Pages 1--56 from HealthPartners Classic

Serving: MinneapolisÑ St. PaulÑ St. Cloud, MinnesotaÑ West Central Wisconsin
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
531 High Option-Self Only
532 High Option-Self and Family
534 Standard Option-Self Only
535 Standard Option-Self and Family

RI 73-009

For changes
in

benefits
see

pages
7.

This plan has "Commendable" accreditation
from the NCQA. See the FEHB Guide
for more information on NCQA. 1
1 Page 2 3
Table of Contents
Introduction ........................................................................................................................................................................ 4
Plain Language .................................................................................................................................................................. 4
Section 1. Facts about this HMO plan .......................................................................................................................... 5-6
How we pay providers...................................................................................................................................... 5
Who Provides My Health Care ........................................................................................................................ 5
Patients' Bill of Rights ...................................................................................................................................... 5
Service Area...................................................................................................................................................... 6
Section 2. How we change for 2001ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.. .................................................................. 7
Program-wide changes...................................................................................................................................... 7
Changes to this Plan ........................................................................................................................................ 7
Section 3. How you get care ...................................................................................................................................... 8-10
Identification cards .......................................................................................................................................... 8
Where you get covered care ............................................................................................................................ 8
° Plan providers ............................................................................................................................................ 8
° Plan facilities .............................................................................................................................................. 8
What you must do to get covered care ............................................................................................................ 8
° Primary care................................................................................................................................................ 8
° Specialty care .......................................................................................................................................... 8-9
° Hospital care .............................................................................................................................................. 9
Circumstances beyond our control .................................................................................................................. 9
Services requiring our prior approval ............................................................................................................ 10
Section 4. Your costs for covered services .................................................................................................................. 11
° Copayments .............................................................................................................................................. 11
° Deductible ................................................................................................................................................ 11
° Coinsurance .............................................................................................................................................. 11
° Your out-of-pocket maximum .................................................................................................................. 11
Section 5. Benefits .......................................................................................................................................................... 12
Overview ........................................................................................................................................................ 12
(a) Medical services and supplies provided by physicians and other health care professionals ................................ 13-20
(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................ 21-24
(c) Services provided by a hospital or other facility, and ambulance services .......................................................... 25-27
(d) Emergency services/ accidents .............................................................................................................................. 28-29
(e) Mental health and substance abuse benefits.......................................................................................................... 30-31
(f) Prescription drug benefits ...................................................................................................................................... 32-34
(g) Special features .......................................................................................................................................................... 35
(h) Dental benefits ............................................................................................................................................................ 36

2001 HealthPartners Classic 2 Table of Contents 2
2 Page 3 4
Table of Contents
(i) Non-FEHB benefits available to Plan members.......................................................................................................... 37
Section 6. General exclusions --things we don't cover ................................................................................................ 38 Section 7. Filing a claim for covered services ................................................................................................................ 39
Section 8. The disputed claims process .................................................................................................................... 40-41
Section 9. Coordinating benefits with other coverage .............................................................................................. 42-45
When you haveÉ
° Other health coverage .............................................................................................................................. 42
° Original Medicare .................................................................................................................................... 42
° Medicare managed care plan .................................................................................................................... 44
TRICARE/ Workers' Compensation/ Medicaid .......................................................................................... 44-45
Other Government agencies .......................................................................................................................... 45
When others are responsible for injuries........................................................................................................ 45
Section 10. Definitions of terms we use in this brochure .............................................................................................. 46
Section 11. FEHB facts .............................................................................................................................................. 47-49
Coverage information .................................................................................................................................... 47
° No pre-existing condition limitation ........................................................................................................ 47
° Where you get information about enrolling in the FEHB Program ........................................................ 47
° Types of coverage available for you and your family.............................................................................. 47
° When benefits and premiums start .......................................................................................................... 47
° Your medical and claims records are confidential .................................................................................. 48
° When you retire ........................................................................................................................................ 48
When you lose benefits .................................................................................................................................. 48
° When FEHB coverage ends...................................................................................................................... 48
° Spouse equity coverage ............................................................................................................................ 48
° Temporary Continuation of Coverage (TCC) .......................................................................................... 48
° Converting to individual coverage .......................................................................................................... 49
° Getting a Certificate of Group Health Plan Coverage ............................................................................ 49
Inspector General Advisory ............................................................................................................................ 49
Department of Defense/ FEHB Demonstration Project .............................................................................................. 50-51
Index ................................................................................................................................................................................ 52
Summary of benefits ........................................................................................................................................................ 54
Rates .................................................................................................................................................................. Back Cover

2001 HealthPartners Classic 3 Table of Contents 3
3 Page 4 5
Introduction
Group Health, Inc. dba HealthPartners Classic
8100 34th Avenue South
Minneapolis, Minnesota 55440

This brochure describes the benefits of HealthPartners Classic under our contract (CS 1048) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclu-sions
of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to bene-fits
that were available before January 1, 2001, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 7. Rates are shown at the end of this brochure.

Plain Language
The President and Vice President are making the Government's communication more responsive, accessible, and
understandable to the public by requiring agencies to use plain language. In response, a team of health plan represen-tatives
and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical terms, we
use common words. "You" means the enrollee or family member; "we" means HealthPartners Classic.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan
with other FEHB plans, you will find that the brochures have the same format and similar information to make com-parisons
easier.

If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us" feed-back
area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance Planning

and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.

2001 HealthPartners Classic 4 Introduction 4
4 Page 5 6
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

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

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

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

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

Who provides my health care?
We are a group practice prepayment plan that allows our members to receive health services at over 70 medical, mental
health and dental facilities and 25 contracting hospitals throughout the Twin cities and surrounding areas, including St.
Cloud. Our medical providers include 575 primary care doctors and over 1,100 community specialists to whom patients
are referred. Members may choose any medical center in our network for primary care. Each covered person in a family
may select a different medical center.

