered:
Long-term rehab therapy
Exercise programs
Developmental therapies

All charges 16
16 Page 17 18
2002 Physicians Health Plan Section 5( a) 17
Speech therapy You pay
Up to 20 visits of speech therapy services per calendar year from a licensed speech therapist –

Note: We cover habilitative or rehabilitative speech therapy.
$10 per office or outpatient visit
20% during covered inpatient admission

Not covered: Developmental therapies
Behavior disorder Stuttering/ stammering
Tongue thrust

All charges

Hearing services (testing, treatment, and supplies)
Hearing exam $10 per visit

Not covered: Hearing aids and supplies All charges
Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
Nothing

One routine eye exam for members age 18 and older every twelve months.
Unlimited eye exams for children through age 17
$20 per visit

Not covered:
Eyeglasses, contact lenses, or related supplies
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Replacements for lenses during the same calendar year the lenses were provided due to accidental ocular injury or intraocular

surgery (such as cataracts)

All charges

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

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

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

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

treatment is by open cutting surgery)

All charges 17
17 Page 18 19
2002 Physicians Health Plan Section 5( a) 18
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, cochlear implants, 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.

20% of charges

Custom molded foot orthotics to be placed in shoes if ordered and/ or provided by a Plan doctor.
Note: Orthopedic and corrective shoes that are an integral part of a brace may be covered equipment if we approve them in advance.
20% of charges

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) dysfunction.
Note: This benefit service is in combination with other TMJ services. See Oral and maxillofacial surgery.
40% of charges

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

Repair or replacement of any non-medically necessary prosthetic devices

All charges

Durable medical equipment (DME)
Rental up to purchase price, or purchase at our option, of durable medical equipment prescribed by your Plan doctor, such as oxygen and

dialysis equipment. Under this benefit, we also cover:
hospital beds;
standard wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Call us at 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; or 260/ 459-2600 for the hearing impaired as soon as your

Plan doctor 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.

20% of charges

Durable medical equipment (DME) – Continued on next page. 18
18 Page 19 20
2002 Physicians Health Plan Section 5( a) 19
Durable medical equipment (DME) (continued) You pay
Not covered:
Motorized wheel chairs, scooters, lifts for wheelchairs, or motor vehicles

Repair or replacement of any non-medically necessary DME
Batteries to operate DME

Common household articles such as: air conditioners, humidifiers, and air purifiers

Disposable or non-durable medical supplies such as: elastic bandages, elastic support, ostomy supplies and gauze

All charges

Home health services
Home health care ordered by a Plan doctor and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), or home

health aide.
Services include oxygen therapy, intravenous therapy, Antibiotic therapy, Growth Hormone Therapy (GHT), and medications if

provided by a Plan home health care agency.
Note: Call 260/ 432-6690, Extension 11, 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. Plan doctor will periodically review the program for
continuing appropriateness and need.
Note: Services such as physical and occupational therapy or durable medical equipment are subject to copayments or coinsurance. See also

Physical and occupational therapies, Speech therapy, and Durable medical equipment (DME).

Nothing

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
Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
Custodial care

All charges

Chiropractic
No benefit All charges 19
19 Page 20 21
2002 Physicians Health Plan Section 5( a) 20
Alternative treatments You pay
No benefit. All charges

Educational classes and programs
Coverage is limited to diabetes self-management training, meeting these minimum requirements:

One visit after receiving a diagnosis of diabetes One visit after receiving a diagnosis that:
-represents a significant change in the patient's symptoms or condition; and
-makes a change in self-management necessary. One visit for refresher or re-education training.

$10 per office visit
Nothing per outpatient or inpatient visit 20
20 Page 21 22

2002 Physicians Health Plan Section 5( b) 21
Section 5 (b). Surgical and anesthesia services provided by doctors and other health care professionals
I M
P O
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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 doctors must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
The amounts listed below are for the charges billed by a Plan doctor or other health care professional for your surgical care. Look in Section 5( c) for charge associated with the facility (i. e.

hospital, surgical center, etc.).
YOUR DOCTOR MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require precertification.
After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your out-of-pocket
maximum. See Section 4, Your out-of-pocket maximum, for more information.

