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Page 1 2
Mercy Health Plans/
Premier Health Plans http:// www. mercyhealthplans. com
2002
A Health Maintenance Organization
with a point of service product

Serving: St. Louis Metro Area (Eastern Missouri Region),
Columbia Metro Area (Central Missouri Region),
Springfield Metro Area (Southwest Missouri Region),
Laredo Metro Area (South Texas Region) and
surrounding counties

Enrollment in this Plan is limited. You must live or work in our Geographic service
area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
Missouri Regions Texas Region
7M1 Self Only HM1 Self Only
7M2 Self and Family HM2 Self and Family

RI 73-756

For changes
in benefits,
see page 8 1
1 Page 2 3

2002 Mercy Health Plans/ Premier Health Plans Table of Contents 2
Table of Contents
Introduction................................................................. 4
Plain Language................................................................ 4
Inspector General Advisory. 4
Section 1. Facts about this HMO plan ........................................................................................................................... 6
We also have point-of service (POS) benefits .............................................................................................. 6
How we pay providers .................................................................................................................................. 6
Who provides my health care........................................................................................................................ 6
Your Rights................................................................................................................................................... 6
Service Area.................................................................................................................................................. 7
Section 2. How we change for 2002 .......................................................... 8
Program-wide changes.................................................................................................................................. 8
Changes to this Plan...................................................................................................................................... 8
Section 3. How you get care ... ...................................................................................................................... 9
Identification cards........................................................................................................................................ 9
Where you get covered care.......................................................................................................................... 9
Plan providers ......................................................................................................................................... 9
Plan facilities .......................................................................................................................................... 9
What you must do to get covered care.......................................................................................................... 9
Primary care............................................................................................................................................ 9
Specialty care........................................................................................................................................ 10
Hospital care ......................................................................................................................................... 11
Circumstances beyond our control.............................................................................................................. 11
Services requiring our prior approval ......................................................................................................... 11
Section 4. Your costs for covered services .................................................................................................................. 13
Copayments .......................................................................................................................................... 13
Deductible............................................................................................................................................. 13
Coinsurance .......................................................................................................................................... 13
Your out-of-pocket maximum .................................................................................................................... 13
Section 5. Benefits ............................................................... 15
Overview..................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals ........... 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 25
(c) Services provided by a hospital or other facility, and ambulance services...................................... 28
(d) Emergency services/ accidents.......................................................................................................... 30
(e) Mental health and substance abuse benefits..................................................................................... 32
(f) Prescription drug benefits................................................................................................................. 34 2
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2002 Mercy Health Plans/ Premier Health Plans Table of Contents 3
(g) Special features................................................................................................................................. 37
Flexible benefits option. 37
24 hour nurse line.. 37
Services for the deaf.. 37
(h) Dental benefits.................................................................................................................................. 38
(i) Point of service product ................................................................................................................... 39
(j) Non-FEHB benefits available to Plan members............................................................................... 46
Section 6. General exclusions --things we don't cover .............................................................................................. 47
Section 7. Filing a claim for covered services ............................................................................................................. 48
Section 8. The disputed claims process........................................................................................................................ 49
Section 9. Coordinating benefits with other coverage ................................................................................................. 51
When you have
Other health coverage..................................................................................................................... 51
Original Medicare........................................................................................................................... 51
Medicare managed care plan .......................................................................................................... 54
TRICARE/ Workers' Compensation/ Medicaid............................................................................................ 55
Other Government agencies........................................................................................................................ 55
When others are responsible for injuries..................................................................................................... 55
Section 10. Definitions of terms we use in this brochure ............................................................................................ 56
Section 11. FEHB facts ................................................................................................................................................ 57

Coverage information.................................................................................................................................. 57
No pre-existing condition limitation .............................................................................................. 57
Where you get information about enrolling in the FEHB Program ............................................... 57
Types of coverage available for you and your family.................................................................... 57
When benefits and premiums start ................................................................................................. 58
Your medical and claims records are confidential ......................................................................... 58
When you retire .............................................................................................................................. 58
When you lose benefits................................................................................................................................... 58

When FEHB coverage ends............................................................................................................ 58
Spouse equity coverage .................................................................................................................. 58
Temporary Continuation of Coverage (TCC) ................................................................................ 58
Converting to individual coverage ................................................................................................. 59
Getting a Certificate of Group Health Plan Coverage.................................................................... 59
Long term care insurance is coming later in 2002 ........................................................................................................ 60
Department of Defense/ FEHB Demonstration Project................................................................................................. 61
Index ............................................................................................................................................................................ 63
Summary of benefits ........................................................................................................................... Inside Back Cover
Rates............................................................................................................................................................... Back Cover 3
3 Page 4 5

2002 Mercy Health Plans/ Premier Health Plans Introduction/ Plain Language 4
Introduction
Mercy Health Plans Premier Health Plans Mercy Health Plans
425 South Woods Mill Road One Corporate Centre, Suite 200 5901 McPherson
Chesterfield, MO 63017 1949 East Sunshine Suites 1 & 2B
Springfield, MO 65804 Laredo, TX 78041

This brochure describes the benefits of Mercy Health Plans/ Premier Health Plans under our contract (CS 2834) with
the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This
brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 8. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means Mercy Health Plans/ Premier Health Plans.

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 physician, pharmacy, or hospital has charged you for services you did not receive, billed you
twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call Mercy Health Plans (Eastern and Central Missouri Regions) at 314-214-8196 or 1-800-327-0763; (Texas Region) at 4
4 Page 5 6
2002 Mercy Health Plans/ Premier Health Plans Introduction/ Plain Language 5
956-723-7667 or 1-800-617-3433; or Premier Health Plans (Southwest Missouri Region) at 417-836-0402 or 1-800-836-0402 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. 5
5 Page 6 7

2002 Mercy Health Plans/ Premier Health Plans Section 1 6
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any
course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the
copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You
cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or
other provider will be available and/ or remain under contract with us.

We also have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a participating
provider without a required referral, or from a non-participating provider. These out-of-network benefits have higher out-of-
pocket costs than our in-network benefits.

How we pay providers
For Network benefits, we contract with individual physicians, medical groups, and hospitals to provide the benefits in this
brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments
or coinsurance.

Who provides my healthcare?
You are required to select a Primary Care Physician (PCP) from Mercy Health Plans/ Premier Health Plans participating
doctors in the Plan's service area. Your PCP will meet many of your health care needs and arrange for specialist care if the
need arises.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us,
our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is listed below.

If you want more information about us, call our Member Services department at:
Mercy Health Plans: (Eastern and Central Missouri Regions) at 314-214-8196 or 1-800-327-0763
Mercy Health Plans: (Texas Region) at 956-723-7667 or 1-800-617-3433
Premier Health Plans: (Southwest Missouri Region) at 417-836-0402 or 1-800-836-0402

or write to:
Mercy Health Plans: 425 South Woods Mill Road, Chesterfield, MO 63017 (Eastern and Central Missouri Regions)
Mercy Health Plans: 5901 McPherson, Suites 1 & 2B, Laredo TX 78041 (Texas Region)
Premier Health Plans: One Corporate Centre, Suite 200, 1949 East Sunshine, Springfield, MO 65804 (Southwest
Missouri Region)

You may also contact us by fax at:
(Eastern and Central Missouri Region): 314-214-8102;
(Southwest Missouri Region): 417-836-0457 ; or
(Texas Region) 956-723-8246 6
6 Page 7 8

2002 Mercy Health Plans/ Premier Health Plans Section 1 7
Visit our website at www. mercyhealthplans. com.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area
is:

MERCY HEALTH PLANS (Eastern and Central Missouri Regions) include these Missouri counties: Audrain, Boone,
Callaway, Chariton, Cole, Cooper, Franklin, Gasconade, Howard, Iron, Jefferson, Lincoln, Linn, Macon, Madison, Maries,
Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis, Pike, Ralls, Randolph, Reynolds, Saline, St. Charles, St.
Francois, St. Louis, St. Louis City, Warren and Washington. The Illinois counties are: Clinton, Jersey, Macoupin, Madison,
Monroe, Randolph and St. Clair.

MERCY HEALTH PLANS (Texas Region) include these Texas counties: Duval, Jim Hogg, Webb and Zapata.
PREMIER HEALTH PLANS (Southwest Missouri Region) include these Missouri counties: Barry, Barton, Benton, Cedar,
Christian, Crawford, Dade, Dallas, Dent, Douglas, Greene, Henry, Hickory, Howell, Jasper, Laclede, Lawrence, McDonald,
Newton, Oregon, Ozark, Phelps, Polk, Pulaski, Shannon, St. Clair, Stone, Taney, Texas, Vernon, Webster and Wright.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live
out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait
until Open Season to change plans. Contact your employing or retirement office. 7
7 Page 8 9
2002 Mercy Health Plans/ Premier Health Plans Section 2 8
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
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))

We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
Your share of the non-Postal biweekly premium for Missouri Regions will increase by $10.31, which equals 39.8% for Self Only or $28.18, which equals 46.8% for Self and Family. Your share of the non-Postal biweekly

premium for the Texas Region will increase by $3.53, which equals 12.5% for Self Only or $7.72, which equals
8.9% for Self and Family.

