Document Body Page Navigation Panel Document Outline

MD-Individual Practice Association, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

MD-Individual Practice Association, Inc.

Pages 1--64 from FEHB Front Page 2002

Page 1 2

MD-Individual Practice
Association, Inc. http:// www. mamsi. com

RI 73-100
A Health Maintenance Organization
Serving: Washington, D. C. , Maryland, Northern
Virginia, Roanoke, Richmond and Tidewater areas

Enrollment codes for this Plan:
JP1 Self Only
JP2 Self and Family

Enrollment in this Plan is limited;
see pages 6 and 7 for requirements.

2003

This Plan has Excellent accreditation
from the NCQA. See the 2003 Guide
for more information on NCQA.

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

Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.

Sincerely,

Kay Coles James Director 2.
2 Page 3 4

Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing,
and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized
OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose. 3.
3 Page 4 5
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
Five Steps to Safer Health Care
1. Speak up if you have questions or concerns.
Choose a doctor who you feel comfortable talking to about your health and treatment. Take a relative or friend
with you if this will help you ask questions and understand the answers. It's okay to ask questions and to
expect answers you can understand.

2. Keep a list of all the medicines you take.
Tell your doctor and pharmacist about the medicines that you take, including over-the-counter medicines such
as aspirin, ibuprofen, and dietary supplements like vitamins and herbals. Tell them about any drug allergies you
have. Ask the pharmacist about side effects and what foods or other things to avoid while taking the medicine.
When you get your medicine, read the label, including warnings. Make sure it is what your doctor ordered, and
you know how to use it. If the medicine looks different than you expected, ask the pharmacist about it.

3. Make sure you get the results of any test or procedure.
Ask your doctor or nurse when and how you will get the results of tests or procedures. If you do not get them
when expected in person, on the phone, or in the mail -don't assume the results are fine. Call your doctor
and ask for them. Ask what the results mean for your care.

4. Talk with your doctor and health care team about your options if you need hospital care.
If you have more than one hospital to choose from, ask your doctor which one has the best care and results for
your condition. Hospitals do a good job of treating a wide range of problems. However, for some procedures
(such as heart bypass surgery), research shows results often are better at hospitals doing a lot of these
procedures.* Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you
understand the instructions.

5. Make sure you understand what will happen if you need surgery.
Ask your doctor and surgeon: Who will take charge of my care while I'm in the hospital? Exactly what will
you be doing? How long will it take? What will happen after the surgery? How can I expect to feel during
recovery? Tell the surgeon, anesthesiologist, and nurses if you have allergies or have ever had a bad reaction to
anesthesia. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the
operation.

This information is brought to you in cooperation with The Federal Government's Office of Personnel Management
and the Quality Interagency Task Force (7/ 00).

* Source: US News and World Report, 7/ 17/ 00 5.
5 Page 6 7

2003 M. D. IPA 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of M. D. IPA under our contract (CS 1935) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for M. D. IPA' s administrative offices is:
MD-Individual Practice Association, Inc. (M. D. IPA) 4 Taft Court
Rockville, MD 20850

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2003, unless those benefits are also shown in this brochure
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language 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 M. D. IPA.
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

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your Plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized Plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it
paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a physician or health care practitioner 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 physician or health care practitioner and ask for an explanation. There may be an error. If the physician or health care practitioner does not resolve the matter, call us at 301-360-8080 or 1-800-251-0956 and
explain the situation. 8.
8 Page 9 10
2003 M. D. IPA 5 Introduction/ Plain Language/ Advisory
If we do not resolve the issue:
Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

CALL THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 9.
9 Page 10 11

2003 M. D. IPA 6 Section 1
Section 1. Facts about this HMO Plan
This Plan is a health maintenance organization (HMO). We require you to see specific ph ysicians, hospitals, facilities and other health care practitioners who contract with us. These Plan physicians and health care practitioners coordinate your health care services. The
Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent Directory of Health Care Professionals.

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 physicians and health care practitioners follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan physicians and health care practitioners, you will not have to submit claim forms or pay bills. You only pay the copayments and coinsurance described in this brochure. When you receive emergency services from non -Plan
physicians and health care practitioners, you may have to submit claim forms.
You should join an HMO because you prefer the Plan's benefits, not because a particular physician or health care practitioner is available. You cannot change Plans because a physician or health care practitioner leaves our Plan. We cannot guarantee
that any one physician, hospital, or other health care practitioner will be available and/ or remain under contract with us.
How we pay physicians, health care practitioners and facilities
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochur e. These Plan physicians and health care practitioners accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans to provide certain information to their FEHB members. You may get information about us, our networks of physicians, health care practitioners and facilities. OPM's FEHB Web site (www. opm. gov/ insure) lists the specific types
of information that we must make available to you.
If you want more information about us, call M. D. IPA's Member Services Department at 301-360-8080 or at 1-800-251-0956 (TTY: 301-360-8111 or 1-800-553-7109), or write to P. O. Box 933, Frederick, MD 21705. You may also contact us by fax at 301-360-8907
or visit our Web site, www. mamsi. com/ federal
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our physicians and health care practitioners practice.
Our service area is:
Washington, D. C.;
Maryland (the entire state)
Virginia
Cities of: Alexandria, Charlottesville, Chesapeake, Clifton Forge, Colonial Heights, Covington, Emporia, Fairfax, Falls
Church, Franklin, Fredericksburg, Hampton, Hopewell, Manassas, Manassas Park, Newport News, Norfolk, Norton, Petersburg, Poquoson, Portsmouth, Radford, Richmond, Roanoke, Salem, Staunton, Suffolk, Virginia Beach,
Waynesboro and Williamsburg 10.
10 Page 11 12
2003 M. D. IPA 7 Section 1
Counties of: Accomack, Albemarle, Alleghany, Amelia, Arlington, Augusta, Bath, Bedford, Bland, Botetourt, Buchanan,
Buckingham, Caroline, Charles City, Chesterfield, Clarke, Craig, Culpeper, Cumberland, Dinwiddie, Fairfax, Fauquier, Floyd, Franklin, Giles, Goochland, Gloucester, Greene, Greensville, Hanover, Henrico, Isle of Wight,
James City, King George, King William, King and Queen, Loudoun, Louisa, Madison, Mathews, Middlesex, Montgomery, Nelson, New Kent, Northampton, Nottoway, Orange, Page, Patrick, Powhatan, Prince George, Prince
William, Pulaski, Rappahannock, Roanoke, Russell, Southampton, Spotsylvania, Stafford, Surry, Sussex, Tazewell, Westmoreland, Wise, Wythe, and York.

Ordinarily, you must get your care from physicians and health care practitioners who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area
unless the services have prior Plan approval.
If you or a covered family member moves 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 moves, you do not have to wait until Open Season to change Plans. Contact your employing or retirement office. 11.
11 Page 12 13
2003 M. D. IPA 8 Section 2
Section 2. How we change for 2003
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
A Notice on the Office of Personnel Management's Privacy Practices is included.

A section of the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will be increase by 15.1% for Self Only coverage, or by 15.5 % for Self and Family coverage.

Prescription drugs -You pay $8 for generic drugs and $17 for brand name drugs on the Plan's formulary. You pay $33 for non-formulary drugs.
Prescription drugs Members pay one copayment per 34 days supply of insulin .
Habilitative services We now cover medically necessary habilitative services for children with Autism, Autism Spectrum Disorder, or Cerebral Palsy.