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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 at least two (2) times the ideal weight for frame,

age, height, and gender.
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information such as:

artificial knuckles and joints, pacemakers, insulin pump, defibrillator.

Voluntary sterilization
Treatment of burns

$10 per office visit

Surgical procedures -Continued on next page. 21
21 Page 22 23
2002 Physicians Health Plan Section 5( b) 22
Surgical procedures (continued) You pay
Note: We cover non-experimental, surgical treatment of morbid obesity that has persisted for at least five (5) years and you have received non-surgical

treatment supervised by a doctor for at least 18 consecutive months that has been unsuccessful.

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.
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 deformaties, cleft lip, cleft palate, birth marks, webbed fingers, and webbed toes.

Note: Generally, services done in the Plan doctor's office is a $10 per visit copayment; and if done in an outpatient facility, there would be a
20% copayment.

$10 per office visit

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 the procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

$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 22
22 Page 23 24
2002 Physicians Health Plan Section 5( b) 23
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate;
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

Treatment for services of Temporomandibular joint dysfunction (TMJ)
Note: This benefit service is in combination with all TMJ services.
40% of charges

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

Treatment of overbite or underbite, maxillary and mandibular osteotomies, dental x-rays, dental supplies, and appliances and all
associated expenses
Orthodontic treatment or braces for teeth

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
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, and advanced
neuroblastoma, breast cancer, multiple myeloma, eplithelial ovarian cancer, and testicular, mediastinal, retroperintoneal and ovarian
germ cell tumors

$10.00 per office visit and
Nothing for the actual transplant

Organ/ tissue transplants -Continued on next page. 23
23 Page 24 25
2002 Physicians Health Plan Section 5( b) 24
Organ/ tissue transplants You pay
Intestinal transplant (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach and pancreas
Note: We use a National Transplant Program (NTP) – United Resource Networks (URN). Transplant services must be provided and arranged
by a Plan doctor and performed at a designated transplant facility.
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Note: Services outside an office visit, you pay nothing.

$10.00 per office visit and
Nothing for the actual transplant

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

Implants of artificial organs involving mechanical or animal origins
Transplants not listed as covered
Solid organ transplants performed as a treatment for cancer

All charges

Anesthesia
Professional services provided in –
Hospital (inpatient)
Hospital outpatient department or other facility
Skilled nursing facility

Nothing

Office $10 per office visit 24
24 Page 25 26

2002 Physicians Health Plan Section 5( c) 25
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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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 doctors must provide or arrange your care and you must be hospitalized in a Plan facility.

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

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

After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your
out-of-pocket maximum. See Section 4, Your out-of-pocket maximum, for more information.

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

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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.

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

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

20% of charges

Inpatient hospital – Continued on next page. 25
25 Page 26 27
2002 Physicians Health Plan Section 5( c) 26
Inpatient hospital (continued) You pay
Not covered: Custodial 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

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms 20% of charges

Prescribed drugs and medicines
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We

do not cover the dental procedures. See Section 5( h) Accidental injury benefit.

20% of charges

Diagnostic laboratory tests, X-rays, and pathology services Nothing
Not covered: Blood and blood derivatives not replaced by the member All charges

Extended care benefits/ skilled nursing care facility benefits
Extended care benefits/ skilled nursing care facility benefits:
60-days per calendar year for confinement in an approved inpatient transitional care unit when ordered by a par doctor.

-bed, board and general nursing care (semi-private room)
-drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the extended care/ skilled nursing facility.

Nothing

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family

Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
Custodial care

All charges 26
26 Page 27 28
2002 Physicians Health Plan Section 5( c) 27
Hospice care You pay
Inpatient and outpatient Hospice care
Family counseling

Note: These services are provided under the direction of a Plan doctor who certifies the patient to be terminally ill with six months or less to

live.

Nothing

Not covered: Funeral arrangements
Pastoral bereavement or legal counseling
Respite care
Nursing care requested by, or for the convenience of, the patient or the patient's family

Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
Custodial care

All charges

Ambulance
Local professional ambulance service when medically appropriate

Note: Non-emergency ambulance transportation may be covered if recommended by a Plan doctor and is medically necessary and
approved in advance by PHP.