We added Point of Service benefits to the Texas Region. (Section 5( i)) 8
8 Page 9 10

2002 Mercy Health Plans/ Premier Health Plans Section 3 9
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:
Eastern and Central Missouri Regions: 314-214-8196 or 1-800-327-0763
Southwest Missouri Region: 417-836-0402 or 1-800-836-0402
Texas Region: 956-723-7667 or 1-800-617-3433

Where you get covered care You get care from "Plan providers" and "Plan facilities". You will only pay copayments and/ or coinsurance and you will not have to file claims. You can
access health care from the point-of-service plan. These services are subject to
a calendar year deductible, coinsurance copayments and balance billing.
(Balance billing refers to the amount billed by a provider that exceeds the
usual, customary and reasonable (UCR) charges allowed for payment by the
Plan). Balanced-billed charges are your responsibility along with the annual
deductible and coinsurance and do not apply to out-of-pocket maximums. You
are responsible for verifying that the required prior approval is given by the
Plan for certain procedures. Please contact Member Services for further
details. If you use our point-of-service program, you can also get care from
non-Plan providers, or from participating providers without a required referral,
but it will cost you more.

Plan providers Plan providers are physicians and other health care professionals in our service
area that we contract with to provide covered services to our members. We
credential Plan providers according to national standards. Log on to
http:// www. mercyhealthplans. com and learn more about our physicians. The
site features our Physician Directory, so you will be able to find the
information you need on our large selection of doctors.

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

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

should ask yourself some questions before you choose your Primary Care
Physician (PCP). What is the doctor's specialty? Does the PCP have a
subspecialty, such as gastroenterology or pulmonology? Is the doctor's office
close to your home, office or school? Are the doctor's office hours convenient
for you? We suggest that you call the doctors you are considering so you can
conduct your own interview. You will be one step ahead in ensuring your
health and the health of your family.

Primary care Your primary care physician can be a family practitioner, general practitioner
internist, or pediatrician. Your primary care physician will provide most of
your health care, or give you a referral to see a specialist. Female Members
have direct access to an Obstetrician or Gynecologist (OB/ GYN). 9
9 Page 10 11
2002 Mercy Health Plans/ Premier Health Plans Section 3 10
Members in the Texas Region must select an OB/ GYN, on or before
open enrollment, to provide health care services within their scope of
practice.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your primary
care physician authorized a certain number of visits without additional
referrals. The primary care physician must provide or authorize all follow-up
care. Do not go to the specialist for return visits unless your primary care
physician gives you a referral. However, you may see an OB/ GYN without a
referral. You can access a non-participating OB/ GYN under your POS
benefit, except for well-woman visits.

When medically necessary, your PCP will arrange for referrals to a specialist.
Your primary care physician and specialist will work together to coordinate
your total care. If you access specialty care without an understanding of the
number of visits and the amount of time approved for treatment, you may be
responsible for the entire bill. Your PCP will arrange a standing referral to a
specialist or specialists center (if necessary). Your PCP, the Chief Medical
Officer and participating specialist will determine the need and parameters of a
standing referral. A standing referral is based on a diagnosis of a life-threatening
condition or disease; a degenerative and disabling condition or
disease; ongoing care from a specialist or required specialized medical care
over a prolonged period of time. Your PCP may request standing referrals.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your PCP will develop a treatment plan
that allows you to see your specialist for a certain number of visits
without additional referrals. Your primary care physician will use our
criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does not
participate with our Plan.

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

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 10
10 Page 11 12
2002 Mercy Health Plans/ Premier Health Plans Section 3 11
_ reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access
to your specialist based on the above circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission to
a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at
Eastern & Central Missouri Regions: 314-214-8196 or 1-800-327-0763
Southwest Missouri Region: 417-836-0402 or 1-800-836-0402
Texas Region: 956-723-7667 or 1-800-617-3433

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

care.

Services requiring our Your primary care physician has authority to refer you for most services. For
prior approval certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically

necessary, and follows generally accepted medical practice.
We call this review and approval process prior approval. Your physician
must obtain prior approval for services such as:

Certain medications All inpatient hospitalization
All skilled nursing facility All rehabilitation facility
Home Health Care, including DME Physical, Speech, and Occupational Therapy
Any procedure that may be cosmetic Surgical procedures 11
11 Page 12 13
2002 Mercy Health Plans/ Premier Health Plans Section 3 12
It is the shared responsibility of both you and your PCP or specialist to assure that
referrals are obtained, accurate and current. You are responsible for verifying the
approved date range of the referral, number of visits and types of services that
have been authorized. When you choose to receive services from a participating
provider without a prior referral from your chosen primary care physician, the
specialists will request that you be responsible for payment of the services. When
this occurs, you may be responsible for the charges. A referral must be obtained
prior to receiving certain services.

It is your responsibility to verify that the required prior approval has been given by
the Plan for out-of-network services. If prior approval is not given, eligible
charges will be subject to the non-compliance reduction and the amount of the
reduction will not apply toward your out-of-pocket maximum or deductible. 12
12 Page 13 14
2002 Mercy Health Plans/ Premier Health Plans Section 4 13
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 and when you go in the hospital, you
pay $0 per admission.

Deductible A deductible is a fixed expense you must incur for certain covered
services and supplies before we start paying benefits for them.
Copayments do not count toward any deductible.

In Missouri Regions, you are required to pay a $500 deductible per
member per calendar year and $1,000 deductible per family per calendar
year for out-of-network benefits. Your cost is 30% coinsurance after the
deductible. The out-of-pocket maximum per member is $3,500
(including the deductible) and $7,000 per family (including deductible).
This deductible applies to POS benefits only.

In the Texas Region, you are required to pay a $1,000 deductible per
member per calendar year and a $2,000 deductible per family per
calendar year for out-of-network benefits. Your cost is 40% coinsurance
after the deductible. There is an unlimited out-of-pocket maximum for
members and their families in the Texas Region.

Note: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the
year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of
your old option to any deductible of your new option.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care. Coinsurance doesn't begin until you meet your deductible.

Example: In our Plan, you pay 50% of our allowance for infertility
services up to $5,000.

In Network In Missouri Regions, after your copayments and/ or coinsurance for in-network
services total $1,100 per person or $3,300 per family enrollment
in any calendar year, you do not have to pay any more for covered
services. However, copayments or coinsurance for the following services
do not count toward your out-of-pocket maximum, and you must
continue to pay copayments or coinsurance for these services:

Chiropractic Infertility
Outpatient Prescription Drugs
In the Texas Region, after your copayments and/ or coinsurance for in-network
services total $1,000 per person or $2,000 per family enrollment in
any calendar year, you do not have to pay any more for covered services.

Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance, and
copayments 13
13 Page 14 15
2002 Mercy Health Plans/ Premier Health Plans Section 4 14
Out of Network In Missouri Regions, after your deductible, coinsurance and/ or
copayments for out-of-network services total $3,500 (including
deductible) per person or $7,000 (including deductible) per family, you
do not have to pay any more for covered services.

In the Texas Region, members and their families have unlimited out-of-pocket
maximums.

Be sure to keep accurate records of your copayments or coinsurance
since you are responsible for informing us when you reach the maximum. 14
14 Page 15 16

2002 Mercy Health Plans/ Premier Health Plans Section 5 15
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and see inside back cover for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact
us at:
Mercy Health Plans (Eastern and Central Missouri Regions): (314) 214-8196 or 1-800-327-0763
Mercy Health Plans (Texas Region): (956) 723-7667 or 1-800-617-3433
Premier Health Plans (Southwest Missouri Region): (417) 836-0402 or 1-800-836-0402

or at our website at www. mercyhealthplans. com.
(a) Medical services and supplies provided by physicians and other health care professionals............................. 16-24
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 25-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 28-29

Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents ......................................................................................................................... 30-31
Medical emergency Ambulance
(e) Mental health and substance abuse benefits .................................................................................................... 32-33
(f) Prescription drug benefits ................................................................................................................................ 34-36
(g) Special features ...................................................................................................................................................... 37
Flexible benefits option
24 hour nurse line
Services for deaf and hearing impaired

(h) Dental benefits ....................................................................................................................................................... 38
(i) Point of service benefits................................................................................................................................... 39-45
(j) Non-FEHB benefits available to Plan members .................................................................................................... 46

Summary of benefits ........................................................................................................................... Inside Back Cover 15
15 Page 16 17
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 16
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
We have no calendar year deductible, however out-of-network benefits services are subject to a calendar year deductible.