Mental Health and Substance Abuse We now cover Residential Crisis Services for qualified intensive mental health and support services from entities licensed by the Maryland Department of Health and Mental Hygiene.
Educational classes and programs -There is a copayment for diabetes self-management classes. You pay $10 per office visit to Primary Care Physician, $20 per visit to a Specialist and $50 per outpatient hospital visit .
Service area expansion We have expanded our service area in the State of Virginia to include the City of Norton and the Counties of Madison, Greene, Culpeper, and Wise. 12.
12 Page 13 14

2003 M. D. IPA 9 Section 3
Section 3. How you get care
Identification cards We will send you a health Plan identification (ID) card. You should carry your ID card with you at all times. You must show it whenever
you receive services from a Plan physician or health care practitioner, or fill a prescription at a Plan pharmacy. Until you receive your health

Plan 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 301-360-8080
or 1-800-251-0956 or write to us at P. O. Box 943, Frederick, MD 21705.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance and you will not have to file claims.
Plan physicians and health care practitioners Plan physicians and other licensed health care professionals in our service area contract with us to provide covered services to our
members.
All of our physicians are credentialed in accordance with the standards set by the National Committee for Quality Assurance (NCQA). For
further information on our credentialing procedures, please contact our Member Services Department at 301-360-8080 or 1-800-251-0956.

We list Plan physicians and health care practitioners in our Directory of Health Care Professionals, which we update periodically. The list is
also on our Web site, www. mamsi. com. Information in the directory is subject to change. For this reason, we recommend that you access our
Web site to look up the most up-to-date information.
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 our Directory of Health Care Professionals, which we update periodically. The list is also on our Web site, www. mamsi. com.
Information in the directory is subject to change. For this reason, we recommend that you access our Web site to look up the most up-to-date
information.

What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a Primary Care Physician (PCP). This decision is
important since your PCP provides or arranges for most of your health care. Please see pages 33 and 34 for information on accessing

Mental Health and Substance Abuse benefits.

To choose a PCP check our Directory of Health Care Professionals or our Web site, www. mamsi. com/ federal. You may call the Member
Services Department at 301-360-8080 or 1-800-251-0956 and we will make the change for you over the phone. Or, if you wish, you may
complete the "Federal Information Form" included in your open season information packet and mail it to us at P. O. Box 943, Frederick, MD
21705. 13.
13 Page 14 15
2003 M. D. IPA 10 Section 3
Primary care Your Primary Care Physician (PCP) can be an internist, an obstetrician/ gynecologist for a woman, a pediatrician for a child, or a
general/ family practitioner for any member of the family. Your PCP will provide most of your health care, or give you a referral to see a
specialist.
If you want to change PCPs or if your PCP leaves the Plan, call us. We will help you select a new one.

Specialty care Your Primary Care Physician (PCP) will refer you to a specialist for needed care. Your referral is valid for one visit/ consultation unless your
PCP authorized a certain number of visits without additional referrals. All follow-up care must be authorized by your PCP issuing you a new

referral, or by approving a Consultant Treatment Plan (CTP) submitted by the specialist. However, female members may see a participating
obstetrician or gynecologist, or a participating Certified Nurse Midwife, for obstetrical and gynecological care without a referral. Obstetrical
and gynecological services include routine care and follow-up services, as well as medically necessary services. Eye refraction exams and
dental care are also available from Plan physicians and health care practitioners without a referral.

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 PCP 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 PCP. He or she 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 PCP, who will arrange for you to see another specialist.
You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or

drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or if we
drop out of the Program, contact your new Plan. 14.
14 Page 15 16
2003 M. D. IPA 11 Section 3
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 Primary Care Physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a
skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 301-360-8080 or
1-800-251-0956. If you are new to the FEHB Program, we will arrange for you to receive care.

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

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the necessary care. 15.
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2003 M. D. IPA 12 Section 3
Services requiring our prior approval Your Primary Care Physician (PCP) has authority to refer you for most services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical

practice.
We call this review and approval process precertification. Your physician must obtain precertification for some services such as, but not
limited to the following:
Acupuncture

Biofeedback
Breast Reconstruction/ Breast Reduction
Reconstructive surgery
Growth Hormone Therapy (GHT)
Infertility Services
Morbid Obesity Surgery
Rhinoplasty
Therapies (Physical Therapy, Occupational Therapy and Speech Therapy)

precertification is required for physical therapy and occupational therapy after the eighth (8 th ) visit for all members
precertification is required for speech therapy from the first (1 st ) visit, but only for members under age 10

Temporomandibular Joint (TMJ) Pain Dysfunction and/ or related
Myofascial Pain Dysfunction (MPD) treatment
Transplants
Uvulopalatopharyngoplasty
Durable Medical Equipment, Orthopedic and Prosthetic Devices

In addition, your admitting physician and facility must also preauthorize any elective inpatient stays.

It is your PCP's or specialist's responsibility to obtain precertification for the procedures listed above before performing them. If the PCP or
specialist does not do this, you will not be liable for the cost of covered services.

We will decide whether or not to precertify a procedure within two working days of the receipt of the information we need to make a
decision.
If we deny the request or if you wish to extend the number of authorized visits, your PCP or specialist may ask us to reevaluate our decision or
extend the number of authorized visits at any time. A decision will be made within one working day of receiving all of the information we need
to make the decision.
If you are not satisfied with our decision, you, or your PCP or specialist on your behalf, may appeal the decision. 16.
16 Page 17 18
2003 M. D. IPA 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayment A copayment is a fixed amount of money you pay to the physician, health care practitioner, 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 are admitted to the
hospital, you pay nothing per admission.

Deductible We do not have a deductible.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for most infertility services and durable medical equipment.

Your catastrophic protection out-of-pocket maximum
for coinsurance and copayments

After your copayment and/ or coinsurance total $1,800 per person or $4,800 per family enrollment in any calendar year, you do not have to
pay any more for covered services. However, copayments and coinsurance for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

Prescription drugs
Dental Discount Benefits
Eyeglasses or contact lenses
In-vitro fertilization

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum. 17.
17 Page 18 19

2003 M. D. IPA 14 Section 5
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 59 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

subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 301-360-8080 or 1-800-251-0956 or at our Web site, www. mamsi. com.

(a) Medical services and supplies provided by physicians and other health care professionals..........................15-24
Diagnostic and treatment services Laboratory, X-ray, and other diagnostic tests

Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical, cardiac and occupational therapies

Speech therapy Habilitative therapies
Hearing services (testing, treatment, and supplies) Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health care professionals ......................25-27

Surgical procedures Reconstruction surgery Oral and maxillofacial surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services...................................................28-30
Inpatient hospital Outpatient hospital or ambulatory surgical

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

Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care. We have no calendar year deductible.