20% of charges 27
27 Page 28 29

2002 Physicians Health Plan Section 5( d) 28
Section 5 (d). Emergency services/ accidents
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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.

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.
After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your out-of-pocket maximum.

See Section 4, Your out-of-pocket maximum, for more information.

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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:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (for
example, the 911 telephone system) or go to the nearest hospital room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us.

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

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

Emergency service/ accident benefits begin on next page. 28
28 Page 29 30
2002 Physicians Health Plan Section 5( d) 29
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $30 per visit
Emergency room care at a hospital, including doctors' services $50 per visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency room care as an outpatient or inpatient at a hospital, including doctors' services

20% of charges

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Ambulance
Professional ambulance service when medically appropriate.
Note: Non-emergency or air ambulance transportation may be covered if recommended by a Plan doctor and is medically necessary and

approved by PHP.

20% of charges 29
29 Page 30 31

2002 Physicians Health Plan Section 5( e) 30
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.
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.
After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your out-of-pocket maximum.

See Section 4, Your out-of-pocket maximum, for more information.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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

include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the
care as part of a treatment plan that we approve.
Note: Drugs prescribed for your condition are covered under the Prescription drug benefits. (See Section 5( f))

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 office visit
Nothing if performed during an approved admission

Diagnostic tests $10 per office visit; otherwise 20% if billed by a hospital or other
facility

Services provided by a hospital or other facility (including prescription drugs billed by the facility)
Services in an approved alternate care setting such as partial hospitalization, residential treatment, or facility-based intensive
outpatient treatment.

20% of charges

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

2002 Physicians Health Plan Section 5( e) 31
Mental health and substance abuse benefits (continued) You pay
Not covered:
Services we have not authorized or 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 You must follow your treatment plan and all of our network authorization processes in order for us to cover your care. These include:
You must use a Plan provider and show them your ID card.
Your Plan provider will contact PHP for all services including pre-certification.

We list mental health and substance abuse Plan providers in the
Provider Directory that we update periodically. This list is also in our Web site.

To obtain more information about our benefits or to obtain a Provider
Directory, contact us at 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired; or through our

Web site at www. phpni. com. 31
31 Page 32 33

2002 Physicians Health Plan Section 5( f) 32
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
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.
After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your out-of-pocket

maximum. See Section 4, Your out-of-pocket maximum, for more information.

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There are important features you should be aware of. These include:
Who can write your prescription. Any physician with a valid Drug Enforcement Agency number can write your prescription.

Where you can obtain them. You may fill the prescription at a Plan pharmacy or by mail from the Plan's mail-order pharmacy.
We use a formulary. A formulary is a list of prescription drugs that PHP encourages doctors to prescribe when appropriate. PHP develops this formulary with the help of PHP doctors. Doctors can prescribe any
medication they choose. We cover non-formulary drugs prescribed by a doctor. However, if the drug is non-formulary, patients may have a higher copayment. We encourage you to discuss with your Plan doctor the
medications being prescribed to you. Plan doctors may submit a prior authorization form to PHP for review if a formulary medication has not worked for you in the past. If approved, the brand name formulary copayment
will apply. You are to confirm with your doctor the determination of PHP's review.
We have an open formulary. If your doctor believes a name brand product is necessary or there is no generic available, your doctor may prescribe a name brand drug from our formulary list. The brand name formulary

copayment will apply. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug formulary brochure, call 260/ 432-6690, Extension 11;
800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired; or visit our Web site at www. phpni. com (click on Pharmacy icon).

These are the dispensing limitations. Generally, prescribed drugs will be dispensed for up to a 34-day supply or 240 milliliter of liquid (8 oz.); 60 grams of ointment, creams or topical preparation; or one
commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin).
If you use certain Prescription Drugs on an extended basis, you may wish to obtain larger quantities through the Plan's mail-order benefit. Through mail-order, you may obtain up to a 90-day supply. Your refill order may be

rejected if you send it too soon after the previous one was filled.
A generic equivalent will be dispensed if it is available, unless your doctor specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your doctor has not

specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic as well as the applicable copay.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer
advertises and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you – and us – less than a name brand
prescription.