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

I M
P O
R T
A N
T

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

$10 per office visit to your primary care
physician

$10 per office visit to a specialist

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

$25 Copayment per visit
Nothing
Nothing
$10 Copayment per office visit
$10 Copayment per office visit

Not covered:
Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or

insurance, attending camp or travel

All charges. 16
16 Page 17 18
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 17
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Preventive care, adult
Routine screenings, such as:
Hearing and vision screening
Blood pressure testing
Complete Blood Count (CBC)
Total Blood Cholesterol -once every three years
Colorectal Cancer screening, including
_ Fecal occult blood test

$10 per office visit

_ Sigmoidoscopy, screening -every five years starting at age 50
Prostate Specific Antigen (PSA test) one annually for men age 40 and
older
$10 per office visit

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

$10 per office visit

Routine mammogram covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period
At age 40 and older, one every calendar year

Nothing

Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing 17
17 Page 18 19
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 18
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and care (through age 22)
Examinations, such as:
_ Eye exams through age 17 to determine the need for vision
correction.

_ Ear exams through age 17 to determine the need for hearing
correction

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

Nothing
$10 per office visit

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

You do not need to precertify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

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

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

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

Surgery benefits (Section 5b).

One time $10 Copayment for all office
visits associated with prenatal care
during a single pregnancy.

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
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

Not covered: reversal of voluntary surgical sterilization, genetic
counseling and voluntary abortions.
All charges. 18
18 Page 19 20
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 19
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination
_ intravaginal insemination (IVI)
_ intracervical insemination (ICI)
_ intrauterine insemination (IUI)

$10 per office visit for the diagnosis of
infertility

For treatment, you pay 50% of the first
$5,000 of the usual, customary and
reasonable (UCR) rate of approved charges,
charges in excess of the UCR rate, and
100% of the charges for infertility services
over $5,000.

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
Fees for preparation and storage of sperm and embryos
Infertility services after voluntary sterilization
Fertility drugs

All charges.

Allergy care
Testing and treatment

Allergy injection
$10 per office visit
Nothing
Allergy serum Nothing

Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 19
19 Page 20 21
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 20
Treatment therapies You Pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 27.

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

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit
Note: Before we cover GHT, there are certain guidelines to be
performed and documented. There are separate guidelines for children
and adults. We will ask you to submit information that establishes that
the GHT is medically necessary for that child or adult. Ask us to
authorize GHT before you begin treatment; otherwise, we will only
cover GHT services from the date you submit the information. If you
do not ask or if we determine GHT is not medically necessary, we will
not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

$10 per office visit
All other services covered at no
additional charge.

Not covered: treatments that have no proven clinical benefit for your
condition.
All charges.

Physical and occupational therapies
60 visits per condition per calendar year for the services of each of the following:

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided up to 36 visits per

condition.

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

Not covered:
long-term rehabilitative therapy
exercise programs
neuro-rehabilitation
work hardening programs or developmental educational therapy

All charges.

Speech therapy
60 visits per condition per calendar year $10 Copayment

Speech Therapy continued on next page 20
20 Page 21 22
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 21
Speech therapy (Continued) You Pay
Not covered: Therapies that are not considered as medically necessary
by the Plan.
All charges

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

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

Not covered:
all other hearing testing

hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of eye, annual eye refractions (to
provide a written lens prescription for eyeglasses or contact lenses) may
be obtained from Plan providers

$10 per office visit

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

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 office visit

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

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

treatment is by open cutting surgery)

All charges. 21
21 Page 22 23
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 22
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: See 5( b) for coverage of the surgery
to insert the device.

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

20% Coinsurance

Not covered:
orthopedic and corrective shoes arch supports

foot orthotics (except those authorized by the Plan) heel pads and heel cups
lumbosacral supports corsets, elastic stockings, support hose, and other supportive
devices
prosthetic replacements provided less than 3 years after the last one we covered

electrical continence aids, anal or urethral implants for cosmetic or psychologic reasons
other dental appliances replacement of cataract lenses necessary after cataract surgery
remote control devices devices employing robotics
all mechanical organs investigational or obsolete devices and supplies
computer assisted devices

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

casts, splints, surgical supplies and appliance, catheters and ilesotomy supplies;

wheelchairs or hospital-type bed;
purchase of a truss, brace or support;
oxygen and the equipment necessary for its administration;
mechanical equipment required for the treatment of a chronic or acute respiratory illness or failure, such as asthmatic equipment; and

ambulatory dialysis.

Nothing

Durable Medical Equipment continued on next page 22
22 Page 23 24
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 23
Durable medical equipment (DME) (Continued) You pay
Note: Call us at:
(Eastern and Central Missouri Regions): 314-214-8196 or 1-800-327-0763
(Southwest Missouri Region): 417-836-0402 or 1-800-836-0402
(Texas Region): 956-723-7667 or 1-800-617-3433

as soon as your Plan physician prescribes this equipment. We will
arrange with a health care provider to rent or sell you durable medical
equipment at discounted rates and will tell you more about this service
when you call.

Not covered:
augmentative communication devices (i. e., computer assisted speech devices, speech teaching machines, telephones, TDD

equipment, etc.)
automated travel devices (i. e., motor scooters, etc.)
chair lifts and other transfer devices
devices that are primarily non-medical in nature or used primarily for comfort (i. e., foam pads, maternity belts, heating pads, etc.)

elevators
equipment designed to alter the environment (i. e., air filters, humidifiers, dehumidifiers, air conditioners, lighting, etc.)

exercise equipment
hygienic items (i. e., shower chairs, raised toilet seats, sauna baths, incontinence supplies, etc.)

massage devices
overhead tables
whirlpools, whirlpool pumps, hot tubs, and related items
telephone alert systems
motorized wheel chairs

All charges.

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

Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

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.
Private duty nursing or nursing assistants.

All charges. 23
23 Page 24 25
2002 Mercy Health Plans/ Premier Health Plans Section 5( a) 24
Chiropractic You Pay
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$10 per office visit
Referrals required for Eastern and
Central MO regions and Texas
Region

Not covered:
Services for examination and/ or treatment of strictly non-neuromusculoskeletal disorders
All charges

Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for: anesthesia, pain
relief
$10 per office visit

Not covered:
Biofeedback Birth Coaches (other prenatal/ parenting education classes)

Homeopathy Hypnotherapy
Massage Therapy Naturopathic services (i. e., herbal therapy, etc.)

All charges.

Educational classes and programs
Coverage is limited to:

Smoking Cessation-Up to $100 for one smoking cessation program per member per lifetime, including all related expenses
such as drugs. (Smoking Cessation programs not available in
the Texas Region)

Diabetes self-management

$25 copayment per program per year
Consistent with type of services
required. 24
24 Page 25 26
2002 Mercy Health Plans/ Premier Health Plans Section 5( b) 25
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

I M
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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.

Plan physicians must provide or arrange your care.
We have no calendar year deductible, however health care services from the point of service plan are subject to a calendar year deductible.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e. hospital, surgical center, etc.).
YOU MUST OBTAIN AUTHORIZATION BEFORE ANY SERVICE IS RENDERED OUT-OF-NETWORK. Please refer to the precertification information in

Section 5( i).

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

weight according to current underwriting standards; eligible
members must be age 18 or over

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

Voluntary sterilization
Treatment of burns

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

$10 per office visit; nothing for
hospital visits

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care. All charges. 25
25 Page 26 27
2002 Mercy Health Plans/ Premier Health Plans Section 5( b) 26
Reconstructive surgery You Pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
_ the condition produced a major effect on the member's
appearance and

_ the condition can reasonably be expected to be corrected by such
surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

_ surgery to produce a symmetrical appearance on the other breast;
_ treatment of any physical complications, such as lymphedemas;
_ breast prostheses and surgical bras and replacements (see
Prosthetic devices)

Note: If you need a mastectomy, you may choose to have 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

Removal of tattoo
Hair transplant for baldness, lipectomy (operation for removal of adipose tissue (fat) from the abdomen or other part of the body) -unless

required by a sickness condition.
Augmentation of mammoplasty (operation for augmentation of the breasts) for cosmetic reasons.

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit

Oral and maxillofacial surgery continued on next page 26
26 Page 27 28
2002 Mercy Health Plans/ Premier Health Plans Section 5( b) 27
Oral and maxillofacial surgery (Continued) You Pay
Not covered:
Enabling procedures for implants, as well as placement, maintenance, restoration, and removal of dental implants.

Oral implants and transplants Any prosthetic superstructure fabricated upon a dental implant is
also excluded.
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges.

Organ/ tissue transplants
Limited to:
Cornea Heart

Heart/ lung Kidney
Kidney/ Pancreas Liver
Lung: Single Double Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Payments are limited to the allowed amount at a participating transplant
facility.