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

HealthPartners, Inc. is a Minnesota nonprofit corporation under Articles of Incorporation dated December 28, 1983,
and is operated under the Minnesota Nonprofit Corporation Act, Minnesota Statues Chapter 317A. HealthPartners was
formed through the affiliation of Group Health, Inc. and MedCenters Health Plan in 1992. Group Health, Inc. (a
501( c) (3) corporation) has been in existence as a nonprofit corporation since 1957. MedCenters Health Plan was
founded in 1972, and is no longer in existence.

HealthPartners is Minnesota's only consumer-guided health plan. Our Board of Directors is composed of consumer-elected
members.

HealthPartners is a licensed HMO in the State of Minnesota. Group Health, Inc. is a federally qualified HMO, and
received that qualification in 1974.

Information on the following topics is available by calling HealthPartners Member Services:
° Plan preauthorization and utilization review procedures
° Use of clinic protocols, practice guidelines and utilization review standards
° Special disease management programs and programs for persons with disabilities
° Prescription drug formulary and procedures for considering requests of patient-specific waivers
° Qualifications of reviewers at the initial decision and reconsideration under the FEHB disputed claims process
Member Services representatives are available from 7: 30 a. m. until 6: 00 p. m., Monday through Friday.
If you want more information about us, call 952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals should
call 952/ 883-5127), or write to HealthPartners, P. O. Box 1309, Minneapolis, MN 55440-1309. You may also contact
us by fax at 952/ 883-5666 or visit our website at www. healthpartners. com.

2001 HealthPartners Classic 5 Section 1 5
5 Page 6 7
Section 1. Facts about this HMO plan
Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is:
The following counties in Minnesota: Anoka, Benton, Carver, Chisago, Dakota, Hennepin, Morrison, Ramsey, Rice,
Scott, Sherburne, Stearns, Washington and Wright.

The following partial county in Minnesota: Mille Lacs and Isanti.
The following counties in Wisconsin: Pierce, Polk and St. Croix.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care. We will not pay for any other health care services.

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

2001 HealthPartners Classic 6 Section 1 6
6 Page 7 8
Section 2. How we change for 2001
Program-wide changes
° The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make
it easier for you to compare plans.

° This year, the Federal Employees Health Benefits Program is implementing network mental health and substance
abuse parity. Our Plan already had parity for mental health and substance abuse treatment. Parity means that
your coverage for mental health, substance abuse, medical, surgical, and hospital services from providers in our
HealthPartners Classic network is the same with regard to deductibles, coinsurance, copays, and day and visit lim-itations
when you follow a treatment plan that we approve. This year all plans in the Federal Employee Health
Benefits Program will have parity.

° Many healthcare organizations have turned their attention this past year to improving healthcare quality and
patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our
patient safety activities by calling 952/ 883-5000 or 1-800-883-2177, or checking our website www. healthpart-ners.
com. You can find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve
your healthcare, take these five steps:

°° Speak up if you have questions or concerns.
°° Keep a list of all the medicines you take.
°° Make sure you get the results of any test or procedure.
°° Talk with your doctor and health care team about your options if you need hospital care.
°° Make sure you understand what will happen if you need surgery.
° We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure per-formed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the lan-guage
referenced only women.

Changes to this Plan

° Your share of the non-Postal premium will increase by 35% for Self Only or 29% for Self and Family and 15%
for Self Only or 17% for Self and Family on the High Option Standard Option.

° We clarified that we do not cover treatment of infertility after the reversal of sterilization.
° We clarified that we cover blood and blood plasma (unless replaced) and blood derivatives under "Treatment ther-apies",
"Inpatient hospital" and "Outpatient hospital or ambulatory surgical center".

° We clarified that we cover vision care for the initial evaluation, fitting of contact or eyeglass lenses if medically
necessary for the post-operative treatment of cataracts or for the treatment of aphakia or keratoconous.

° We clarified that no more than a 90-day supply of prescription drugs will be dispensed at a time.
° We clarified that we cover all acute leukemias for organ/ tissue transplants.
° We clarified that we cover services due to physical complications of all stages following a mastectomy, including
lymphedemas.

° Under "Prescription drug benefits", we clarified that your prescription drug copayment per manufacturer's pre-packaged
dispensing unit.

° We changed our coverage of tobacco cessation products so that the 60-day limit does not have to be "consecutive".
° Under "Organ/ tissue transplants", we clarified the list of covered autologous bone marrow transplants.
° We changed our coverage requirements for accidental dental injuries, so that the treatment must be "initiated"
within twelve months, rather than "completed" within twelve months, of the date of injury. The former require-ment
was not always reasonable for children who might have to wait until their growth is completed for certain
repairs.

° Under "When others are responsible for injuries", we added restrictions change when we can recover
subrogation/ reimbursement amounts.

2001 HealthPartners Classic 7 Section 2 7
7 Page 8 9
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharma-cy.
Until you receive your ID card, use your copy of the Health Benefits
Election Form, SF-2809, your health benefits enrollment confirmation (for
annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 952/ 883-5000
or 1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127).

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

° Plan providers Plan providers are physicians and other health care professionals in our service
area that we contract with to provide covered services to our members. We
credential Plan providers according to national standards. HealthPartners
Classic is a group practice prepayment plan that allows members to receive
health services at over 80 medical, mental health and dental facilities.
HealthPartners Classic medical providers include 712 primary care doctors and
over 5,969 community specialists to whom patients are referred. Members can
choose any medical center in the Plan's network for their primary care. Each
covered person in a family may select a different medical center.

We list Plan providers in the provider directory, which we update periodically.
°Plan facilities Plan facilities are hospitals and other facilities in our service area that we
contract with to provide covered services to our members. We list these in
the provider directory, which we update periodically. HealthPartners Classic
contracts with 22 hospitals throughout the Twin Cities and surrounding
areas, including St. Cloud. If you need to be hospitalized, your primary care
physician or specialist will make the necessary hospital arrangements and
supervise your care.