Prescription drug benefits begin on next page. 32
32 Page 33 34
2002 Physicians Health Plan Section 5( f) 33
Section 5 (f). Prescription drug benefits (continued) We cover certain prescription drugs in limited quantities. Such drugs include but are not limited to: Viagra,
Muse, and Caverject. Please contact the Plan for limits.
When you have to file a claim. If you are out of the area and have an emergency where there is no Plan pharmacy, then you may have to pay for the prescription and send the Plan a letter of explanation with your

receipt.
Pre-authorization is required on certain medications. If your doctor wants to prescribe one, he or she will submit a preauthorization request to PHP before the drug is dispensed. Such drugs include but are not limited to: nail

fungus treatments, growth hormone, and multiple sclerosis medications.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan doctor and obtained from a Plan pharmacy:

Diabetic supplies
Drugs and medicines that by Federal law of the United States require a doctor's prescription for their purchase

Insulin (with a copayment applied to each vial)
Disposable needles and syringes needed to inject prescribed diabetes medications

Contraceptive drugs and devices
Note: Intravenous fluids and medications for home use, implantable drugs, and some injectable contraceptive drugs (such as Depo Provera),

are covered under Section 5( a).

$5 generic per prescription unit
$15 brand name formulary per prescription unit

$40 brand name non-formulary per prescription unit

Mail-order:
Up to a 90-day supply of certain Prescription Drugs that you use on an extended basis.

Note: Nail fungus drugs and fertility drugs are not available through the mail-order program.

$10 generic per prescription unit
$30 brand name formulary per prescription unit

$80 brand name non-formulary per prescription unit

Norplant and other internally implanted time-released medications
Note: There will be no refund of any portion of these charges if the implanted time-released medication is removed before the end of its

expected life.

40% of charges per implantation

Fertility drugs
Note: Up to a consecutive 14-day supply of medication, unless limited by drug manufacturer's packaging per prescription, order, or refill.

Fertility drugs are not available through the mail-order program.

40% of charges

Covered medications and supplies – Continued on next page. 33
33 Page 34 35
2002 Physicians Health Plan Section 5( f) 34
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Smoking cessation drugs and medication, including nicotine patches
Vitamins, nutrients and food supplements even if a Plan doctor prescribes or administers them

Nonprescription medicines

All Charges 34
34 Page 35 36

2002 Physicians Health Plan Section 5( g) 35
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

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

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

Services for deaf and hearing impaired A Telecommunication Device for the Deaf (TDD) is available for the deaf and hearing impaired by calling PHP at 260/ 459-2600.
High risk pregnancies PHP case managers will work with your Plan doctor to coordinate services necessary for the management of your high-risk pregnancy.
A PHP case manager could contact you to discuss your medical needs, services available, and to answer benefit questions.

Centers of excellence for transplants/ heart
surgery/ etc

When your Plan doctor contacts PHP regarding your transplantation, a PHP case manager will provide beneficial information regarding
PHP's Designated Transplant Facilities. A PHP case manager will contact you or your designee to coordinate your care and answer
benefit questions related to your transplant.

Travel benefit/ services overseas You will have coverage for emergency services while traveling. Please refer to Section 5( d) for benefit information. If overseas, you
may be required to pay for services rendered. If submitting to PHP for payment, you will need to have your itemized bills and receipts

converted to U. S. currency (if applicable), provide an explanation of the services, and include member information from your ID card, for
payment consideration. 35
35 Page 36 37

2002 Physicians Health Plan Section 5( h) 36
Section 5 (h). Dental benefits
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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.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient; we do not cover the dental services unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.
After you have met your out-of-pocket maximum, you do not have to pay anything more for covered services. Certain services do not count toward your out-of-pocket

maximum. See Section 4, Your out-of-pocket maximum, for more information.