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

Nothing

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

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in

Office Hospital (inpatient)
Hospital outpatient department Skilled nursing facility
Ambulatory surgery center

$10 per office visit
Nothing
Nothing
Nothing
Nothing 27
27 Page 28 29
2002 Mercy Health Plans/ Premier Health Plans Section 5( c) 28
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

I M
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T

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

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

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

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

YOU MUST OBTAIN AUTHORIZATION BEFORE ANY SERVICE IS RENDERED OUT-OF-NETWORK. Please refer to the precertification

information in Section 5( i).

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

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

Nothing

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
Custodial care (see definition under Extended care benefits) 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 28
28 Page 29 30
2002 Mercy Health Plans/ Premier Health Plans Section 5( c) 29
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

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

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility
benefits

Skilled Nursing Facility (SNF):

Medically Necessary room and board, services and supplies, including
medications provided under the direction of a Participating Physician
in a Participating Skilled Nursing Facility for the care and treatment of
an Injury or Illness which would otherwise require inpatient
confinement in a Hospital. Coverage for up to a maximum of one-hundred
twenty (120) days per calendar year.

Nothing
.

Not covered: Custodial care, which is care designed to assist with
activities of daily living such as bathing, exercising, moving a
patient, cooking, cleaning, etc. and involves non-medical
personnel. For an institutionalized individual, custodial care
includes room and board, non-skilled care, or such other care that
is provided to an individual who cannot reasonably be expected to
live outside an institution. Rest care, respite care, and home care
provided by a family member (including a spouse, sibling, child, or
parent of the member) is also considered custodial care.

All charges

Hospice care
Services provided either on an inpatient or an outpatient basis, based
on approved acceptable medical practices, when approved in advance
by the Plan's Chief Medical Officer or designee.

This benefit is available once per lifetime for terminally ill person with
a life expectancy of less than six months.

Nothing

Not covered: Independent nursing, homemaker services, services
received out-of-network.
All charges

Ambulance
Local professional ambulance service when medically appropriate Nothing 29
29 Page 30 31
2002 Mercy Health Plans/ Premier Health Plans Section 5( d) 30
Section 5 (d). Emergency services/ accidents
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.

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

coordinating benefits with other coverage, including with Medicare.

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergent or urgent situation, if possible call your Plan physician immediately. If the emergency is so urgent that failure to get immediate medical
attention could be life threatening or cause serious harm, go immediately to the nearest emergency facility.
Once an urgent or life-threatening situation has been brought under control, you will need to call your Plan
physician as soon as reasonably possible, so that any continued care can be arranged and authorized. If
you do not report emergency treatment, as soon as reasonably possible thereafter, care may not be covered.

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

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.

Emergencies outside our service area: If you require health care services, present your I. D. card to the physician or hospital caring for you and identify yourself as a Mercy Health Plans member. If you

need to be hospitalized, call Member Services as soon as possible. Member Services will notify your Plan
physician and arrange to have your medical records shared with the attending physician. Arrangements
will be made for you to be transferred to the care of a Plan doctor and hospital when it is medically
appropriate. Your Plan physician will coordinate all follow-up care upon return to the area.

If follow-up care is required outside the area, you must contact your Plan physician to receive
authorization for the continued care. 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. The Plan pays reasonable
charges for emergency services to the extent the services would have been covered if received from Plan
providers. 30
30 Page 31 32
2002 Mercy Health Plans/ Premier Health Plans Section 5( d) 31
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center $25 per office visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit, except
Copayment charge will be
waived if you are admitted
to an observation, outpatient
surgery, outpatient
procedure, or inpatient care
setting.

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

$50 per visit, except
Copayment charge will be
waived if you are admitted
to an observation, outpatient
surgery, outpatient
procedure, or inpatient care
setting.

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

All charges

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered:
air ambulance (unless Medically necessary)
air ambulance transportation out of a foreign country is not covered under any circumstances

All charges 31
31 Page 32 33
2002 Mercy Health Plans/ Premier Health Plans Section 5( e) 32
Section 5 (e). Mental health and substance abuse benefits
I M
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T

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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

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

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

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social
workers
Medication management

$10 per visit

Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day

hospitalization, facility based intensive outpatient treatment

Nothing

Mental health and substance abuse benefits continued on next page 32
32 Page 33 34
2002 Mercy Health Plans/ Premier Health Plans Section 5( e) 33
Mental health and substance abuse benefits (Continued) You pay
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
You must obtain services from Participating Providers and authorized in
advance by the Plan by calling the Mental Health and Substance Abuse
Member Assistance Hotline (MH/ SA Hotline) for assistance.

(Eastern and Central Missouri): (314) 729-4600 or 1-800-413-8008
(Southwest Missouri): (417) 836-0402 or 1-800-836-0402
(Texas): (956) 723-7667 or 1-800-617-3433

Limitation We may limit your benefits if you do not obtain a treatment plan. 33
33 Page 34 35
2002 Mercy Health Plans/ Premier Health Plans Section 5( f) 34
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.
There are a handful of medications that require prior authorizations. Your Plan physician has a listing of the specific drugs.

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.

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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You must fill your prescription at a Plan pharmacy, except in the case of a medical emergency. You have access to over 15,000 pharmacies nationwide. Also, you are

covered under the mail service pharmacy benefit. This benefit allows you to obtain covered
maintenance prescriptions used to treat chronic or long-term health conditions (high blood pressure
or diabetes) through the Walgreen's Healthcare Plus mail service pharmacy.

We use a formulary. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a thirty (30) day supply at a Plan Pharmacy. Drugs are

prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. A
"formulary" is a list of drugs approved for use by your physician in connection with specific
conditions. You pay a copayment of $7 in the case of a generic drug, $12 in the case of a brand
drug and $25 for Non-formulary approved drugs dispensed in accordance with the formulary. We
cover non-formulary drugs prescribed by a Plan doctor.

If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription
drug brochure, call Mercy Health Plans
(Eastern and Central Missouri Regions): 314-214-8196 or 1-800-327-0763
(Southwest Missouri Region) 417-836-0402 or 1-800-836-0402
(Texas Region): 956-723-7667 or 1-800-617-3433

These are the dispensing limitations. Prescription drugs will be dispensed for up to a thirty-( 30) day supply. If you choose to receive the brand drug (with the approval of your physician), you will
be responsible for the appropriate copayment plus the cost difference between the "brand" name
and the "generic" name drug. Prescriptions filled through the Walgreen's Healthcare Plus mail
service pharmacy, is limited up to a ninety-( 90) day supply. If an order is placed more than two
weeks before the refill date, the order may be returned unfilled with a request to resubmit them at a
later date.

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

Covered Prescription drug benefits continued on next page 34
34 Page 35 36
2002 Mercy Health Plans/ Premier Health Plans Section 5( f) 35
Prescription drug benefits (Continued)
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.

When you have to file a claim. If you use a participating pharmacy you will not have to file a claim. However, if you receive emergency services out-of-network and purchase prescriptions, you
must contact member services for reimbursement.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

Disposable needles and syringes needed to inject covered prescribed medication

Diabetic supplies, including insulin syringes needles, glucose test tablets and test tape, Benedict's solution or equivalent, glucose
monitors and acetone test tablets
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as

Not covered.
Drugs for sexual dysfunction (see Section 3 -Services requiring our prior approval)

Insulin; a copay charge applies to each vial
Contraceptive drugs and devices

You are entitled to receive prescription drugs included on the formulary at the
time a prescription written is actually filled by a participating pharmacy. You
will pay a Copayment of $7 for generic drugs, $12 Copayment for brand drugs
and $25 Copayment for non-formulary approved drugs. If a brand drug is
dispensed when a generic alternative is available and your physician has not
specified Dispense as Written (DAW) for the name brand drug, you pay the
appropriate Copayment plus the difference in cost of the brand drug and the
generic drug.

$7 Copayment for generic drugs
on Formulary

$12 Copayment for brand drugs on
Formulary

$25 Copayment for Non-formulary
approved drugs

2 Copayments for a 90-day supply
for mail-order

Covered medications and supplies continued on next page 35
35 Page 36 37
2002 Mercy Health Plans/ Premier Health Plans Section 5( f) 36
Covered medications and supplies
Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available

Prescriptions dispensed by other than a Plan pharmacy, except in the case of a medical emergency
Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressing and antiseptics
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Appetite suppressants and other drugs taken for the purpose of weight loss

Drugs which have not been approved by the FDA
Fertility drugs

All Charges 36
36 Page 37 38
2002 Mercy Health Plans/ Premier Health Plans Section 5( g) 37
Section 5 (g). Special features
Feature Description

Flexible benefits
option

Under the flexible benefits option, we determine the most effective way
to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative

benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

24 hour nurse line
(not available in Texas)

For any of your health concerns, 24 hours a day, 7 days a week, you
may call:

(Eastern and Central Missouri): 800-811-1187; or
(Southwest Missouri): (417) 888-8888 or 800-909-TEAM (8326)
and talk with a registered nurse who will discuss treatment options and
answer your health questions.