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

I M
P O
R T
A N
T

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

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist

Professional services of physicians
In an urgent care center

During a hospital stay
In a skilled nursing facility

Nothing

At home $10 per visit from your Primary Care Physician
$20 per visit from a specialist
Laboratory, X-ray and other diagnostic tests
Tests, such as:
Blood tests Urinalysis

Non-routine pap tests Pathology
X-rays Non-routine Mammograms
CAT Scans/ MRI Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise,
$20 per office visit to a specialist
$50 per outpatient hospital visit 19.
19 Page 20 21
2003 M. D. IPA 16
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol

Colorectal Cancer Screening, including:
-Fecal occult blood test
-Sigmoidoscopy screening every five years starting at age 50

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $10 per office visit to your Primary Care Physician
$20 per office visit to a specialist
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnostic and Treatment services, above.
$10 per office visit to your Primary Care Physician

$20 per office visit to a specialist
Nothing per visit to a Certified Nurse Midwife

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Routine immunizations limited to:

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

Influenza vaccine, annually, age 50 and over
Pneumococcal vaccine, once at age 65 or older

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist

Not covered:
Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
All charges 20.
20 Page 21 22
2003 M. D. IPA 17
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics (AAP), American Academy of Family Physicians

(AAFP), and the Advisory Committee on Immunization Practices (ACIP)
$10 per office visit to your Primary Care Physician

$20 per office visit to a specialist
Well-child care for routine examinations, immunizations and care (up to age 22)
Examinations, such as:
-Ear exams to determine the need for hearing correction
-Examinations done on the day of immunizations (up to age 22)

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist

Eye exams to determine the need for vision correction $25 per office visit to a specialist
Maternity Care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
Office visit copayments for routine obstetrical care are waived after the first maternity care visit.

Routine care includes office visits, one office sonogram (as part of prenatal care) and laboratory work.
You do not have to obtain a referral to see a participating obstetrician or gynecologist, or a participating Certified Nurse Midwife, for obstetrical
and gynecological care. Obstetrical and gynecological services include routine care and follow-up services, as well as medically necessary
services. A participating obstetrician/ gynecologist may issue referrals for pregnancy-related illnesses through the postpartum period.

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.

Circumcisions are covered 100% during newborn stay.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery

benefits (Section 5b).

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist
Nothing per visit to a Certified Nurse Midwife 21.
21 Page 22 23
2003 M. D. IPA 18
Family planning You pay
A broad range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures 5 (b))
Surgically implanted contraceptives
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 to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit

Not covered: reversal of voluntary surgical sterilization All charges
Infertility services Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)

In-vitro fertilization is covered for married members when the following criteria is met:

-your oocytes are fertilized with your spouse's sperm
-you and your spouse have a history of infertility of at least 2 years, or

-your infertility is associated with endometriosis, or exposure in-utero to diethylstilbestrol (DES), or blockage of, or surgical
removal of one or both fallopian tubes (not due to voluntary sterilization), or abnormal male factors, including oligospermia,
contributing to the infertility
-you have been unable to attain a successful pregnancy through a less costly treatment that is covered by the Plan

In-vitro fertilization is limited to three (3) in-vitro attempts per live birth and a maximum lifetime benefit of $100,000, except drugs (an attempt is counted
toward this limit when injectable medications are started).

$10 per office visit to your Primary Care Physician
50% per office visit to other Plan physicians or health care practitioners

Note: We cover injectable and oral fertility drugs for covered in-vitro fertilization services, and Clomid (clomiphene) for artificial insemination.
When covered, all infertility drugs are covered under the prescription drug benefit.
Not covered:
Assisted reproductive technology (ART) procedures, such as:

-embryo transplant, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), sex selection, surrogacy, host

uterus, gene therapy, cryopreservation, and pre-implantation diagnosis

Other services and supplies related to ART procedures
Cost of donor sperm, donor eggs, and related costs
Infertility services after reversal of voluntary sterilization

All charges 22.
22 Page 23 24
2003 M. D. IPA 19
Allergy care You pay
Testing and treatment
Allergy injections
$10 per office visit to your Primary Care Physician

$20 per office visit to a specialist
Allergy serum Nothing
Not covered:

provocative food testing and sublingual allergy desensitization.
All charges

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

Transplants on page 27.
Respiratory and inhalation therapy Dialysis hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)

Notes: Growth hormone is covered under the prescription drug benefit. We will only cover GHT when we precertify the treatment. See Services

requiring our prior approval in Section 3.

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit

Physical, cardiac and occupational therapies
Up to two months or 60 visits (whichever is more) per condition, for the services of the following:
qualified physical therapists and
occupational therapists.

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to two months or 60 visits (whichever
is more) per condition.

$20 per office visit to a specialist
$50 per outpatient hospital visit
Nothing per visit during covered inpatient admission

Not covered:
long-term rehabilitative therapy

exercise programs, gym or pool memberships
work hardening/ functional capacity programs or evaluations

All charges

Speech therapy
Up to two months or 60 visits (whichever is more) per condition $20 per office visit to a specialist
$50 per outpatient hospital visit
Nothing per visit during covered inpatient admission 23.
23 Page 24 25
2003 M. D. IPA 20
Habilitative Therapies You pay
Habilitative services for children under age 19 with congenital or genetic birth defects. Treatment is provided to enhance the child's ability to

function. Services include:
Speech therapy
Occupational therapy; and

Physical therapy

Notes: No day or visit limits apply to these services. A congenital disorder means a significant structural or functional abnormality that was present

from birth.
Includes medically necessary habilitative services coverage for children with Autism, an Autism Spectrum disorder, or Cerebral Palsy

$20 per office visit to a specialist
$50 per outpatient hospital visit

Hearing services (testing, treatment, and supplies)
Hearing testing
Hearing aid examinations for children under 19; hearing aids covered under Durable Medical Equipment.
$10 per office visit to your Primary Care Physician

$20 per office visit to a specialist
Not covered:
Hearing aids, except as covered for children under age 19 under Durable Medical Equipment in this section
All charges

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye $10 per office visit to your Primary
Care Physician

$20 per office visit to a specialist
One pair of eyeglasses or contact lenses per lifetime to correct an impairment directly caused by accidental ocular injury or intraocular

surgery (such as for cataracts) 50% of charges
Annual eye refraction exams to provide a written lens prescription
You do not have to obtain a referral from your Primary Care Physician for this service $25 per office visit to a specialist

Not covered:
Eyeglasses or contact lenses
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 to your Primary Care Physician

$20 per office visit to a specialist
$50 per outpatient hospital 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

All charges 24.
24 Page 25 26
2003 M. D. IPA 21 Section 5( a)
Orthopedic and prosthetic devices You pay
Orthopedic devices, such as:
Artificial limbs and eyes; stump hose

External lenses following cataract removal
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Enteral equipment and supplies
Ostomy supplies except deodorants, filters, lubricants, tape, appliance cleaners, adhesive and adhesive removers

Orthotic braces and splints not available over-the-counter
Surgical dressings not available over-the-counter; (see Durable Medical Equipment)

A hair prosthesis for hair loss resulting from chemotherapy or radiation treatment for cancer. There is a limit of one hair prosthesis per lifetime,
with a maximum cost of $350.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following
mastectomy.
Note: Orthopedic and prosthetic devices must be preauthorized. We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment

information. See 5( b) for coverage of the surgery to insert the device.

50% of charges

Not covered:
orthopedic and corrective shoes
shoes and foot orthotics, including heel pads, heel cups and arch supports

lumbosacral supports
corsets trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements provided less than 5 years after the last one we covered (except as needed to accommodate growth in children or for
socket replacement for members with significant residual limb volume or weight changes)

external penile devices
speech prosthetics (except electrolarynx)

All charges 25.
25 Page 26 27
2003 M. D. IPA 22 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;

wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps and insulin pump supplies
surgical dressings not available over-the-counter
Note:. Durable medical equipment must be preauthorized. Call us at 301-360-8080 or 1-800-251-0956 if your Plan physician prescribes this

equipment and you need assistance locating a health care physician or health care practitioner to rent or sell you durable medical equipment. You may
also call us to see if a certain piece of equipment is covered.