I M
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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. Services must be provided within 12 months of the accident.
20% of charges

Not covered:
Injury to the teeth caused by eating, chewing, or biting.
Services provided after 12 months of the accident
Temporary prosthetics including but not limited to: – partial or full dentures or bridges or

– replacement prosthesis – manipulative, corrective or cosmetic adjustments of the teeth
– orthodontia services
Any other dental services

All charges

Dental benefits
We have no other dental benefits. 36
36 Page 37 38

2002 Physicians Health Plan Section 5( i) 37
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.
In keeping with the goal of providing preventive health maintenance, PHP offers the following programs free of charge to existing members:

Smoking Cessation – a reimbursement program for members who utilize any type of therapy for smoking cessation in order to successfully stop smoking for a duration of not less than
one year after therapy has stopped. Therapies include: nicotine patches, nicotine gum, nicotine inhalers and/ or classes. For more information, please contact us 260/ 432-6690,
Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired or through our Web site at www. phpni. com.

Weight Loss – a reimbursement program for members who are concerned with weight loss. Your program must include a Plan doctor to monitor your weight loss. For more
information, please contact us 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; or 260/ 459-2600 for the hearing impaired or through our Web site at www. phpni. com.

Preventive dental care is an important part of health maintenance. However, PHP is unable to offer you dental benefits. 37
37 Page 38 39

2002 Physicians Health Plan 38 Section 6
Section 6. General exclusions – things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or
condition.
We do not cover the following:
Care by non-Plan doctors 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 doctor or facility barred from the FEHB Program. 38
38 Page 39 40

2002 Physicians Health Plan 39 Section 7
Section 7. Filing a claim for covered services
When you see Plan doctors, 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.

You will only need to file a claim when you receive emergency services from non-plan doctors. Sometimes these doctors bill us directly. Check with the doctor. If you need to file the claim, here is the process:

Medical, Hospital and Drug Benefits
In most cases, Plan doctors and facilities file claims for you. Doctors must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92

form. For claims questions and assistance, contact us at 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired, or through our
Web site at www. phpni. com.
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 Plan doctor 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:
Physicians Health Plan of Northern Indiana, Inc. 8101 West Jefferson Boulevard

Fort Wayne, Indiana 46804-4163

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim within 12 months after the date of 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. 39
39 Page 40 41

2002 Physicians Health Plan Section 8 40
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Physicians Health Plan of Northern Indiana, Inc., 8101 West Jefferson Boulevard, Fort Wayne, Indiana 46804-4163; 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 Plan doctors' 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.

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 Plan doctors' 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 doctors, 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. 40
40 Page 41 42

2002 Physicians Health Plan Section 8 41
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 contact us at 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing impaired, or through our Web site at
www. phpni. com 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. 41
41 Page 42 43

2002 Physicians Health Plan Section 9 42
Section 9. Coordinating benefits with other coverage
You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard
to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We,
like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for

premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or 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 choices available to Medicare
beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan (Part A or Part B) The Original Medical Plan (Original Medicare) is 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 for us to cover your care. We do not waive your
copayments, coinsurance, and deductibles for all services.

(Primary payer chart begins on next page.)

When you have other health coverage 42
42 Page 43 44
2002 Physicians Health Plan Section 9 43
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.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Areanactiveemployee with theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability),

2) Are an annuitant,

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

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

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),

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

(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,

(except for claims related to Workers'

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

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

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

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

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

b) Are an active employee, or

c) Are a former spouse of an annuitant, or

d) Are a former spouse of an active employee

Please note, if your Plan doctor does not participate in Medicare, you will have to file a claim with Medicare 43
43 Page 44 45

2002 Physicians Health Plan Section 9 44
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 and we will pay the balance of covered charges. You will not need to do anything. To find

out if you need to do something about filing your claims, call us at 260/ 432-6690, Extension 11; 800/ 982-6257, Extension 11; 260/ 459-2600 for the hearing
impaired, or visit our Web site at www. phpni. com.
We waive some costs when you have the Original Medicare Plan--When Original Medicare is the primary payer, we may waive some copayments and

coinsurance, for services that Medicare covers. However, we will not waive copayments, coinsurance, or deductibles for services that Medicare does not cover
and we do. Please contact us for specific information.
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 of the managed care plan's network and/ or service area (if you use
our Plan providers). We will not waive copayments and coinsurance. for services that your Medicare manage care plan does not cover. 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. 44
44 Page 45 46

2002 Physicians Health Plan Section 9 45
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under Medicare Part A or Part B 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 members, 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 care for injuries for injuries or illness caused by another person, you must reimburse us for all of the expenses we
paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement according to plan limits.