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your

primary care physician provides or arranges for most of your health care. To
choose a primary care physician, call your clinic. Each covered person in a
family may select a different medical center.

°Primary care Your primary care physician can be a family practitioner, internist or pedia-trician.
Your primary care physician will provide most of your health care,
or give you a referral to see a specialist.

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

° Specialty care Your primary care physician will refer you to a specialist for needed care.
However, a woman may see a plan gynecologist associated with her clinic
for her annual wellness exam 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 primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number
of visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).

2001 HealthPartners Classic 8 Section 3 8
8 Page 9 10
Section 3. How you get care
° If you are seeing a specialist when you enroll in our Plan, talk to your pri-mary
care physician. Your primary care physician will decide what treat-ment
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 partici-pate
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 partici-pate
with our Plan.

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

° If you have a chronic or disabling condition and lose access to your spe-cialist
because we:

°° terminate our contract with your specialist for other than cause; or
°° drop out of the Federal Employees Health Benefits (FEHB) Program
and you enroll in another FEHB Plan; or

°° reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.

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

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

If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 952/ 883-5000 or 1-800-883-
2177 (hearing impaired individuals should call 952/ 883-5127). 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 92nd day after you become a member of this Plan, whichever happens
first.

These provisions apply only to the benefit of the hospitalized person.
Circumstances beyond our Under certain extraordinary circumstances, such as natural disasters, we control 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.

2001 HealthPartners Classic 9 Section 3 9
9 Page 10 11
Section 3. How you get care
Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from us.
Before giving approval, we consider if the service is covered, medically nec
essary, and follows generally accepted medical practice.
We call this review and approval process prior authorization. Your Plan
physician must obtain prior authorization for services, such as:

° reconstructive surgery

° investigative/ experimental treatments
° promising therapies/ new technologies
° transplants
° medically necessary dental care, such as orthagnathic surgery
° durable medical equipment and prosthetics
° home health care
° skilled nursing care
° hospice care
° habilitative therapy
There may be additional services for which we require prior authorization.
Your Plan physician is responsible for obtaining prior authorization.

2001 HealthPartners Classic 10 Section 3 10
10 Page 11 12
2001 HealthPartners Classic 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
° Copayments A copayment is a fixed amount of money you pay to the provider when you
receive services.

Example: When you see your primary care physician you pay a copayment
of $10 for the High Option Plan and $15 for the Standard Option Plan per
office visit; and when you go in the hospital, you pay $200 per admission
for the Standard Option Plan, in addition to the coinsurance shown below.

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

° We have a separate deductible for accidental injury dental benefits.

°Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care.

Example: In our Plan, you pay 20% of our allowance for infertility services
and durable medical equipment; and when you go in the hospital for the
Standard Option Plan, you pay a $200 copayment per admission and 20% of
the next $3,500 of charges per calendar year.

° Your out-of-pocket After your copayments and/ or coinsurance total $3,000 per person or $5,000
per family enrollment in any calendar year, you do not have to pay any
more for covered services.

Be sure to keep accurate records of your copayments and/ or coinsurance
since you are responsible for informing us when you reach the maximum.

maximum for coinsurance
and copayments 11
11 Page 12 13
Section 5. Benefits --OVERVIEW (See page 7 for how our benefits changed this year and page 54 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the fol-lowing
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127) or at our website at
www. healthpartners. com.

(a) Medical services and supplies provided by physicians and other health care professionals 13-20 {page #'s of section}

(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................... 21-24
°Surgical procedures °Oral and maxillofacial surgery
°Reconstructive surgery °Organ/ tissue transplants
°Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services.................................................................... 25-27
°Inpatient hospital °Extended care benefits/ skilled nursing care facility
benefits

°Outpatient hospital or ambulatory surgical center °Hospice care
°Ambulance

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

(e) Mental health and substance abuse benefits.................................................................................................................... 30-31
(f) Prescription drug benefits ................................................................................................................................................ 32-34
(g) Special features ...................................................................................................................................................................... 35
° Careline Nurse Line ° Babyline Service ° Partners for Better Health Phone Line ° Services for deaf and hearing impaired
(h) Dental benefits ...................................................................................................................................................................... 36
(i) Non-FEHB benefits available to Plan members .................................................................................................................. 37
Summary of benefits.................................................................................................................................................................... 54

2001 HealthPartners Classic 12 Section 5

°Diagnostic and treatment services
°Lab, X-ray, and other diagnostic tests
°Preventive care, adult
°Preventive care, children
°Maternity care
°Family planning
°Infertility services
°Allergy care
°Treatment therapies
°Rehabilitative therapies

°Hearing services (testing, treatment, and supplies)
°Vision services (testing, treatment, and supplies)
°Foot care
°Orthopedic and prosthetic devices
°Durable medical equipment (DME)
°Home health services
°Alternative treatments
°Educational classes and programs 12
12 Page 13 14
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Section 5 (a) Medical services and supplies provided by physicians and other
health care professionals

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.
° 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.