50% of charges

Hearing aids for children under age 19, prescribed, fitted and dispensed by a licensed audiologist 50% of charges up to $1,400 per ear every 36 months
Not covered:
Power-operated vehicles
Duplicate or backup equipment
Parts and labor costs for supplies and accessories replaced due to wear and tear such as wheelchair tires and tubes

Educational, vocational, or environmental equipment
Deluxe or upgraded equipment and supplies
Home or vehicle modifications, seat lifts
Over-the-counter medical equipment and supplies
Activities of daily living aids (such as grab bars and utensil holders)
Personal hygiene equipment
Paraffin baths, whirlpools, and cold therapy
Augmentative communication devices
Infertility monitors
Physical fitness equipment
Hearing aids for those over 19 years old
Continuous pulse oximetry unless skilled nursing is involved in home care and it is part of their medically necessary equipment

All charges 26.
26 Page 27 28
2003 M. D. IPA 23 Section 5( a)
Home health services You pay
Medically necessary 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. You may use the Home Health Care benefit to facilitate medically necessary shift
nursing. We allow 35 hours per week for a period not to exceed 21 days or 105 hours

Services include oxygen therapy, intravenous therapy and medications.
Medical foods prescribed by a physician when determined to be your sole source of nutrition

Nothing

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

home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative;
foods that you can obtain without a prescription, even if prescribed by your physician or determined to be your sole source of nutrition, except
for foods used to treat inherited metabolic diseases;
private duty nursing

All charges

Chiropractic
Chiropractic services are covered up to a maximum benefit of $500 50% of charges up to the maximum benefit and all charges thereafter.

Alternative treatments
Acupuncture up to twelve (12) visits per calendar year for postoperative and chemotherapy nausea and vomiting, nausea of
pregnancy, postoperative dental pain and as part of a comprehensive treatment program for chronic pain

Biofeedback for pain management, migraine treatment, bowel training and pelvic floor training for urinary incontinence

$20 per office visit to a specialist
$50 per outpatient hospital visit

Not covered:
naturopathic services hypnotherapy

massage therapy herbal medicine
homeopathy

All charges 27.
27 Page 28 29
2003 M. D. IPA 24 Section 5( a)
Educational classes and programs You pay
Childbirth education classes:
When you complete the childbirth education class, submit a copy of the certificate of completion with the dates attended, as well as a copy

of your canceled check or receipt to P. O. Box 948, Frederick, MD 21705.

All charges we will reimburse up to $50 for childbirth education
classes

Smoking cessation program
When you complete the smoking cessation program, submit a copy of the certificate of completion with the dates attended, as well as a copy

of your canceled check or receipt to P. O. Box 948, Frederick, MD 21705.

All charges we will reimburse up to $100 for the smoking cessation
program

Diabetes self-management classes $10 per office visit to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit 28.
28 Page 29 30
2003 M. D. IPA 25 Section 5( b)
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.
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. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

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T

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 procedure
Biopsy procedure
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an individual's Body Mass Index (BMI) is greater than 35, with

documented comormidities, or 40 without documented comorbidities. Eligible members must be age 18 or over. The member's PCP must
submit clinical records documenting the member's participation in a physician supervised weight loss program. Documentation must show
the member attended at least one visit per month for six consecutive months of the weight loss program during the latest twelve month
period.
Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

Voluntary sterilization (e. g. Tubal ligation, Vasectomy)
Surgically implanted contraceptives and intrauterine devices (IUDs). Note: Devices are covered under 5( a).

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 to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit

Not Covered
Reversal of voluntary sterilization All charges 29.
29 Page 30 31
2003 M. D. IPA 26 Section 5( b)
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. Your physician
must precertify repair of congenital anomalies.
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 to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges

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; facial defects due to congenital syndromes such as cleft

lip/ cleft palate, Crouzon's and Pierre-Robin's.
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 to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit

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

All charges 30.
30 Page 31 32
2003 M. D. IPA 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea

Heart
Heart/ lung
Kidney
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 Hodgkins 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 at a Medicare approved center.

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 for Cardiac Surgery, Transplants and Joint Replacement and if approved by the Plan's medical director in
accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

$10 per office visit to your Primary Care Physician
$20 per office visit to a specialist
$50 per outpatient hospital visit

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 services related to non-covered transplants
All services associated with complications resulting from the removal of an organ from a non-member

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)

Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 31.
31 Page 32 33
2003 M. D. IPA 28 Section 5( c)
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 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 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).
YOUR ATTENDING PHYSICIAN MUST GET PREAUTHORIZATION FOR ELECTIVE HOSPITAL STAYS.

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

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

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood products, derivatives and components, artificial blood products and biological serum. Blood products include any product created from

a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, immunoglobulin, and
prolastin.
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

Non-covered facilities, such as nursing homes and schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private duty nursing care

All charges 32.
32 Page 33 34
2003 M. D. IPA 29 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood products, derivatives and components, artificial blood products and biological serum.

Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia services

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

$50 per visit

Not covered: Whole blood and concentrated red blood cells blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care benefits:
All necessary services provided for up to 60 days per calendar year in a skilled nursing facility when full-time nursing care is necessary and

confinement in a skilled nursing facility is medically appropriate as determined by a Plan physician and approved by the Plan.

Services include:
Bed, board and general nursing care

Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan

physician

Nothing

Not covered:
custodial care
rest cures, domiciliary or convalescent care
personal comfort items, such as telephone, television, barber services, guest meals and beds

All charges 33.
33 Page 34 35
2003 M. D. IPA 30 Section 5( c)
Hospice Care You pay
Supportive or palliative care for a terminally ill member in the home or hospice facility. These services are provided under the direction of a Plan

physician who certifies that you are in the terminal stages of illness, with a life expectancy of approximately six (6) months or less.

Services include:
Inpatient and outpatient care
Family counseling

Nothing

Not covered: Independent nursing, private duty nursing, homemaker services All charges
Ambulance
Professional ambulance service when medically appropriate Nothing 34.
34 Page 35 36
2003 M. D. IPA 31 Section 5( d)
Section 5( d) Emergency services/ accidents
I M
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A N
T

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

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.

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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are
emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, 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 or outside our service area:
If you are in an emergency situation, please call your Primary Care Physician. In extreme emergencies, if you are unable to contact your physician, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest

hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours, unless it was not reasonably possible to notify
us within that time. It is your responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in a non-Plan
facility and Plan physicians believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full. Benefits are available for care from non-Plan physicians or health
care practitioners in a medical emergency only if delay in reaching a Plan physician or health care practitioner 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 physicians or health care practitioners must be approved by the Plan or provided by Plan physicians or health care practitioners. 35.
35 Page 36 37
2003 M. D. IPA 32 Section 5( d)
Benefit Description You pay
Emergency within or outside our service area
Emergency care at a physician's office $10 per office visit to your Primary
Care Physician

$20 per office visit to a specialist

Emergency care at an urgent care center $25 per visit

Emergency care at an emergency room. $50 per visit, waived if the emergency results in an admission to a hospital

Not covered:
Elective care or non-emergency care

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges

Ambulance
Professional ambulance service, including air ambulance, when medically appropriate.