Services for deaf and
hearing impaired

Mercy Health Plans/ Premier Health Plans offers a TDD Line:
Mercy Health Plans (Eastern and Central Missouri Region) at 314-214-8299 or 800-698-4807

Mercy Health Plans (Texas Region) at 877-206-7903
Premier Health Plans (Southwest Missouri Region) at 417-837-0249 or 800-446-1468 37
37 Page 38 39
2002 Mercy Health Plans/ Premier Health Plans Section 5( h) 38
Section 5 (h). Dental benefits
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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 and are payable only when we determine they are

medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of

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

other coverage, including with Medicare.

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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. Orthodontic braces are not
covered. The need for these services must result from an accidental
injury. All services in connection with this benefit must be provided
within six (6) months from the date of the Accidental Injury.

20% Copayment.

Dental benefits
We have provided for dental care at affordable prices for you and your eligible dependent( s) through CAREington
dental network. A list of participating dentists is provided with the provider directory. Following are significant
points of the program:

No claim forms to file. You pay only the copay shown in the schedule of benefits at the time of service.
To receive significant savings from a participating dentist, merely show your CAREington membership card at each visit and you will receive the discount.

CAREington only contracts with dentists who meet their credentialing criteria and must continue to meet the high standards of quality established.

Not covered:
dental implants 38
38 Page 39 40
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 39
Section 5 (i). Point of service benefits
I M
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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 and are payable only when we determine they are medically necessary.
I M

P O
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Facts about this Plan's POS option
At your option, you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need care,
except for the benefits listed below under "What is not covered." Benefits not covered under Point of Service must either be received
from or arranged by Plan doctors to be covered. When you obtain covered non-emergency medical treatment from a Plan doctor
without a referral from a Plan doctor, you are subject to the deductibles, coinsurance and maximum benefit stated below.

What is covered

Benefits Subject to UCR limits, precertification required for certain procedures.
Missouri Regions Texas Region PLAN MAXIMUMS

Medical Benefit Maximum Per Member
(While Covered)
Calendar Year Deductible-Member
(Family)
Calendar Year Out-of-Pocket Maximum-Member
(Family)

$2,500,000
$500
(2 x Member)
$3,500 Includes Deductible
(2 x Member)

Unlimited
$1,000
(2 x Member)
Unlimited

MEDICAL SERVICES
Services and Supplies 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Surgery performed in a Physician's Office 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Allergy Services
-Office Visits
-Injections/ Treatment
-Allergy serum

30% Coinsurance After Deductible
30% Coinsurance After Deductible
30% Coinsurance After Deductible

40% Coinsurance After Deductible
40% Coinsurance After Deductible
40% Coinsurance After Deductible
Lab and X-ray 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Maternity (includes prenatal, delivery, and
postnatal care)
30% Coinsurance After Deductible 40% Coinsurance After Deductible

INPATIENT HOSPITAL SERVICES 30% Coinsurance After Deductible 40% Coinsurance After Deductible
OUTPATIENT SERVICES

Emergency Care $50 Copayment per visit, except
Copayment charge will be waived when
inpatient admission for the same condition
occurs within 24 hours

$50 Copayment per visit, except
Copayment charge will be waived when
inpatient admission for the same condition
occurs within 24 hours
Non-Emergency Services
-Outpatient Surgery
-Diagnostic Tests
30% Coinsurance After Deductible
30% Coinsurance After Deductible
40% Coinsurance After Deductible
40% Coinsurance After Deductible
Urgent Care $25 Copayment per visit $25 Copayment per visit 39
39 Page 40 41
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 40
Benefits Subject to UCR limits, precertification required for certain procedures.
Missouri Regions Texas Region Outpatient Rehabilitative Therapy

Services: Physical and Occupational
Speech

30% Coinsurance After Deductible
(Max. of up to 60 visits per condition per
calendar year)

40% Coinsurance After Deductible
(Max. of up to 60 visits per condition per
calendar year)
MISCELLANEOUS COVERED
SERVICES

Home Health Agency Services
(includes intravenous fluids and
medications)

30% Coinsurance After Deductible 40% Coinsurance After Deductible

Skilled Nursing Facility Services 30% Coinsurance After Deductible
(Max. of up to 120 days per calendar year)
40% Coinsurance After Deductible
(Max. of up to 120 days per calendar year)
Ambulance 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Prosthetic Equipment 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Chemotherapy, radiation therapy and
inhalation therapy
Covered In-Mercy Network Only 40% Coinsurance After Deductible

Dialysis services Covered In-Mercy Network Only 40% Coinsurance After Deductible
Durable Medical Equipment and Supplies 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Diabetes Services 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Transplant Services Covered In-Mercy Network Only 40% Coinsurance After Deductible
Family Planning Services Covered In-Mercy Network Only 40% Coinsurance After Deductible
Infertility Services Covered In-Mercy Network Only 40% Coinsurance After Deductible
Accidental Dental 30% Coinsurance After Deductible 40% Coinsurance After Deductible
Hospice Services Covered In-Mercy Network Only 40% Coinsurance After Deductible
Alcoholism/ Chemical Dependency
-Inpatient
-Outpatient
Covered In-Mercy Network Only
Covered In-Mercy Network Only
40% Coinsurance After Deductible
40% Coinsurance After Deductible
Mental Health
-Inpatient
-Outpatient
Covered In-Mercy Network Only
Covered In-Mercy Network Only
40% Coinsurance After Deductible
40% Coinsurance After Deductible
Routine Immunizations Covered In-Mercy Network Only 40% Coinsurance After Deductible
Preventive care, including well-baby/ child
care and periodic check-ups Covered In-Mercy Network Only 40% Coinsurance After Deductible
Mammography Covered In-Mercy Network Only 40% Coinsurance After Deductible
Outpatient Prescription Drug
-Generic
-Brand Name
-Mail-Order

Covered in PCS Network Only
Covered in PCS Network Only
Covered in PCS Network Only

Covered in PCS Network Only
Covered in PCS Network Only
Covered in PCS Network Only

When a Member seeks services from a Non-Participating Provider and/ or fails to follow pre-established guidelines, reimbursement for
HMO Covered Services will be made for "Covered Services". The Member will be required to share a larger part of the "Eligible
Charges" by satisfying the annual up front Deductible and paying the required coinsurance. Preventive care or "well care" is not
covered (Missouri Members only), along with other benefit limitations described herein. Finally, when health care is received from a
Non-Participating Provider, the Member will be responsible for submitting a completed claim form along with an itemized bill.

"Covered Services" means only the medical care, services and supplies rendered under the following conditions: (a) prescribed by a
Physician for the therapeutic treatment of injury, illness or pregnancy; (b) deemed Medically Necessary and appropriate in type, level,
setting, and length of service by the Plan; (c) rendered in accordance with generally accepted medical practice and professionally
recognized standards; (d) not considered to be experimental, investigational, or which are performed for research purposes.

"Eligible Charges or Eligible Expenses" means the usual, customary and reasonable (UCR) Rate for Covered Services rendered by a
Provider reduced by any Non-compliance Reduction.

In order to receive certain benefits, Members are required to comply with the specific pre-certification requirements described in
connection with the Utilization Management Program as outlined. The Member is responsible for making sure the Plan is contacted 40
40 Page 41 42
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 41
before services are rendered. Failure to comply with the requirement of the Utilization Management Program described will result in
a reduction in the Benefits Payable.

Services do not need to be obtained within the service area to be eligible for coverage under POS.
Pre-certification
For pre-certification of services call:
(Eastern and Central Missouri): (314) 214-8196 or 1-800-327-0763
(Southwest Missouri): (417) 836-0402 or 1-800-836-0402
(Texas): (956) 723-7667 or 1-800-617-3433

You must obtain authorization before any service is rendered. It is your responsibility to verify that the required pre-certifications
have been given by the Plan for coverage. This is called pre-certification. If pre-certification is not given, or you fail to comply with
the requirements, eligible charges will be subject to the Non-compliance reduction. Non-compliance reduction means the charges
considered for payment are reduced as a result of your failure to comply with the pre-certification. These eligible charges will not be
used to meet a deductible or out-of-pocket maximum.

In the Missouri Regions, Services Subject to Pre-Certification Review and Non-compliance Reduction
1. Inpatient Hospitalization. 50% Reduction in Eligible Charges.

2. Outpatient surgical procedures. 50% Reduction in Eligible Charges (the
Reduction applies to both the facility and the
professional charges).