Benefit Description You pay
Diagnostic and treatment services High Option Standard Option
Professional services of physicians $10 per office visit. $15 per office visit.
° In physician's office
° In an urgent care center
° Office medical consultations
° Second surgical opinion
Professional services of physicians Nothing Nothing
° During a hospital stay
° In a skilled nursing facility

Not covered: genetic counseling and studies not required for All charges. All charges.
diagnosis and treatment

Lab, X-ray and other diagnostic tests High Option Standard Option
Tests, such as: Nothing Nothing
° Blood tests
° Urinalysis
° Non-routine pap tests
° Pathology
° X-rays
° Non-routine Mammograms
° Cat Scans/ MRI
° Ultrasound
° Electrocardiogram and EEG

2001 HealthPartners Classic 13 Section 5a 13
13 Page 14 15
Benefit Description You pay
Preventive care, adult High Option Standard Option
Routine health exams, periodic health assessments, and cancer Nothing Nothing
screenings, such as:

° Blood lead level Ð One annually
° Total Blood Cholesterol Ð once every three years, ages 19 through 64
° Colorectal Cancer Screening, including
°° Fecal occult blood test
°° Sigmoidoscopy, screening Ð every five years starting at age 50
° Prostate Specific Antigen (PSA test) Ð one annually for men age 40
and older

° Routine pap test
° Testing and treatment of sexually transmitted diseases and testing
for HIV and HIV related conditions provided by a Plan or non-Plan
provider

° Routine hearing exams
Routine mammogram Ðcovered for women age 35 and older, Nothing Nothing
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
Adult Immunizations
Not covered: Physical exams required for obtaining or continuing All charges. All charges.
employment or insurance, attending schools or camp, or travel.

Preventive care, children High Option Standard Option
° Child health supervision services, including well-child care Nothing Nothing
charges for routine examinations, immunizations and care
(through age 22).

° Routine hearing and eye exams.

Maternity care High Option Standard Option
Complete maternity (obstetrical) care, such as: Nothing Nothing
° Prenatal care
° Delivery
° Postnatal care
Note: Here are some things to keep in mind:
° You do not need to prior authorize your normal delivery; see
page 15 for other circumstances, such as extended stays for
you or your baby.

2001 HealthPartners Classic 14 Section 5a
Continued on next page. 14
14 Page 15 16
Benefit Description You pay
Maternity care continued High Option Standard Option
° You may remain in the hospital up to 48 hours after a regular Nothing Nothing
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.

° We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover
other care of an infant who requires non-routine treatment only
if we cover the infant under a Self and Family enrollment.

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

Not covered: Routine sonograms to determine fetal age, size or sex. All charges. All charges.

Family planning High Option Standard Option
° Family planning services provided by a Plan Provider or Nothing. Nothing.
non-Plan provider

° Voluntary sterilization $10 per office visit $15 per office visit
° Surgically implanted contraceptives 20% of charges. 20% of charges.
° Injectable contraceptive drugs
° Intrauterine devices (IUDs)
Not covered: reversal of voluntary surgical sterilization or All charges. All charges.
genetic counseling,

Infertility services High Option Standard Option
Diagnosis and treatment of infertility, such as: 20% of charges. 20% of charges.
° Artificial insemination:
°° intravaginal insemination (IVI)
°° intra-cervical insemination (ICI)
°° intrauterine insemina-tion (IUI)
° Fertility drugs
Note: We cover injectable fertility drugs under medical benefits
and oral fertility drugs under the prescription drug benefit. We cover
the diagnosis of infertility services provided by a Plan or
non-Plan provider.

Not covered: All charges. All charges.
° Assisted reproductive technology (ART) procedures, such as:
°° in vitro fertilization
°° embryo transfer and GIFT
° Services and supplies related to excluded ART procedures
° Cost of donor sperm or ova
° Cost of storage of donor sperm, ova or embryo
° Treatment of infertility after reversal of sterilization
° Artificial insemination for surrogate pregnancy

2001 HealthPartners Classic 15 Section 5a 15
15 Page 16 17
Benefit Description You pay
Allergy care High Option Standard Option
Testing and treatment Nothing. Nothing.
Allergy injection and serum
Not covered: provocative food testing and sublingual allergy All charges. All charges.
desensitization

Treatment therapies High Option Standard Option
° Chemotherapy and radiation therapy $10 per office visit. $15 per office visit.
Note: High dose chemotherapy in association with autologous
bone marrow transplants are limited to those transplants listed
under Organ/ Tissue Transplants on page 23.

° Respiratory and inhalation therapy
° Dialysis Ð Hemodialysis and peritoneal dialysis
° Intravenous (IV)/ Infusion Therapy
° Blood and blood plasma (unless replaced) and blood derivatives Nothing. Nothing
for the treatment of blood disorders.

° Growth hormone therapy (GHT) 20% of charges. 20% of charges.
Note: Ð We will only cover GHT when your Plan physician prior
authorizes the treatment. If we determine GHT is not medically
necessary, we will not cover the GHT or related services and
supplies. See Services requiring our prior approval in Section 3.

Not covered: Growth hormones which are not for growth All charges. All charges.
hormone deficiency or chronic renal insufficiency.

Rehabilitative therapies High Option Standard Option
We cover physical therapy, occupational therapy and speech therapy $10 per office visit. $15 per office visit.
for the following services:

° qualified physical therapists;
° speech therapists; and
° occupational therapists.
Note: We only cover rehabilitative therapy to restore bodily function
or speech when there has been a total or partial loss of bodily function
or functional speech due to illness or injury. You must achieve
significant functional improvement, within a predictable period of time
(generally within a period of two months), toward your maximum
potential ability to perform functional daily living activities.

° Habilitative care rendered for congenital, developmental or medical
conditions which have significantly limited the successful initiation
of normal speech and motor development.

Note: To be considered habilitative, significant functional improvement
and measurable progress must be made toward achieving functional
goals and your maximum potential ability, within a predictable period
of time. We will supplement and coordinate such services with similar

2001 HealthPartners Classic 16 Section 5a
Continued on next page. 16
16 Page 17 18
Benefit Description You pay
Rehabilitative therapies continued High Option Standard Option
benefits made available by other agencies, including the public $10 per office visit. $15 per office visit.
school system. Our Plan Medical Director will determine
whether measurable progress has been made based on objective
documentation.

° Cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, is provided for Phase I. Phase II is
provided if we determine it is medically necessary. Phase III
is not covered.