See 5( c) for non-emergency service.
Nothing 36.
36 Page 37 38
2003 M. D. IPA 33 Section 5( e)
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 and are payable only when we determine they are medically necessary.

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

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

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

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

Professional services, including individual or group therapy by health care practitioners such as psychiatrists, psychologists, or clinical social
workers

Medication management

$20 per office visit to a specialist
$50 per outpatient hospital visit

Diagnostic tests $20 per office visit to a specialist
$50 per outpatient hospital visit

Services provided by a hospital or other facility while an inpatient Nothing
Services provided by a hospital or other facility while an outpatient. This includes partial hospitalization and facility based intensive
outpatient treatment.
$20 per office visit
$50 per outpatient hospital visit

Services in approved alternative care settings such as half-way house and residential treatment.

Note: The services covered in approved alternative settings are limited to those provided by participating licensed professionals according to a
treatment plan that has been approved by a Plan psychiatrist and Primary Care Physician.

$20 per office visit 37.
37 Page 38 39

2003 M. D. IPA 34 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Not covered:
Services we have not approved
Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan physician to be

necessary and appropriate

All charges

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
Once you have been referred for mental health services, you must be evaluated by a Psychiatric Physician. This physician will discuss with
you a recommended course of treatment at the appropriate provider level.
We list mental health and substance abuse physicians and health care practitioners in our Directory of Health Care Professionals , which we

update periodically. The list is also on our Web site, www. mamsi. com . Information in the directory is subject to change; for this reason, we
recommend that you access our Web site to look up the most up-to-date information.

Limitation We may limit your benefits if you do not obtain a treatment plan. 38.
38 Page 39 40

2003 M. D. IPA 35 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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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.

We have no calendar year deductible.
Certain drugs require your physician to get prior authorization from us before they can be prescribed under the Plan. The Plan requires prior authorization for these drugs to make sure that they are being prescribed and

consumed according to FDA -approved indications and dosing schedules. If your pharma cist tells you that your prescription drug requires prior authorization, ask your pharmacist or physician to call the Pharmacy Services
Department at 1-800-205-3636 for further instructions.
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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There are important features you should be aware of. These include:
Who can write your prescription? A licensed physician must write the.
Where you can obtain them. You may fill the prescription at a Plan pharmacy. You may fill prescriptions for maintenance medications either by mail or at a retail pharmacy. Maintenance medications are those drugs

used on a continual basis, for six months or longer, for the treatment of chronic health conditions such as high blood pressure, asthma, or diabetes. To locate the name of a participating pharmacy near you, refer to your
Directory of Health Care Professionals, call our Member Services Department at 301-360-8080 or 1-800-251-0956, or visit our Web site, www. mamsi. com.

We use a formulary. A formulary is a listing of prescription drugs that are preferred by the Plan for use. All generic drugs are on the formulary, as well as certain name brand drugs. Drugs that are on the formulary are
selected based on safety, efficacy and cost. This listing is periodically reviewed and updated by a team of physicians and pharmacists. M. D. IPA uses an open formulary. This means you are covered for all
prescription medications written in accordance with FDA guidelines for a particular therapeutic indication whether or not the medication appears on the formulary, except for prescription drugs or classes of drugs
listed under "Not Covered" in this section of the brochure. However drugs not specifically listed on our formulary are subject to a non-formulary copayment. Drugs requiring prior authorization will be covered
once reviewed and approved by the Plan.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name

brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a copy of the formulary, call the Member Services Department at 301-360-8080 or 1-800-251-0956.

These are the dispensing limitations. You may obtain up to a 34-day supply of non-maintenance prescription drugs at a Plan pharmacy or by mail order. Prescriptions for covered maintenance medications
may be filled or refilled at a Plan retail pharmacy, or through the mail by Express Scripts, Inc. (ESI). You may obtain up to a consecutive 90-day supply of maintenance prescription medications after the first 34 day
supply fill with one copayment for each month's supply. For more information on mail order benefits, you can reach Express Scripts, Inc. at 1-888-828-2579. A prescription can be refilled when you have used 75
percent of the medication. For example, a prescription that was filled for a 34-day supply can be refilled after 26 days.

Covered medications and supplies --continued on next page 39.
39 Page 40 41
2003 M. D. IPA 36 Section 5( f)
We follow FDA dispensing guidelines. Generic drugs will be dispensed when substitution is permissible for prescriptions filled at a retail pharmacy or through mail order. If generic substitution is permissible (i. e., a
generic drug is available and the prescribing physician does not require the use of a brand name drug), but you request the brand name drug, you pay the name brand copayment plus the cost difference between the
generic and the name brand drug. If you fill a prescription for a brand name and there is no generic available, you will be responsible for either the formulary or non-formulary brand name copayment.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand name drugs. They must contain the same active ingredients and must be equivalent in
strength and dosage to the original brand name product. Generics cost less than the equivalent brand name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these
drugs meet the same standards of quality and strength as brand name drugs. You can save money by using generic drugs. However, you and your physician have the option to request a brand name if a generic option
is available.

When you have to file a claim. Usually, there are no claim forms to fill out when you fill a prescription at a Plan pharmacy. In some cases, however, you may pay out-of-pocket, such as when you are outside the
service area in a medical emergency. If this happens, send the following information to P. O. Box 948, Frederick, MD 21705.

your receipt
the drug NDC number
the pharmacy's NABP number, and
the prescribing physician's or dentist's DEA number

Benefit Description You pay After the calendar year deductible

Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those

listed as Not covered.
Insulin, with a copayment charge applied to each 34 day supply. Diabetic supplies, including insulin syringes, needles, glucose test

tablets and test tape, Benedict's solution or equivalent, and acetone tests tablets.
Disposable needles and syringes for the administration of covered, prescribed medications.
Oral contraceptive drugs (you may obtain up to three cycles of oral contraceptive drugs at one time with a copayment charge applied to
each cycle); contraceptive devices.
Fertility drugs injectable and oral fertility drugs for authorized in-vitro fertilization procedures; only Clomid (clomiphene) is covered

for artificial insemination.
Limited Benefits

Drugs to treat sexual dysfunction are limited. Contact the Plan for dosage limits.

Drugs prescribed for smoking cessation are limited to 90 day supply within a 365 day period.

$8 per generic drug
$17 per brand name drug in the Plan's formulary

$33 per brand name drug not in the Plan's formulary
20% up to $50 for injectable drugs, except for insulin.
Note: If there is no generic equivalent available, you will still have to pay the
brand name copayment.

Covered medications and supplies --continued on next page 40.
40 Page 41 42
2003 M. D. IPA 37 Section 5( f)
Not covered:
Drugs and supplies for cosmetic purposes, including drugs for weight loss or control

Nonprescription medicines
Vitamins and nutritional substances that can be purchased without a prescription

Medical supplies such as dressings and antiseptics
Artificial insemination fertility drugs except Clomid (clomiphene)
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Replacement Prescription Drug Products resulting from loss, theft, spoilage, or breakage of original product
Drugs available over-the-counter that do not require a prescription order by federal or state law before being dispensed, and any drug
that is therapeutically equivalent to an over-the-counter drug

All charges 41.
41 Page 42 43
2003 M. D. IPA 38 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

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

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

Centers for Cardiac Surgery, Transplants and Joint
Replacement

We use specific institutions called Centers for Cardiac Surgery, Transplants and Joint Replacement. These Centers do a large volume of these procedures each
year and have a comprehensive program of care. A list of these facilities can be found in the Directory of Health Care, or you can call the Member Services
Department at 301-360-8080 or 1-800-251-0956 for an up-to-date listing.