3. Health Services provided during Confinement. 50% Reduction in Eligible Charges (the
Reduction applies to both facility and professional
charges).

4. Home health care. 50% Reduction in Eligible Charges.

5. MRI, RAST tests and CAT scans. 50% Reduction in Eligible Charges.
6. Prosthetics. 100% Reduction in Eligible Charges;
No Benefit Payable.

7. Durable Medical Equipment. 100% Reduction in Eligible Charges;
No Benefit Payable.

8. Physical Therapy, Occupational Therapy and
Speech Therapy.
100% Reduction in Eligible Charges;
No Benefit Payable.

Note: It is the Member's responsibility to verify that the required certification has been given by the Plan. If certification is not given,
or the Member fails to comply with the requirements stated in this Section, Eligible Charges will be subject to the Non-compliance
Reduction and the amount of the reduction will not apply toward the Member's Out-of-Pocket Maximum or Deductible.

Also, you are required to notify the Plan three (3) days in advance of any hospital admission for a non-emergency. If it is impossible
to notify the Plan, you must obtain pre-certification review as soon as reasonably practical prior to the provisions of the service and in
no event less than one (1) business day prior to the service. If you fail to comply with the pre-certification requirements, there is a
50% reduction of eligible charges for non-compliance.

Care rendered in connection with a Pregnancy will be treated as an exception to the three (3) day prior notice requirement. The Pre-certification
Review requirement will be treated as satisfied if proper notice is given by the Member no later than the fifth month of
Pregnancy and the Member notifies the Plan within one (1) business day after admission to the Hospital for delivery. 41
41 Page 42 43
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 42
In the Texas Region, precertification is required for the following services:
Inpatient confinement, including inpatient confinement for maternity care; and Maternity Care
Transplant Services
The Member or the Member's designated representative must notify MERCY HEALTH PLANS (MHP) to precertify the admission,
maternity care or transplant, as the case may be, prior to receiving any of the services or supplies associated with that admission,
maternity care, or transplant.

To initiate the precertification process, call MHP at the telephone number listed on the Member's identification card. This call must be
made as follows:

For a non-emergency inpatient confinement, the call must be made at least seven (7) days prior to any planned admission into a Hospital.
For an inpatient confinement due to a Medical Emergency, the call must be made within two (2) working days after the time of the admission or as soon thereafter as reasonably possible; and
For maternity care, the call must be made within twenty-four (24) hours after the birth or as soon thereafter as possible.
The Member may request a review of the Precertification decision pursuant to the MHP grievance procedure as described in this
brouchure.

FAILURE TO PRECERTIFY WILL RESULT IN A 50% REDUCTION OF POS BENEFITS.
The additional percentage or dollar amount of the UCR, which a Member may pay as a penalty for failure to obtain precertification
under this section is not a covered expense, and will not be applied to the Deductible or the maximum out-of-pocket limit, if any.

Deductible
"Deductible" means the amount of Eligible Charges payable by each member before benefits are payable. No Benefit is payable for
any part of Eligible Charges used to meet a Deductible.

In the Missouri Regions, you will pay a $500 deductible per member per calendar year and $1,000 deductible per family per calendar
year.

In the Texas Region, you will pay a $1,000 deductible per member per calendar year and $2,000 deductible per family per calendar
year.

Coinsurance
"Coinsurance" means the Member's share of the cost of Eligible Charges stated as a percentage up to the Out-of-Pocket Maximum.
In the Missouri Regions, members are responsible for 30% coinsurance after the deductible.
The out-of-pocket maximum per member is $3,500 (including the deductible) and $7,000 per family (including deductible). The
lifetime maximum benefit is $2,500,000 per member. The member's out-of-pocket expenses under POS do not qualify for the Plan's
in-Plan out-of-pocket maximum.

In the Texas Region, members and their families have unlimited out-of-pocket maximums, as well as an unlimited lifetime maximum
benefit. The member's out-of-pocket expenses under POS do not qualify for the Plan's in-Plan out-of-pocket maximum.

Members are responsible for a 40% coinsurance after the deductible.
When you use a non-participating provider and fail to follow pre-established guidelines, reimbursement for covered services, you are
responsible for sharing a larger part of the cost for the services. The benefit when a non-participating hospital is used is shown in the
POS outline of benefits. The Plan will pay a participating hospital in full even though the POS benefit (and non-Plan doctor) are being
used. The hospital charge, sometimes called facility charge, does not cover any charges for doctor's services. 42
42 Page 43 44
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 43
True emergency care is always payable as an in-Plan benefit.
Charges by a Provider in excess of the UCR Rate will not be covered by MHP and will not be counted toward your Deductible or
maximum out-of-pocket limit, if any.

Maximum benefit
The maximum limit is $2,500,000 lifetime maximum per member in Missouri Regions.
In the Texas Region, members have unlimited lifetime maximums.

Hospital/ extended care
In the Missouri Regions, members are responsible for 30% coinsurance after the deductible.
In the Texas Region, members are responsible for a 40% coinsurance after the deductible.
Emergency benefits
You will pay a $50 Copayment per visit for service and supplies, except the Copayment charge will be waived when inpatient
admission for the same condition occurs within twenty-four (24) hours.

What is not covered
The following are not covered under the POS benefit in the Missouri Regions:
Well-child care and immunizations Eye and ear examinations to determine the need for vision and hearing correction

Alcoholism and drug abuse services, including but not limited to diagnosis and medical treatment and services. Prescription drugs other than drugs provided by a hospital to a member as an inpatient
Chiropractic services Hemodialysis and dialysis services
Services for treatment of mental or nervous disorders. Non-symptomatic mammography services
Promotion of conception including, but not limited to, treatment of impotency or infertility, in vitro fertilization, embryo transplantation, reproductive therapy, artificial insemination, or reversal of voluntarily induced sterility.
Smoking cessation services Any organ transplant surgery or procedures, including services rendered on behalf of an organ recipient or an organ donor.
Charges in excess of the Eligible Charge for the service provided as determined by MHP, or any charges which exceed a calendar year maximum, or other benefit maximum.
Any types of services, supplies or treatment not specifically provided for herein.
The following are not covered under the POS benefit in the Texas Region:

HMO benefits received Hospice care

Outpatient prescription drugs Hearing aids, including fitting
If a Member is admitted to a Hospital on a Friday or Saturday and such admission is not Medically Necessary, hospital charges incurred on the day of admission and on the following day, if a Saturday, are not covered.
Services provided by the Member's spouse, parent, child, grandparent, brother, sister or parent-in-law Reversal of surgical sterilization
Sterilization procedures Chiropractic services 43
43 Page 44 45
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 44
How to obtain benefits
A. In Missouri: If a charge is made to a Member for any expenses which are covered under this POS benefit, written proof of
such charge must be furnished to the Plan within thirty-one (31) days of actual payment of the charge by the Member, within
thirty-one (31) days of notice of such charge to the Member, or, at the latest, within twelve (12) months after the performance
of the service. Failure of the Member to timely furnish such proof of claim to the Plan will result in denial of the Member's
claim for reimbursement. Proof of claim includes, but is not limited to, receipt of a duly completed claimant's statement,
attending Physician's Statement, itemized provider bills, medical records, and, if applicable, an accident report. Proof of claim
includes, but is not limited to, receipt of a duly completed claimant's statement, attending Physician's Statement, itemized
provider bills, medical records, and, if applicable, an accident report. A claim form can be obtained from your employer or
from the Plan. Submit your claim form along with proof of claim to Mercy Health Plans/ Premier Health Plans, P. O. Box 4568,
Springfield, Missouri 65808-4568.

In Texas:
1) Within twenty (20) days after the Member receives Covered Services, or as soon as reasonably possible, the Member or
someone on the Member's behalf, must notify the Plan in writing of their claim.
2) Within fifteen (15) days after the Plan receives the Member's written notice of claim., the Plan must:
a) acknowledge receipt of the claim;
b) begin any investigation of the claim;
c) specify the information the Member must provide to file proof of loss. (The Plan can request additional
information during the investigation, if necessary); and
d) send the Member any forms the Plan require for filing proof of loss. If the Plan does not send the forms within
this time period, the Member can file proof of loss by giving the Plan a letter describing the occurrence, the
nature and extent of the claim. The Member must give the Plan this letter within the time period for filing proof
of loss.
3) Within ninety (90) days after the Member receive Covered services, the Member must send the Plan written proof of claim.
If it is not reasonably possible to give the Plan written proof of claim in the time required, the Plan will not reduce or deny
the claim for being late if the proof is filed as soon as reasonably possible, unless the Member is not legally capable, the
required proof must always be given to the Plan no later than one year from the date otherwise required.
4) Within fifteen (15) business days after the Plan receives all the information required to secure final proof of claim, the Plan
must:
a) give the Member written notice that their claim or part of their claim has been accepted and pay benefits within
five (5) business days after the Plan notify the Member of acceptance; or
b) give the Member written notice that their claim has been rejected and the reason( s) for the rejection; or
c) give the Member written notice if the Plan need more time to make their decisions and the reasons the Plan need
additional time. However, the Plan must notify the Member of their final decision within forty-five (45) days.