Not covered: All charges. All charges.
° long-term rehabilitative therapy
° exercise programs

Hearing services (testing, treatment, and supplies) High Option Standard Option
Hearing testing (see Preventative care, adults, children) Nothing Nothing
Not covered: All charges. All charges.
° all other hearing testing
° hearing aids, testing and examinations for them

Vision services (testing, treatment, and supplies) High Option Standard Option
° Diagnosis and treatment of illness and injury to the eye; and $10 per office visit. $15 per office visit.
° Initial evaluation, lenses and fitting for contact or eyeglass lenses $10 per office visit. $15 per office visit.
if medically necessary for the post-surgical treatment of cataracts All charges for lens All charges for lens
or for the treatment of aphakia or keratoconous. replacement beyond replacement beyond
the initial pair. the initial pair.

° Eye exam to determine the need for vision correction Nothing. Nothing.
(see preventive care).

° Annual eye refractions.
Not covered: All charges. All charges.
° Eyeglasses or contact lenses and, except as described above
° Eye exercises
° Radial keratotomy and other refractive surgery

Foot care High Option Standard Option
Routine foot care when you are under active treatment for a $10 per office visit. $15 per office visit.
metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric
shoe inserts.

2001 HealthPartners Classic 17 Section 5a
Continued on next page. 17
17 Page 18 19
Benefit Description You pay
Foot care continued High Option Standard Option
Not covered: All charges. All charges.
° Cutting, trimming or removal of corns, calluses, or the free
edge of toenails, and similar routine treatment of conditions of
the foot, except as stated above.

° Treatment of weak, strained or flat feet or bunions or spurs; and
of any instability, imbalance or subluxation of the foot (unless
the treatment is by open cutting surgery).

Orthopedic and prosthetic devices High Option Standard Option
We cover the following: 20% of charges. 20% of charges.
° Orthopedic devices, such as braces and foot orthotics;
° Prosthetic devices, such as artificial limbs and eyes;
° Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy;

° Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices
as hospital benefits; see Section 5 (c) for payment information.
See 5( b) for coverage of the surgery to insert the device; and

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

° Orthopedic and corrective shoes when approved by this Plan based
on our criteria.

Not covered: All charges. All charges.
° orthopedic and corrective shoes, unless approved by Plan based
on our criteria

° over-the-counter foot orthotics
° replacement or repair of any covered items if they are damaged
or destroyed by member misuse, abuse or carelessness; lost;
or stolen.

° duplicate or similar items.
° items which are primarily educational in nature or for vocation,
comfort, convenience or recreation.

Durable medical equipment (DME) High Option Standard Option
Rental or purchase, at our option, including repair and adjustment, of 20% of charges. 20% of charges.
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;

2001 HealthPartners Classic 18 Section 5a
Continued on next page. 18
18 Page 19 20
Benefit Description You pay
Durable medical equipment (DME) continued High Option Standard Option
° blood glucose monitors; and 20% of charges. 20% of charges.
° insulin pumps.
Not covered: All charges. All charges
° replacement or repair of any covered items if they are damaged or
destroyed by member misuse, abuse or carelessness; lost; or stolen.

° duplicate or similar items.
° items which are primarily educational in nature or for vocation,
comfort, convenience or recreation.

° household equipment, such as exercise cycles, air purifiers, water
purifiers, air conditioners, non-allergenic pillows, mattresses or
water beds.

° household fixtures, such as escalators or elevators, ramps,
swimming pools or saunas.

° modifications to the home, such as wiring, plumbing or charges to
install equipment.

° vehicle, car or van modifications, such as hand brakes, hydraulic
lifts and car carriers.

° Rental of medically necessary durable medical equipment while
your own equipment is being repaired, that is beyond one month
rental.

Home health services High Option Standard Option
We cover home health care ordered by a Plan physician and provided
by a registered nurse (R. N.), licensed practical nurse (L. P. N.), or
home health aide, as shown below:

° Physical therapy, occupational therapy, speech therapy, $10 per office visit. $15 per office visit.
respiratory therapy and home health aide services.

° TPN/ intravenous therapy, skilled nursing services, prenatal and Nothing. Nothing.
postnatal services, child health services, and phototherapy.

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

° care by nurses primarily for hygiene, feeding, exercising, moving
the patient, homemaking, companionship or giving oral medication.

Alternative treatments High Option Standard Option
We cover the following services: $10 per office visit. $15 per office visit.
° Acupuncture Ð by a certified Plan acupuncturist for:
°° anesthesia
°° pain management
°° chemical dependency

2001 HealthPartners Classic 19 Section 5a
Continued on next page. 19
19 Page 20 21
Benefit Description You pay
Alternative treatments continued High Option Standard Option
°° headaches $10 per office visit. $15 per office visit.
°° nausea
° Biofeedback for:
°° incontenance
°° headaches
°° musculo-skeletal spasms which do not respond to other treatments
°° mental/ nervous disorders
°° neurological retraining
° Chiropractic services for rehabilitative care, provided to diagnose
and treat acute neuromusculo-skeletal conditions.

Not covered: All charges. All charges.
° naturopathic services
° hypnotherapy

Educational classes and programs High Option Standard Option
° Smoking Cessation Nothing Nothing
° We cover education for the management of chronic health problems $10 per office $15 per office
(such as diabetes) visit/ session. visit/ session.

2001 HealthPartners Classic 20 Section 5a 20
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals

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.
° 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 services described in this section are for the charges billed by a physician or other
health care professional for your surgical care. The amount that you pay for these
services depends on where the services are provided and follow the benefits described
in Section 5 (a) and (c), unless otherwise specified below.

° YOUR PLAN PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME
SURGICAL PROCEDURES. Please refer to the prior authorization information
shown in Section 3 to be sure which services require prior authorization and identify

which surgeries require prior authorization Benefit Description You pay

Benefit Description You pay
Surgical procedures High Option Standard Option
Such as: Nothing Nothing
° 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
° Insertion of internal prosthetic devices. See 5( a) Ñ Orthopedic braces and prosthetic devices for device coverage information.