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. Your full
cooperation is required.
We may bring a lawsuit against a named recovery source necessary and appropriate action to preserve or enforce our rights under this subrogation. We shall be
responsible only for those legal fees and expenses related to your recovery that we agree to in writing. 45
45 Page 46 47

2002 Physicians Health Plan Section 10 46
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.
Copayment A copayment is an amount of money that you pay directly to the provider when you receive covered services. A copayment may be either a fixed dollar amount or a

percentage of eligible expenses.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Non-health related services such as assistance with activities of daily living or health related services that:

Do not seek to cure; Are provided when the medical condition of the Member is not changing;
Do not require administration by skilled, licensed medical personnel because a non-professionally qualified person can be trained to perform them.

Experimental or The plan uses a variety of authoritative sources including: investigational services governmental regulatory agencies, scientific literature, medical experts and other
recognized authorities in the medical field to determine whether medical procedures are experimental and/ or investigational.

Group health coverage The contract between PHP and the Office of Personnel Management for FEHB employees.
Medical necessity Health Services that are determined by PHP to be all of the following: medically appropriate and necessary to meet the Member's basic health needs;
the most cost-effective method of treatment and rendered in the most cost-effective manner and type of setting appropriate for the delivery of the Health Service;
consistent in type, frequency and duration of treatment with relevant guidelines of national medical, research and health care coverage organizations and governmental
agencies; accepted by the medical community as consistent with the diagnosis and prescribed
course of treatment and rendered at a frequency and duration considered by the medical community as medically appropriate;
required for reasons other than the comfort or convenience of the member or his or her doctor;
of a demonstrated medical value in treating the condition of the Member; and consistent with patterns of care found in established managed care environments for
treatment of the particular health condition.
Plan allowance Plan allowance is the amount we use to determine our payment and your copayment for covered services. Plans determine their allowances in different ways. We determine our

allowance as follows: in-network-contracted charges for Plan doctors / out-of-network the median reimbursement amount in PHP's judgment for such service in the
geographical area where the service was rendered.
Us/ We Us and we refer to Physicians Health Plan.
You You refers to the enrollee and each covered family member. 46
46 Page 47 48

2002 Physicians Health Plan Section 11 47
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get See www. opm. gov/ insure. Also, your employing or retirement office information about enrolling can answer your questions, and give you a Guide to Federal

in the FEHB Program Employees 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 do not 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.

When benefits and The benefits in this brochure are effective on January 1. If you joined 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. 47
47 Page 48 49

2002 Physicians Health Plan Section 11 48
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments

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

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

OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service.
If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you may be
eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.
Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for 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.
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. 48
48 Page 49 50

2002 Physicians Health Plan Section 11 49
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Group Health Plan Coverage 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 Coverage that indicates
how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or
eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing
coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate
from those plans.

For more information, get OPM pamphet 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 questions. 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. 49
49 Page 50 51

2002 Physicians Health Plan Long Term Care Insurance 50
Long Term Care Insurance Is Coming Later in 2002!
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 care 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. LTC insurance 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.

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 or chronic care you may need? You should consider buying long-term care insurance. 50
50 Page 51 52

2002 Physicians Health Plan Index 51
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear .
Accidental injury 36 Allergy tests 16
Allogeneic (donor) bone marrow transplant23
Alternative treatment 20 Ambulance 27
Anesthesia 24 Autologous bone marrow transplant 16
Biopsies 21 Birthing centers 14
Blood and blood plasma 25/ 26 Breast cancer screening 13
Casts 21/ 25 Changes for 2002 6
Chemotherapy 16 Childbirth 14
Chiropractic 19 Cholesterol tests 13
Circumcision 12 Claims 39
Coinsurance 10 Colorectal cancer screening 13
Congenital anomalies 21 Contraceptive devices and drugs 21/ 33
Coordination of benefits 42 Covered charges 7
Covered providers 7 Crutches 18
Deductible 10 Definitions 46
Dental care 36 Diagnostic services 12
Disputed claims review 40 Donor expenses (transplants) 23/ 24
Dressings 25 Durable medical equipment (DME) 18
Educational classes and programs 20 Effective date of enrollment 4
Emergency 28 Experimental or investigational 38/ 46
Eyeglasses 17 Family planning 15