5. If payment of the claim or part of the claim requires the performance of an act by the Member, the Plan will pay within five (5) business days after the date the act was performed by the Member.

B. Failure to Furnish Proof of Claim
Failure to furnish proof within the required time established in paragraph A of this Section shall not invalidate or reduce any
claim if it was not reasonably possible to give proof within such time, provided such proof is provided as soon as reasonably
possible.

C. If a claim is denied, a Subscriber may obtain a review of the denial through the disputed claims process in Section 8.
D. Payment of Claim
In Missouri: All benefits are payable to the Subscriber unless benefits are assigned. If any such benefits remain unpaid at the
Subscriber's death, or if the Subscriber is, or its administrator's opinion, incapable of giving a legally binding receipt for
payment of any benefit, or its administrator may, at its option, pay such benefit to any one or more of the Subscriber's relatives
as follows: spouse, mother, father, child or children, brother( s), or sister( s) or any other relative of blood or marriage. Any
payment so made will constitute a complete discharge of obligations to the extent of such payment under this benefit. 44
44 Page 45 46
2002 Mercy Health Plans/ Premier Health Plans Section 5( i) 45
In Texas:
Benefits will be paid to the Member or to the Provider if a valid assignment has been made by the Member. Any benefits that
are unpaid to the Member at their death will be paid either to the beneficiary or their estate, if no beneficiary is named. If
benefits are payable to the Member, or the estate of the Member or to a beneficiary who cannot execute a valid release, the Plan
may pay benefits up to $1,000 to someone related to the Member or a beneficiary by blood or marriage whom the Plan deem to
be equitably entitled to such benefits. The Plan will be discharged to their extent of any such payments made by the Plan in
good faith.

Benefits paid on behalf of a covered dependent child may be paid to a person who is not the Subscriber, if an order issued by a
court of competent jurisdiction in this or any other state names such person the managing conservator of the child. To be
entitled to receive benefits, a managing conservator of a child must submit to the Plan with the claim form, written notice that
such person is the managing conservator of the child on whose behalf that claim is made and submit a certified copy of a court
order establishing the person as managing conservator. This will not apply in the case of any unpaid medical bill for which a
valid assignment of benefits has been exercised or to claims submitted by the Subscriber where the Subscriber has paid any
portion of a medical bill that would be covered under the terms of this POS Rider.

When services are paid for or rendered by the Texas Department of Human Services on behalf of the Subscriber or a covered
dependent, payment for the services will be made directly to the Texas Department of Human Services. In the case of a
covered dependent child, when services are paid or rendered by the Texas Department of Human Services on behalf of such
covered dependent child, payment for the services will be made directly to the Texas Department of Human Services if:

1) The parent who is a Subscriber is:
a) a possessory conservator of the child under an order issued by a court in Texas; or
b) is not entitled to possession of or access to the child and is required by court order or court-approved agreement to
pay child support;
2) The Texas Department of Human Services is paying benefits on behalf of the child under Chapter 31 or Chapter 32,
Human Resources Code; and The Plan is notified through an attachment to the claim for insurance benefits when the
claim is first submitted to the Plan that the benefits must be paid directly to the Texas Department of Human Services. 45
45 Page 46 47
2002 Mercy Health Plans/ Premier Health Plans Section 5( j) 46
Section 5 (j). 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

Wellness Programs
The following wellness programs are available at the Plan's participating hospitals. Program fees may apply.
Members are encouraged to contact the participating hospital nearest you for more information.

Health Screenings
Fitness and Weight Management
Health Education
Support/ Therapy Groups
Parenting Classes
Birth/ Baby Care Programs
Children's Health Programs
Senior Programs 46
46 Page 47 48
2002 Mercy Health Plans/ Premier Health Plans Section 6 47
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 and we agree, as discussed under What Services Require Our
Prior Approval on page 11.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

Educational Services;
Expenses you incurred while you were not enrolled in this Plan;
Experimental or investigational procedures, treatments, drugs or devices;
Services provided by a first degree relative;
Services provided in connection with the reversal of an elective sterilization procedure.
Services provided in connection with treatment or surgery to change gender or restore sexual function;

Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
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;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or

Services, drugs, or supplies you receive while you are not enrolled in this Plan. 47
47 Page 48 49
2002 Mercy Health Plans/ Premier Health Plans Section 7 48
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.

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

Medical, Hospital and Drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
(Eastern and Central Missouri Regions): 314-214-8196 or 1-800-327-0763
(Southwest Missouri Region): 417-836-0402 or 1-800-836-0402
(Texas Region): 956-723-7667 or 1-800-617-3433

. When you must file a claim such as for out-of-area care submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills
and receipts should be itemized and show:

Covered member's name and ID number;
Name and address physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Mercy Health Plans/ Premier Health Plans
P. O. Box 4568
Springfield, MO 65808-4568

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service,
unless timely filing was prevented by administrative operations of Government or
legal incapacity, provided the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 48
48 Page 49 50
2002 Mercy Health Plans/ Premier Health Plans Section 8 49
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:

Mercy Health Plans, 425 South Woods Mill Road, Chesterfield, MO 63017 (Eastern and Central MO)
Mercy Health Plans, 5901 McPherson, Suites 1 & 2B, Laredo TX 78041 (Texas)
Premier Health Plans, One Corporate Centre, Suite 200, 1949 East Sunshine, Springfield, MO 65804 (Southwest MO)

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or 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 2, 1900 E
Street, NW, Washington, DC 20415-3620.

The disputed claims process, continued on next page 49
49 Page 50 51
2002 Mercy Health Plans/ Premier Health Plans Section 8 50
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the review
request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of
reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the
only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at:
(Eastern and Central Missouri Regions): 314-214-8196 or 1-800-327-0763
(Southwest Missouri Region): 417-836-0402 or 1-800-836-0402
(Texas Region): 956-723-7667 or 1-800-617-3433
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 2 at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 50
50 Page 51 52
2002 Mercy Health Plans/ Premier Health Plans Section 9 51
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under
another group health plan or have automobile insurance that pays
health care expenses without regard to fault. This is called "double
coverage."

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in
this brochure.

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

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.

Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. 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 The Original Medicare Plan (Original Medicare) is available everywhere (Part A or Part B) 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. 51
51 Page 52 53
2002 Mercy Health Plans/ Premier Health Plans Section 9 52
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.
Your care must continue to be authorized by your Plan PCP. We will
not waive any of our copayments, coinsurance, or deductibles.

(Primary payer chart begins on next page.) 52
52 Page 53 54
2002 Mercy Health Plans/ Premier Health Plans Section 9 53
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) Are an active employee with the Federal government (including
when you or a family member are eligible for Medicare solely
because of a disability),


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, and
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 53
53 Page 54 55

2002 Mercy Health Plans/ Premier Health Plans Section 9 54
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 314-214-
8196 or 1-800-327-0763; (Texas Region) at 956-723-7667 or 1-
800-617-3433; or Premier Health Plans (Southwest Missouri
Region) at 417-836-0402 or 1-800-836-0402 or visit our website
at www. mercyhealthplans. com.

We do not waive any costs when you have Medicare.
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),
but we will not waive any of our copayments, coinsurance, or
deductibles. If you enroll in a Medicare managed care plan, tell us. We
will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits
with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care
plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be Medicare Part A or B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and , if you can't get premium-free Part A, we will not
ask you to enroll in it. 54
54 Page 55 56
2002 Mercy Health Plans/ Premier Health Plans Section 9 55
TRICARE TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover you, we
pay first. See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our Providers.

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

When others are responsible When you receive money to compensate you for
for injuries medical or hospital care injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover

the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 55
55 Page 56 57
2002 Mercy Health Plans/ Premier Health Plans Section 10 56
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Assistance with activities of daily living (bathing, dressing, eating, etc.).
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services.

Experimental or Services determined by the Plan to not be generally accepted by health
Investigational service care professional as effective in treating the illness for which their use is proposed. These services are said not be proven scientifically to

effectively treat the condition prescribed.

Group health coverage Any plan on an insured or uninsured basis which provides medical or dental benefits or services: (a) group coverage, (b) services plan
contracts, (c) coverage under any trustee plans, welfare plans or
employee benefit organization plans, or (d) benefits under Medicare.

Medical necessity Health care services and supplies that are ordered by a Plan physician and found to be medically appropriate and necessary to meet basic health
needs.