WeeCall Program Our maternity programs offer women support and education throughout pregnancy. We will mail you educational materials, and obstetrical nurses are
available to talk to you on the telephone at no cost. Call the Member Services Department at 301-360-8080 or 1-800-251-0956 for more information about our

maternity programs.

Plan Publications There are several publications available to you at no cost. They include: Advance Directives
HealthLine (immunization and preventive health check-up schedule)
HealthSense Member Newsletter
Healthy Living Series
Directory of Health Care Professionals
WeeCall Pregnancy Education
Vaccination Facts

Call the Member Services Department at 301-360-8080 or 1-800-251-0956 to request a copy of any of these publications.

Health Education and Disease Management
Programs
Healthwise Knowledgebase online source for members to research health questions
Diabetes care
Behavioral Health/ Depression care
Asthma
Cardiovascular Prevention
Breast Cancer Prevention 42.
42 Page 43 44
2003 M. D. IPA 39 Section 5( h)
Section 5( h). Dental benefits
I M
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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.

This Plan is a discount program. 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. See Section 5

(c) for inpatient hospital benefits.
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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Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

You must request treatment within seventy-two (72) hours after the accident occurs. If your injury cannot be reasonably treated within seventy-two (72) hours (example: if you
have sustained medical injuries to such an extent to render dental treatment during this time period impossible), an extension may be granted if you make the request within sixty (60)
days of the date of injury.
Dental treatment for accidental injury is a limited benefit intended to stabilize your dental condition and includes only the following:

Emergency examination
Periapical and panoral radiographs

Root canal therapy
Emergency, temporary splinting of the teeth
Prefabricated post and core
Simple, minimal restorative procedures (fillings)
Emergency extractions
Post-traumatic crowns are covered if it is the only treatment available

Note: Injury as a result of chewing, biting or poor dental hygiene is not covered.

$20 per visit 43.
43 Page 44 45

2003 M. D. IPA 40 Section 5( h)
Dental Discount benefits
The following list summarizes the fees for dental services provided by a participating PLAN GENERAL DENTIST ONLY. Services rendered by a plan general dentist that are not on the fee schedule, are provided at a 25 percent

reduction of usual and customary (UCR) costs. Services (whether on the fee schedule or not) rendered by a Plan dental specialist are also provided at a 25 percent reduction of costs. The fees listed on this page, and the following
page, do not reflect the payment to a Plan dental specialist. Cosmetic and implant-related services (implants, abutments, posts, screws and implant-supported prosthetics) are provided at a 10 percent discount by both plan
general and specialist dentists. You do not have to obtain a referral from your Primary Care Physician to obtain the following dental care services. For additional information, contact us at 301-360-8080 or 1-800-251-0956; for a
complete list of fe es, or a list of participating dentists, please refer to the M. D. IPA 2003 Federal Plan Dental Guide. The list is also on our Web site, www. mamsi. com/ federal.

Service You pay Type I Diagnostic and Preventive Services
D1203 Topical Application of Fluoride (Prophylaxis not Included) Child N/ C D0120 Periodic Oral Examination $20.00
D0150 Comprehensive Oral Evaluation $34.00 D1110 Prophylaxis Adult $35.00
D1120 Prophylaxis Child $27.00 Radiological Services
D0210 Intraoral Complete Series (including bitewings) $55.00 D0220 Intraoral Periapical First Film $11.00
D0272 Bitewings 2 Films $19.00 D0330 Panoramic Film $53.00
Type II Basic Dental Services, Silver Restorations and All Other Services Amalgam Restorations Adult
D2150 Amalgam 2 Surfaces, Permanent $67.00 Amalgam Restorations Child
D1351 Sealant Per Tooth $22.00 D2120 Amalgam 2 Surfaces, Primary $60.00
Composite Restorations (White Filling) D2331 Resin 2 Surfaces, Anterior $74.00
D2381 Resin 2 Surfaces, Posterior Primary $77.00 D2386 Resin 2 Surfaces, Posterior Permanent $89.00
Type III Major Dental Services Crown and Inlay Services
D2920 Recement Crown $44.00 D2930 Prefabricated Stainless Steel Crown--Primary Tooth $119.00
D2950 Core Buildup, Including Any Pins $70.00 D2952 Cast Post and Core In Addition to Crown $174.00
D2954 Prefabricated Post and Core In Addition to Crown $144.00 Bridge Services
D6930 Recement Bridge $60.00 D6970 Cast Post and Core in Addition to Bridge $151.00
Endodontic Services D3110 Pulp Cap Direct (Excluding Final Restoration) $34.00
D3310 Anterior (Excluding Final Restoration) $337.00 D3330 Molar (Excluding Final Restoration) $551.00
Periodontic Services D4341 Periodontal Scaling and Root Planing Per Quadrant $90.00
D4910 Periodontal Maintenance Procedures (Following Active Therapy) $65.00 Prosthodontics Removable
D5110 Complete Denture Maxillary $599.00 D5213 Maxillary Partial Denture Cast Metal Framework with Resin Denture Bases
(Including any Conventional Clasps, Rest and Teeth) $662.00 D5730 Reline Complete Maxillary Denture (Chairside) $137.00 44.
44 Page 45 46
2003 M. D. IPA 41 Section 5( h)
D5740 Reline Partial Maxillary Denture (Chairside) $126.00 Oral Surgery Services
D7110 Single Tooth $62.00 D7210 Surgical Removal of Erupted Tooth Requiring Evaluation of Mucoperiosteal Flap
And Removal of Bone and/ or Section of Tooth $95.00 D7230 Removal of Impacted Tooth Partially Bony $190.00
D7240 Removal of Impacted Tooth Completely Bony $230.00 For all services performed by a Dental Specialist (including Orthodontic Services) and any services not listed
above, you pay a fee of 75 percent of the Dentist's Usual and Customary fee. Cosmetic and implant-related services are offered by both General and Specialist dentists, for which you pay 90 percent of the Dentist's Usual
and Customary fee. 45.
45 Page 46 47

2003 M. D. IPA 42 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums.

PPO DENTAL PLAN
In addition to the Dental Discount benefit described in Section 5 (h) of this brochure, M. D. IPA provides a PPO dental Plan to all 2003 Federal members. There is no additional premium for this benefit and enrollment is automatic when you enroll in M. D. IPA's FEHB

health Plan (JP) for 2003.
Members may go to the dentist of their choice; however, the benefit is usually better when you visit a dentist who participates in the PPO. The benefit provides reimbursement of up to $1,000 per contract year for covered dental procedures. The PPO dental Plan

covers diagnostic (e. g., X-rays), preventive (e. g., exams, cleanings), basic (e. g., fillings), an d major procedures (e. g.,. root canals, surgical extractions).