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

° Norplant (a surgically implanted contraceptive) and intrauterine 20% of charges. 20% of charges.
devices (IUDs) Note: Devices are covered under 5( a).

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

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

2001 HealthPartners Classic 21 Section 5b 21
21 Page 22 23
Benefit Description You pay
Reconstructive surgery High Option Standard Option
° Surgery to correct a functional defect Nothing Nothing
° 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; port wine stains*; webbed fingers; and
webbed toes.

* Note: port wine stains do not have to result in a functional defect to
be covered.

° All stages of breast reconstruction surgery following a Nothing Nothing.
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.

Not covered: All charges. All charges.
° Cosmetic surgery Ð 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, unless determined medically
necessary by the Plan Medical Director

Oral and maxillofacial surgery High Option Standard Option
Oral surgical procedures, limited to: Nothing Nothing
° Reduction of fractures of the jaws or facial bones;
° Surgical correction of cleft lip, cleft palate (limited to dependent
children to age 18);

° 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, including non-dental treatment of
temporomandibular joint dysfunction (TMJ).

° Orthognathic surgery for the treatment of a skeletal malocclusion 25% of charges. 25% of charges.
when a functional occlusion cannot be achieved through non-surgical
treatment alone and a demonstrable functional impairment exists.

2001 HealthPartners Classic 22 Section 5b
Continued on next page. 22
22 Page 23 24
Benefit Description You pay
Oral and maxillofacial surgery continued High Option Standard Option
Not covered: All charges. All charges.
° Oral implants and transplants
° Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)

° Orthodontic services (pre or post operative) associated with
orthognathic surgery.

Organ/ tissue transplants High Option Standard Option
Transplant services are covered at our designated centers of excellence Nothing The first $200 of
for transplants and are limited to: Charges per person
° Cornea per admission plus
° Heart 20% of the next
° Heart/ Lund $3,500 in charges
° Kidney per calendar year.

° Kidney/ Pancreas for diabetes
° Liver, for bilary atresia ion children, primary bilary cirrhosis, post
acute viral infection (including hepatitis A, hepatitis B antigen
e negative and hepatitis C) causing acute atrophy or post necrotic
cirrhosis, primary sclerosing cholangitis and alcoholic cirrhosis

° Lung: Single Ð Double, for primary pulmonary hypertension,
Eisenmenger's syndrome, end stage pulmonary fibrosis, alpha 1
antitrypsin disease, cystic fibrosis and emphysema

° Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; Hodgkin's lymphoma;
non-Hodgkin's lymphoma; Burkitt's lymphoma; neuroblastoma;
breast cancer; multiple myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

° Allogenic (donor) bone marrow transplants or peripheral stem cell
support associated with high dose chemotherapy for acute
myelogenous leukemia; acute lymphotytic leukemia; chronic
myelogenouis leukemia; severe combined immunodeficiency
disease; Wiscott-Aldrich syndrome; and aplastic anemia

Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

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

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

° Implants of artificial organs
° Transplants not listed as covered

2001 HealthPartners Classic 23 Section 5b 23
23 Page 24 25
Benefit Description You pay
Anesthesia High Option Standard Option
Professional services provided in Ð Nothing
° Hospital (inpatient)
° Hospital outpatient department
° Skilled nursing facility
° Ambulatory surgical center

° Office $10 per office visit. $15 per office visit.

2001 HealthPartners Classic 24 Section 5b

The amount that you
pay for these services
depends on where the
services are provided
and follows the bene-fits
described in
Section 5 (a) and (c). 24
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Section 5 (c). Services provided by a hospital or other facility, and ambulance
services

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

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

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

° The amounts listed below are for the charges billed by the facility (i. e., hospital or
surgical center) or ambulance service for your surgery or care and any costs associated
with the professional charge (i. e., physicians, etc.) which are described in Section 5( a)
or (b).

Benefit Description You pay
Inpatient hospital High Option Standard Option
Room and board, such as Nothing. The first $200 of
° ward, semiprivate, or intensive care accommodations; charges per person
° general nursing care; and per admission plus
° meals and special diets. 20% of the next
Other hospital services and supplies, such as: $3,500 of charges
° Operating, recovery, maternity, and other treatment rooms per calendar year
° Prescribed drugs and medicines
° Diagnostic laboratory tests and X-rays
° Administration of blood and blood products
° Blood and blood plasma (unless replaced) and blood derivatives
° Dressings, splints, casts, and sterile tray services
° Medical supplies and equipment, including oxygen
° Anesthetics, including nurse anesthetist services
° Take-home items
° Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year
deductible applies.)

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

Not covered: All charges. All charges.
° Custodial care
° Non-covered facilities, such as nursing homes, extended care
facilities, schools

° Personal comfort items, such as telephone, television, barber
services, guest meals and beds

° Private nursing care

2001 HealthPartners Classic 25 Section 5c 25
25 Page 26 27
Benefit Description You pay
Outpatient hospital or ambulatory surgical center High Option Standard Option
° Operating, recovery, and other treatment rooms Nothing Nothing
° Prescribed drugs and medicines
° Diagnostic laboratory tests, X-rays, and pathology services
° Administration of blood, blood plasma, and other biologicals
° Blood and blood plasma (unless replaced) and blood derivatives Pre-surgical testing

° Dressings, casts, and sterile tray services
° Medical supplies, including oxygen
° Anesthetics and anesthesia service
NOTE: Ð We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

Extended care/ skilled nursing care facility benefits High Option Standard Option
We cover a comprehensive range of benefits for up to 180 days per Nothing The first $200 of
period of confinement when full-time skilled nursing care is necessary charges per person
and confinement in a skilled nursing facility is medically appropriate as per admission plus
determined by your Plan doctor and prior authorized by this Plan. All 20% of the next
necessary services are covered, including: $3,500 of charges per

° Bed, board and general nursing care calendar year
° Drugs, biologicals, services and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your

Plan doctor.
Period of confinement means (1) continuous stay in a hospital or skilled
nursing facility, or (2) a series of two or more stays in a hospital or
skilled nursing facility for the same condition in which the end of each
inpatient stay is separated from the beginning of the next one by less
than 90 days. Same condition means illness or injury related to a former
illness or injury that is (1) within the same ascertainable diagnosis, or (2)
within the scope of complications, or related conditions.