Plan allowance The Plan's determination of charges for medical care, services and supplies that do not exceed the fees and prices generally approved for
cases of comparable nature and severity at the time and place. The Plan
will use the following guidelines for determining usual, customary and
reasonable (UCR):

a. The usual fee frequently charged by the provider for a service or
supply;
b. The widely accepted rate of fees charges in the same area by the
health professionals of like training and experience; and
c. Unusual circumstances or complication requiring additional time
skill and experience in connection with the provided services or
supply.

Us/ We Us and we refer to Mercy Health Plans/ Premier Health Plans.
You You refers to the enrollee and each covered family member. 56
56 Page 57 58

2002 Mercy Health Plans/ Premier Health Plans Section 11 57
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or

retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.

Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 57
57 Page 58 59
2002 Mercy Health Plans/ Premier Health Plans Section 11 58
When benefits and The benefits in this brochure are effective on January 1. If you joined
premiums start this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. Annuitants'

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

Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

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

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

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

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

When you retire When you retire, you can usually stay in the FEHB 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.

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.

_ Temporary continuation
of coverage (TCC) 58
58 Page 59 60

2002 Mercy Health Plans/ Premier Health Plans Section 11 59
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.

Converting to 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)
Group Health Plan Coverage is a Federal law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage.

If you leave the FEHB Program, we will give you a Certificate of Group
Health Plan 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 pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked question. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 59
59 Page 60 61

2001 Mercy Health Plans/ Premier Health Plans Long Term Care Insurance 60
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:

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.

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 planing.

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.

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.

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.
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.

What is long term care
(LTC) insurance?

I'm healthy. I won't need
long term care. Or, will I?

Is long term care expensive?
But won't my FEHB plan,
Medicare or Medicaid cover
my long term care?

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

How can I find out more about the
program NOW? 60
60 Page 61 62

2002 Mercy Health Plans/ Premier Health Plans DoD/ FEHB Demonstration Project 61
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to enroll in the FEHB
Program. The demonstration will last for three years and began with the 1999 open
season for the year 2000. Open season enrollments will be effective January 1, 2002.
DoD and OPM have set up some special procedures to implement the Demonstration
Project, noted below. Otherwise, the provisions described in this brochure apply.

Who is eligible DoD determines who is eligible to enroll in the FEHB Program. Generally, you may enroll if:

You are an active or retired uniformed service member and are eligible for Medicare;
You are a dependent of an active or retired uniformed service member and are eligible for Medicare;
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees Health
Benefits Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.

The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA area
When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2001 open season, November 12, 2001, through December 10, 2001. Your coverage will begin
January 1, 2002. DoD has set-up an Information Processing Center (IPC) in Iowa to
provide you with information about how to enroll. IPC staff will verify your
eligibility and provide you with FEHB Program information, plan brochures,
enrollment instructions and forms. The toll-free phone number for the IPC is
1-877/ DOD-FEHB (1-877/ 363-3342).

You may select coverage for yourself (Self Only) or for you and your family (Self and
Family) during open season. Your coverage will begin January 1, 2002. If you
become eligible for the DoD/ FEHB Demonstration Project outside of open season,
contact the IPC to find out how to enroll and when your coverage will begin.

DoD has a web site devoted to the Demonstration Project. You can view information
such as their Marketing/ Beneficiary Education Plan, Frequently Asked Questions,
demonstration area locations and zip code lists at www. tricare. osd. mil/ fehbp. You
can also view information about the demonstration project, including "The 2002
Guide to Federal Employees Health Benefits Plans Participating in the DoD/ FEHB
Demonstration Project," on the OPM web site at www. opm. gov.

See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC).
Under this DoD/ FEHB Demonstration Project the only individual eligible for TCC is
one who ceases to be eligible as a "member of family" under your self and family

Temporary Continuation
Of Coverage (TCC) 61
61 Page 62 63
2002 Mercy Health Plans/ Premier Health Plans DoD/ FEHB Demonstration Project 62
enrollment. This occurs when a child turns 22, for example, or if you divorce and
your spouse does not qualify to enroll as an unremarried former spouse under title 10,
United States Code. For these individuals, TCC begins the day after their enrollment
in the DoD/ FEHB Demonstration Project ends. TCC enrollment terminates after 36
months or the end of the Demonstration Project, whichever occurs first. You, your
child, or another person must notify the IPC when a family member loses eligibility
for coverage under the DoD/ FEHB Demonstration Project.

TCC is not available if you move out of a DoD/ FEHB Demonstration Project area,
you cancel your coverage, or your coverage is terminated for any reason. TCC is not
available when the demonstration project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project. 62
62 Page 63 64
2002 Mercy Health Plans/ Premier Health Plans Index 63
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 38 Allergy care 19
Allogeneic bone marrow transplants 27
Alternative treatments 24 Ambulance 29, 31
Ambulatory surgical center 29 Anesthesia 27
Autologous bone marrow transplant 27
Changes for 2002 8 Chiropractic 24
Claims 48, 49 Coinsurance 13, 42
Copayments 13 Deductible 13, 42
Definitions 56 Dental benefits 38
Department of Defense 61 Disputed claims review 49
Durable medical equipment (DME) 22
Educational classes and programs 24
Emergency 30 FEHB Demonstration Project 61
FEHB facts 57 Family planning 18
Flexible benefits option 37

Foot care 21 General Exclusions 47
Hearing services 21 Home health services 23
Hospice care 29 Hospital 11, 28
Identification Cards 9 Immunizations 17, 18
Infertility 19 Inpatient Hospital 28
Lab 17 Long term care 60
Maternity Care 18 Medicaid 55
Medicare 51 Mental Health & Substance
Abuse Benefits 32 Non-FEHB Benefits 46
Nurse line (24-hr) 37 Oral and maxillofacial surgery 26
Orthopedic devices 22 Out-of-pocket expenses 13
Outpatient hospital 29 Point of service (POS) benefits
39 Preventive care, adult 17
Preventive care, children 18 Prescription drugs 34
Preventive services 17

Prior approval 11 Primary care 9
Program-wide changes 8 Prosthetic devices 22
Providers 9 Service Area 7
Skilled nursing facility care 29 Smoking cessation 24
Specialty care 10 Substance abuse 32
Surgery
Anesthesia 27 Oral 26

Outpatient 29 Reconstructive 26
Surgical procedures 25 TDD line 37
TRICARE 55 Temporary continuation of
coverage (TCC) 58 Transplants 27
Treatment therapy 20 Vision services 21
Wellness Programs 46 Workers' Compensation 55
X-rays 17 Your Rights 6 63
63 Page 64 65
2002 Mercy Health Plans/ Premier Health Plans Notes 64
NOTES: 64
64 Page 65 66
2002 Mercy Health Plans/ Premier Health Plans Notes 65
NOTES: 65
65 Page 66 67
2002 Mercy Health Plans/ Premier Health Plans Notes 66
NOTES: 66
66 Page 67 68
2002 Mercy Health Plans/ Premier Health Plans Summary of Benefits
Summary of benefits for the Mercy Health Plans/ Premier Health Plans -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 16

Services provided by a hospital:
Inpatient ............................................................................................
Outpatient .........................................................................................
Nothing
Nothing
28
29

Emergency benefits:
In-area ..............................................................................................
Out-of-area.......................................................................................
$50 Copayment per visit, except
Copayment charge will be waived
when inpatient admission for the
same condition occurs within 24
hours

31

Mental health and substance abuse treatment...................................... Regular benefits 32
Prescription drugs.................................................................................. $7/$ 12/$ 25 Copayment 34
Dental Care........................................................................................ Discounted fee schedule 38
Vision Care........................................................................................ $10 per office visit; one pair of
eyeglasses or contact lenses to
correct an impairment directly
caused by accidental ocular injury
or intraocular surgery (such as
cataracts)

21

Special features:
Flexible benefits option 24 hour nurse line (not available in Texas)

Services for deaf and hearing impaired

37

Point of Service benefits --Yes 39
Protection against catastrophic costs
(your out-of-pocket maximum).........................................................

Nothing after $1,100/ Self Only or
$3,300/ Family (Missouri Regions)
or $1,000/ Self Only or
$2,000/ Family (Texas Region)
enrollment per year.

Some costs do not count toward
this protection

13 67
67 Page 68
2002 Mercy Health Plans/ Premier Health Plans Rates
2002 Rate Information for
Mercy Health Plans/ Premier Health Plans

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, 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. Such persons not subject to postal rates must 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

Missouri Regions (see page 7 for service area)
Self Only 7M1 $97.86 $36.22 $212.03 $78.48 $115.52 $18.56

Self and Family 7M2 $223.41 $88.44 $484.06 $191.62 $263.75 $48.10
Texas Region (see page 7 for service area)
Self Only HM1 $95.32 $31.77 $206.52 $68.84 $112.79 $14.30

Self and Family HM2 $223.41 $94.32 $484.06 $204.36 $263.75 $53.98 68

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