Members will receive a separate identification card for this benefit in their enrollment kit. It is issued by MAMSI Life and Health Insurance Company (MLH), which provides and administers this benefit.
Look for important details about this Plan, its usage, as well as a listing of participating dentists, in the 2003 Dental Benefits Guide. This Guide is in the enrollment packet, or can be obtained by calling Member Services at 1-800-251-0956, or 301-360-8080. You can
also find information about the dental Program on our Web site, www. mamsi. com/ federal.

TLC LASER VISION CORRECTION DISCOUNT
TLC Laser Eye Centers offer M. D. IPA members a preferred savings for laser vision correction. For more information on this benefit, please contact TLC toll-free at 1-877-PLAN TLC.

ASHN COMPLEMENTARY HEALTH C ARE ACCESS PROGRAM
As a member with M. D. IPA, you will receive a 25 percent discount on services rendered by an American Specialty Health Networks (ASHN ) participating chiropractor, acupuncturist or massage therapist that are not reimbursed under your FEHB benefits. For more

information about the ASHN Access Program, please call ASHN at 1-877 -327-2746, or click on the "Members" icon on our Web site, www. mamsi. com and then click on "Complementary Services".

OPTICAL SERVICES
Discounts are available on eyewear and related services at participating optical centers listed in the Plan's Directory of Health Care Professionals. Members simply show their health Plan identification card at a participating center to receive a discount on eyeglasses,

including single, multifocal or designer and other optical services.
Contact lenses may also be available at a discount. Please contact the Member Services Department for the names of participating health care practitioners.

NATIONAL FITNESS N ETWORK DISCOUNT
The National Fitness Network offers discounts at area health and fitness clubs of up to 30 percent to M. D. IPA members. For more information or for questions regarding registration, call National Fitness Network at 1-800-811-5454, or visit their Web site,
www. nationalfitnessnetwork. com. 46.
46 Page 47 48
2003 M. D. IPA 43 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan physician 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 12.
We do not cover the following:
Care by non-Plan physicians or health care practitioners except for authorized referrals or emergencies (see Emergency Benefits);

Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a physician, health care practitioner or facility barred from the FEHB Program.
Services, drugs or supplies you receive without charge while in active military service. 47.
47 Page 48 49
2003 M. D. IPA 44 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your health Plan identification card and pay your copayment
or coinsurance.
You will only need to file a claim when you receive emergency services from non-Plan physicians or health care practitioners. Sometimes these physicians or health care practitioners bill us directly. Check with the physician or

health care practitioner. If you need to file the claim, here is the process:

Medical and Hospital benefits In most cases, physicians or health care practitioners 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 301-360-8080 or at 1-800-251-0956.

When you must file a claim such as for services you receive outside of the Plan's service area submit it on the HCFA-1500 or a claim
form that includes the information shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;

A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: P. O. Box 948, Frederick, MD 21705

Prescription drugs Usually, there are no claim forms to fill out when you fill a prescription at a Plan pharmacy. In some cases, however, you may pay out-of-pocket,
such as when you are outside the service area in a medical emergency. If this happens, send the following information to P. O.

Box 948, Frederick, MD 21705:
your receipt

the drug NDC number
the pharmacy's NABP number, and
the prescribing physician's or dentist's DEA number

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
2003 M. D. IPA 45 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within six months from the date of our decision; and
(b) Send your request to us at: Customer Support, P. O. Box 933, Frederick, MD 21705
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as 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 you about the claim; and
Your daytime phone number and the best time to call. 49.
49 Page 50 51
2003 M. D. IPA 46 Section 8
Note: If you want OPM to review more than one claim, 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 a physician or a health care practitioner, 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.
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 have not responded yet to your initial request for care or preauthorization/ prior approval, then call us at 301-360-8080 or 1-800-251-0956, 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 may call OPM's Health Benefits Contracts Division 3 at 202-606-0737 between 8 a. m. and 5 p. m. eastern time. 50.
50 Page 51 52
2003 M. D. IPA 47 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage 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 a term used to describe the various

health Plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care Plan you have.
The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) Plan that is available everywhere in the United States. It is the way everyone used to get
Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any physician, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original
Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your

care must continue to be authorized by your Plan PCP, or precertified as required. 51.
51 Page 52 53
2003 M. D. IPA 48 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart A. When either you or your covered spouse are age 65 or over and Then the primary payer is..
Original Medicare This Plan 1) 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 ESRC 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 52.
52 Page 53 54

2003 M. D. IPA 49 Section 9
Claims process when you have the Original Medicare Plan You have to file all claims with the appropriate payer and obtain an
Explanation of Benefits (EOB) for the secondary payer when you have both our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first and issue the provider of service an Explanation of Benefits for submission
to the secondary payer the provider of service.
When Original Medicare is the primary payer, Medicare processes your claim first and will issue an EOB to the provider of service;
the EOB must accompany the claim when submitted to our Plan for secondary payment consideration. In most cases, your claims
will be coordinated and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out
if you need to do something to file your claim, call us at 301-360-8080 or 1-800-251 -0956.

We waive some costs if the Original Medicare Plan is your primary payer. When Original Medicare is the primary payer, we will waive
some out-of-pocket costs. All copayment and coinsurance amounts will be applied until you meet your Medicare Part B deductible. Once the
Medicare Part B deductible has been met, all copayments and coinsurance are waived. We will pay all amounts identified as "patient
responsibility" on the Medicare Explanation of Benefits as long as the service rendered is a covered benefit. We will pay the Inpatient
Medicare deductible.

Medicare managed care Plan If you are eligible for Medicare, you may choose to enroll in and get you r Medicare benefits from a Medicare managed care Plan. These are
health care choices (like HMOs) in some areas of the country. In most Medicare managed care Plans, you can only go to physicians,
specialists, or hospitals that are part of the Plan. Medicar e 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. 53.
53 Page 54 55
2003 M. D. IPA 50 Section 9
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 Medicare Part A or Part B If you do not have one or both parts of Medicare, you can still be 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.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or

CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about
these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable Plan premiums.)
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 under the program.

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 physicians or

health care practitioners.

Medicaid When you have this Plan and Medicaid, we pay first. Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one

of these State programs, eliminating your FEHB 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 under the State program. 54.
54 Page 55 56
2003 M. D. IPA 51 Section 9
When other Government agencies are responsible for your care We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse
us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need other information, contact us for our
subrogation procedures. 55.
55 Page 56 57
2003 M. D. IPA 52 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 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 Medical or non-medical services: Which are furnished mainly to assist you in the activities of daily
living;
For which professional skills or training is not required; and
Which are not likely to result in the improvement of your condition or in your recovery

Experimental or investigational services A drug, device, treatment or procedure is considered experimental if: It is not recognized, in accordance with generally accepted medical
standards, as being safe and effective for your condition;
It requires approval by a governmental authority (including the U. S. Food and Drug Administration) before you can use it, but

they have not granted that approval; or
It is the subject of a written protocol used by the treating facility for research, clinical trials, or other tests or studies to evaluate its

safety, effectiveness, toxicity, or maximum tolerated dose.
We evaluate investigational/ experimental treatments on a case-by-case basis as well as on a continual basis as new and emerging treatments

become available. We use a variety of resources to assist the Medical Director in deciding if a service is experimental or investigational
including specific database searches of the National Institutes of Health (NIH) and the Health Care Financing Administration (HCFA), review
by independent medical experts and an independent technology assessment firm.