Not covered: custodial care All charges. All charges.

Hospice care High Option Standard Option
We cover supportive and palliative care in your home or a hospice if you
are terminally ill. We cover the following services:

° Outpatient care, family counseling and continuous care*. Nothing. You pay $10 per
office visit.

° Inpatient care. Nothing. You pay the first
$200 of charges per
admission plus 20%
of the next $3,500
of charges.

° Respite care*. 20% of charges. 20% of charges.
* Note: Respite care is limited to 5 days per episode, and respite All charges. All charges.
care and continuous care combined are limited to 30 days.

2001 HealthPartners Classic 26 Section 5c 26
26 Page 27 28
Benefit Description You pay
Ambulance High Option Standard Option
° Ambulance and medical transportation for medical emergencies 20% of charges. 20% of charges.
described in section 5( d).

° Prior authorized transfers between network hospitals for treatment Nothing. Nothing.
if initiated by a Plan physician.

2001 HealthPartners Classic 27 Section 5c 27
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Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.

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

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

What to do in case of emergency:
Emergencies within our service area: If you need emergency care, call your clinic, or call the CareLinesm nurse after hours at 612/ 339-3663 (hearing impaired individuals should call 952/ 883-5474). The service nurse or Plan

doctor will recommend how, when and where to obtain the appropriate treatment. In extreme emergencies, if you are
unable to contact your clinic or the CareLinesm nurse, contact the local emergency system (e. g., 911 telephone sys-tem)
or go to the nearest hospital emergency room.

Emergencies outside our service are: You must notify us within two days of admittance to an out-of-net-work hospital, or as soon as reasonably possible under the circumstances. If a Plan doctor believes care can be better

provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in
full. Follow-up care recommended by non-Plan providers must be approved by this Plan or provided by our providers.
Benefit Description You pay

Benefit Description You pay
Emergency within our service area High Option Standard Option
° Emergency care at a doctor's office $10 per office visit. $15 per office visit.
° Emergency care at an urgent care center $10 per office visit. $15 per office visit.
° Emergency care as an outpatient or inpatient at a hospital, $40 per visit. $40 per visit.
including doctors' services

Note: copay waived if admitted to the hospital for the same
condition within 24 hours.

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

2001 HealthPartners Classic 28 Section 5d 28
28 Page 29 30
Benefit Description You pay
Emergency outside our service area High Option Standard Option
° Emergency care at a doctor's office
° Emergency care at an urgent care center
° Emergency care as an outpatient at a hospital, including doctors'
services

° Emergency care as an inpatient at a hospital, including doctors'
services

Not covered: All charges. All charges.
° 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

Ambulance High Option Standard Option
° Ambulance and medical transportation for medical emergencies 20% of charges. 20% of charges.
described in section 5( d).

Note: air ambulance is covered if medically necessary.

2001 HealthPartners Classic 29 Section 5d

20% of the first
$2,500 of
charges per cal-endar
year.

20% of the first
$2,500 of
charges per cal-endar
year.

20% of the first
$2,500 of
charges per cal-endar
year.

The first $200 of
charges per per-son
per admis-sion
plus 20% of
the next $3,500
of charges per
calendar year. 29
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Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will
achieve "parity" with other benefits. This means that we will provide mental health and
substance abuse benefits differently than in the past.

When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
° All benefits are subject to the definitions, limitations, and exclusions in this brochure.
° Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

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

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

Note: In-Network 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.

° Professional services, including individual or group therapy by $10 per office visit. $15 per office visit.
providers such as psychiatrists, psychologists, or clinical social
workers

° Medication management
° Group therapy $5 per office visit. $7.50 per office visit.
° Diagnostic tests Nothing. Nothing.
° Services provided by a hospital or other facility Nothing
° Services in approved alternative care settings such as:
° Residential treatment
° Partial hospitalization or full-day hospitalization for mental
health services

Not covered: Services we have not approved. All charges.
Note: OPM will base its review of disputes about treatment plans
on the treatment plan's clinical appropriateness. OPM will
generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.

2001 HealthPartners Classic 30 Section 5e

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

The first $200 of
charges per person
per admission plus
20% of the next
$3,500 of charges per
calendar year. 30
30 Page 31 32
Prior authorization To be eligible to receive these enhanced mental health and substance abuse benefits you must follow your treatment plan and all of our network authori-zation
processes. These include:
You do not need a referral from your primary care Physician to obtain men-tal
or substance abuse services. You must use a mental or substance abuse
provider that is in our Plan network and associated with your clinic. We list
the mental and substance abuse providers associated with your clinic's care
system in our provider directory. If you have questions or need a provider
directory, call HealthPartners Member Services Department at 952/ 883-5000
or 1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127).

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued cov-erage

with your provider for up to 90 days under the following conditions:
° If your mental health or substance abuse professional provider with whom
you are currently in treatment leaves the plan at our request for other than
cause.

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

Network limitation We may limit your benefits if you do not follow your treatment plan.

2001 HealthPartners Classic 31 Section 5e 31
31 Page 32 33
Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
° We cover prescribed drugs and medications, as described in the chart beginning on the
next page.

° All benefits are subject to the definitions, limitations and exclusions in this brochure and
are payable only when we determine they are medically necessary.

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

There are important features you should be aware of. These include:
° Who can write your prescription. A plan or referral physician must write the prescription.
° Where you can obtain them. You must fill the prescription at a plan pharmacy or by mail.
° We use a formulary. This is a current list, which may be revised from time to time, of prescription drugs covered
by us. Non-formulary drugs will be covered when prescribed by a Plan doctor. It is the Plan doctor's responsibil-ity
to obtain authorization for non-formulary drugs.