Fecal occult blood test 13 General Exclusions 38
Hearing services 17 Home health services 19
Hospice care 27 Home nursing care 19
Hospital 25 Immunizations 13
Infertility 15 Inhospital physician care 12
Inpatient Hospital Benefits 25 Insulin 33
Laboratory and pathological services 13
Machine diagnostic tests 13 Magnetic Resonance Imagings (MRIs)
13 Mail-order Prescription Drugs 33
Mammograms 13 Maternity Benefits 14
Medicaid 45 Medically necessary 46
Medicare 42 Members 4
Mental Conditions/ Substance Abuse Benefits 30
Neurological testing 13 Newborn care 14
Non-FEHB Benefits 37 Nurse
Licensed Practical Nurse 19 Nurse Anesthetist 25
Registered Nurse 19 Nursery charges 14
Obstetrical care 14 Occupational therapy 16
Ocular injury 17 Office visits 12
Oral and maxillofacial surgery 23 Orthopedic devices 17
Ostomy and catheter supplies 19 Out-of-pocket expenses 10
Outpatient facility care 26

Oxygen 18/ 19/ 25/ 26 Pap test 13
Physical examination 13 Physical therapy 16
Physician 7 Precertification 9/ 31
Preventive care, adult 13 Preventive care, children 13
Prescription drugs 32 Preventive services 13/ 14
Prior approval 31 Prostate cancer screening 13
Prosthetic devices 17 Psychologist 30
Psychotherapy 30 Radiation therapy 16
Renal dialysis 16 Room and board 25
Second surgical opinion 12 Skilled nursing facility care 26
Smoking cessation 37 Speech therapy 17
Splints 25 Sterilization procedures 15
Subrogation 45 Substance abuse 30
Surgery 21 Anesthesia 24
Oral 23 Outpatient 26
Reconstructive 23 Syringes 33
Temporary continuation of coverage 48 Transplants 23
Treatment therapies 16 Vision services 17
Well child care 13 Wheelchairs 18
Workers' Compensation 45 X-rays 13/ 23/ 26 51
51 Page 52 53
2002 Physicians Health Plan 52
Notes 52
52 Page 53 54
2002 Physicians Health Plan 53
Notes 53
53 Page 54 55
2002 Physicians Health Plan 54
Notes 54
54 Page 55 56

2002 Physicians Health Plan Summary 55
Summary of benefits for Physicians Health Plan of Northern Indiana – 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................. Office visit copay: $10 primary care; $10 specialist 12

Services provided by a hospital:
Inpatient............................................................................................
Outpatient .........................................................................................

20% of the first $2,500 up to the out-of-pocket maximum of $500 per person or
$1,500 per family

25
26
Emergency benefits:

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

$50 per Plan hospital emergency room visit or $30 per Plan urgent care center
visit
20% of the first $2,500 up to the out-of-pocket maximum

28

Mental health and substance abuse treatment....................................... Regular cost sharing. 30
$5 generic/ $15 brand name formulary/ $40 brand name non-formulary per
prescription unit or refill

Prescription drugs
Up to a 34 day supply .........................................................................

Mail-order drugs
Up to a 90 day supply of maintenance medication ............................. $10 generic/$ 30 brand name
formulary/$ 80 brand name non-formulary per prescription unit or refill

32

Dental Care ..........................................................................................
No benefit
All charges 36

Vision Care ..........................................................................................
Limited to one annual eye refraction for members 18 and over
$20 17

Protection against catastrophic costs (your out-of-pocket maximums).......................................................
Some costs do not count toward this protection. The out-of-pocket maximums are separate for medical and mental health/ substance
abuse services.

Nothing after $500/ Self Only or $1, 500 Self and Family enrollment per year 10 55
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2002 Rate Information for Physicians Health Plan of Northern Indiana, Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for
that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB guides are published for Postal Service
Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization. Refer to the applicable FEHB Guide.

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

Self Only DQ1 $ 91.76 $30.58 $198.80 $ 66.27 $108. 58 $ 13.76
Self and Family DQ2 $206.18 $68.73 $446.73 $148.91 $243. 98 $ 30.93 56

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