Medical necessity Services which are reasonably necessary in the exercise of good medical practice in accordance with professional standards accepted in the
United States for the treatment of an active illness or injury. We determine medical necessity.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in
different ways. M. D. IPA's Plan allowance is based on an internally-developed fee schedule. Each CPT, HCPC or ADA procedure code is

assigned a regional rate, based on your physician's or health care practitioner's office address. This rate includes your copayment or
coinsurance amount. Participating physicians or health care practitioners accept this rate, including your copayment or coinsurance
amount, as payment in full.

Us/ We Us and we refer to M. D. IPA.
You You refers to the enrollee and each covered member. 56.
56 Page 57 58

2003 M. D. IPA 53 Section 11
Section 11. FEHB facts
No pre-existing condition limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition
before you enrolled.

Where you can get information about enrolling in the FEHB

Program

See www. opm. gov/ insure. Also, your employing or retirement office can answer your questions, and give you a Guide to Federal Employees
Health Benefits Plans, brochures for other Plans, and other materials you need to make an informed decision about your FEHB coverage.
These materials tells you:
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 for you and your family Self Only coverage is for you alone. Self and Family coverage is for 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.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled
for self and family coverage in the Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or

administrative order requiring you to health benefits for your child( ren).
If this law applies to you, you must enroll for self and family coverage in a health Plan that provides full benefits in the area where your
children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If 57.
57 Page 58 59
2003 M. D. IPA 54 Section 11
you do not do so, your employing office will enroll you involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for self and family coverage in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option If you have a Self Only enrollment in a fee-for-service Plan or in an
HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same
option of the same Plan; or
If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your

enrollment to Self and Family in Blue Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the
FEHB Program, you cannot cancel your enrollment, change to Self only, or change to a Plan that doesn't serve the area in which your
children live, unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in
effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into
retirement (if eligible) and cannot make any changes after retirement. Contact your employing office for further information

When benefits and premiums start The benefits in this brochure are effective on January 1. If you joined 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.

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). 58.
58 Page 59 60

2003 M. D. IPA 55 Section 11
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 coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is
the case even when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get RI70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download
the guide from OPM's Web site, www. opm. gov/ insure.
Temporary Continuation Coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22 or marry, etc..

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC: Get the RI-79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.
Converting to individual coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot

convert);
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and
we will not impose a waiting period or limit your coverage due to pre-existing conditions. 59.
59 Page 60 61

2003 M. D. IPA 56 Section 11
Getting a Certificate of Group Health Plan Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer group coverage. If you lea ve 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 questions. These highlight HIPAA rules,
such as the requirement that federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies you can contact for more information. 60.
60 Page 61 62

2003 M. D. IPA 57 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you are a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC partners receives your application.

FEHB Doesn't Cover It
Neither FEHB Plans nor Medicare cover the cost of long term care. Also called custodial care, long term care helps you perform the activities of daily living, such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health related questions that you need to answer is the same during and after Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze".

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 61.
61 Page 62 63

2003 M. D. IPA 58 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 39 Family planning 18 Out-of-pocket expenses 13 Allergy care 19 Fecal occult blood test 16 Outpatient facility care 29
Alternative treatment 23 Fraud 4 Oxygen 23 Allogenic (donor) bone marrow transplant 27 General Exclusions 43 Pap test 15
Ambulance 30 Hearing services 20 Physical examination 16 Anesthesia 27 Home health services 23 Physical therapy 19
Autologous bone marrow 27 Hospice care 30 Pre-surgical testing 29 Biopsy 25 Home nursing care 23 Precertification 12
Blood and blood plasma 29 Hospital 28 Preventive care, adult 16 Casts 29 Immunizations 16 Preventive care, children 17
Catastrophic out-of-pocket maximum 13 Infertility 18 Prescription drugs 35 Changes for 2003 8 Inpatient Hospital Benefits 28 Prior approval 12
Chemotherapy 19 Insulin 36 Prostate specific antigen test 16 Childbirth education classes 24 Laboratory and pathological services 15 Radiation therapy 19
Chiropractic 23 Magnetic Resonance Imaging (MRIs) 15 Room and board 28 Cholesterol screening 16 Mail Order Prescription Drugs 35 Second surgical opinion 15
Circumcision 17 Mammograms 16 Skilled nursing facility care 29 Claims 44 Maternity Care 17 Speech therapy 19
Coinsurance 52 Medicaid 49 Splints 28 Colorectal cancer screening 16 Medically necessary 43 Sterilization, voluntary 25
Congenital anomalies 26 Medicare 47 Subrogation 50 Contraceptive devices and Drugs 36 Mental Health/ Substance Abuse Benefits 33 Substance abuse 33
Coordination of benefits 47 Newborn 17 Surgery Crutches 22 Non -FEHB Benefits 42
Anesthesia 27 Deductible 13 Nurse Oral 26

Definitions 52 Licensed Practical Nurse 23 Outpatient 29 Dental care 39
Licensed Vocational Nurse 23 Reconstructive 26 Diagnostic services 15 Nurse Anesthetist 28 Syringes 36

Dialysis 19 Obstetrical Nurse 38 Temporary continuation of Coverage 55 Disputed claims process 45
Registered Nurse 23 Transplants 27 Donor expenses (transplants) 27 Nursery charges 17 Treatment therapies 19

Dressings 29 Obstetrical care 17 Vision services 20 Durable medical equipment (DME) 22 Occupational therapy 12 Well-child care 17
Educational classes and Programs 24 Ocular injury 20 Wheelchairs 22 Effective date of enrollment 27 Office visits 15 Worker's Compensation 50
Emergency 31 Oral and Maxillofacial surgery 26 X-Rays 15 Experimental or Investigational 43 Orthopedic devices 21
Eyeglasses 20 Ostomy supplies 21 62.
62 Page 63 64
2003 M. D. IPA 59 Summary of Benefits
Summary of benefits for the M. D. IPA Health Plan 2003
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 copayment: $10
primary care; $20 specialist 15

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

Outpatient .....................................................................................
Nothing
$50 copayment

29
Emergency benefits:
In or out-of-area .......................................................................... $25 per urgent care center visit

$50 per emergency room visit
32

32
Mental health and substance abuse treatment..................................... Regular cost sharing 33
Prescription drugs............................................................................. $8 per generic drug
$17 per brand name drug in the Plan's formulary

$33 per brand name drug not in the Plan's formulary
20% up to $50 for injectable drugs, except for insulin.

Dental Care ................................................................................... Discount fee schedule 40
Vision Care ................................................................................... $25 copayment for eye refraction exam 20

Special features: Centers for Cardiac Surgery, Transplants, and Joint Replacement, WeeCall, Plan Publications, Health Education and Disease Management Programs 38
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)................... Nothing after $1,800/ Self Only or $4,800/ Family enrollment per year
Some costs do not count toward this protection
13 63.
63 Page 64
2003 M. D. IPA 60 Rates
2003 Rate Information for
M. D. IPA

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 a special FEHB guide is published for Postal Service
Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization. Refer to the applicable FEHB Guide.

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

Washington, D. C. area, all of Maryland and N. Va/ Central Va/ Richmond/ Tidewater/ Roanoke
Self Only JP1 $104.10 $34.70 $225.55 $75.18 $123.19 $15.61

Self and Family JP2 $249.62 $83.55 $540.84 $181.03 $294.70 $38.47 64.

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