° These are the dispensing limitations. Unless otherwise specified in this section, you may receive up to a 30-day
supply per prescription. No more than a 90-day supply will be covered and dispensed at a time. If there is a
generic equivalent, brand name drugs are only covered up to the charge that would apply to the generic drug,
minus any required copayment. If a copayment is required, you must pay one copayment for each 30-day supply,
or portion thereof, or for each manufacturer's pre-packaged dispensing unit (but not less than your physicians'
recommendation of a 30-day supply), except as follows:

°° For insulin a copayment will apply per vial or box of insulin cartridges.
°° For contraceptive barrier devices, a copayment will apply per device.
°° For Mail order drugs, see benefit described below.
° If you request a refill too soon after the last one was filled, it may not be filled at that time. It may require up to
14 days to get mail order prescriptions filled, so this service is best for maintenance drugs, not for drugs you need
immediately or for drugs you are taking on a short-term basis. Federal or state regulations may prevent us from
filling certain prescriptions through our mail order service, such as laws which prohibit us from sending narcotic
drugs across state lines.

° When you have to file a claim. You do not need to file a claim for drugs obtained at a network pharmacy or
through our mail order service. You would need to file a claim for prescription drugs covered as part of an out-of-area
emergency, if you did not get them at a network pharmacy. See section 7. For instructions on filing a claim.

2001 HealthPartners Classic 32 Section 5f

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Benefit Description You pay
Covered medications and supplies High Option Standard Option
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

° Insulin, with a copay applied per vial
° Diabetic testing supplies
° Disposable needles and syringes for the administration of
covered medications

° Drugs for sexual dysfunction (see Prior authorization below)
° Oral contraceptive drugs and contraceptive barrier devices, a
single copay charge will apply for 3 cycles of oral contraceptive
drugs or for each barrier device

° Tobacco cessation products, as determined by this Plan, limited to
a 60-day supply per calendar year. Benefits will be limited to one
product at a time, and no more than a 30-day supply will be covered
and dispensed at a time.

Mail order benefits High Option Standard Option
You may also get outpatient prescription drugs which can be self-administered
through HealthPartners mail order service. For
information on how to obtain drugs through HealthPartners mail
order service, please call our Member Services Department at
952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals
should call 952/ 883-5127). This benefit does not apply to drugs
listed under Limited Benefits below.

Limited benefits High Option Standard Option
° Injectable implantable contraceptive drugs or devices (such as, 20% of charges. 20% of charges. Depo Provera, Norplant, IUDs)
° Growth hormones
° Injectable drugs for the treatment of infertility
° Special dietary treatment for phenylketonuria (PKU)
° Drugs to treat sexual dysfunction. Contact us for dose limits.
Here are some things to keep in mind about our prescription
drug program:

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

2001 HealthPartners Classic 33 Section 5f

$8 copay per
prescription unit
or refill for each
30-day supply or
portion thereof,
or for each man-ufacturer's
pre-packaged
dis-pensing
unit (but
not less than
your physicians
recommendation
of a 30-day
supply).

$10 copay per
prescription unit
or refill for each
30-day supply or
portion thereof,
or for each man-ufacturer's
pre-packaged
dis-pensing
unit, if
applicable (but
not less than
your physicians
recommendation
of a 30-day
supply).

$16 copay per pre-scription unit or
refill for each 90-day supply or por-tion
thereof, or for three manufactur-er's
pre-packaged dispensing unit (but
not less than your physicians recom-mendation).

$20 copay per pre-scription unit or
refill for each 90-day supply or por-tion
thereof, or for three manufactur-er's
pre-packaged dispensing unit (but
not less than your physicians recom-mendation).

Continued on next page. 33
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Benefit Description You pay
Limited benefits continued High Option Standard Option
° We have an open formulary. If your physician believes a name 20% of charges. 20% of charges.
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 patients needs at a lower cost.

Not covered: All Charges. All Charges
° Drugs and supplies for cosmetic purposes
° Vitamins, nutrients and food supplements even if a physician
prescribes or administers them, except as specified

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

° Vitamins and nutritional substances, unless specified in this section
° Medical supplies such as dressings and antiseptics
° Drugs to enhance athletic performance.

2001 HealthPartners Classic 34 Section 5f 34
34 Page 35 36
Section 5 (g). Special Features
Feature Description
CareLine sm nurse line When you call the CareLine after regular clinic hours, you reach a skilled nurse who is specially trained to assess medical conditions of all kinds. Call
612/ 339-3663 or 1-800-551-0859 and talk with a registered nurse who will
discuss treatment options and answer your health questions.

BabyLine sm Service If you're an expecting or new parent and have questions after regular clinic hours, our BabyLine service is just for you. BabyLine is staffed by obstetric

nurses who can help with questions relating to pregnancy, new baby care,
nursing and postpartum concerns. Call 612/ 333-BABY (333-2229) or 1-
800-845-9297.

Partners for Better Health The HealthPartners Partners for Better Health Phone Line is a special Phone Line service designed to help you improve your health, prevent disease and lead a

healthier lifestyle.
When you call 952/ 883-7800 weekdays between 8 a. m. and 6 p. m., you will
speak directly with a health educator or registered dietitian who will help
you develop a personalized action plan to make healthier choices in you
daily routine. You can also register for health education classes, learn about
member discounts for many health and safety products, plus much more.

Services for deaf and hearing If you are deaf or hearing impaired, we have phone lines which you may call impaired for the following services:

Member Services: 952/ 883-5127
CareLine sm Service: 952/ 883-5474
Baby Line sm Service: 952/ 883-5127

Partners for Better Health: 952/ 883-7498

2001 HealthPartners Classic 35 Section 5g 35
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Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

° Plan dentists must provide or arrange your care.
° There is a $50 calendar year deductible for emergency accidental dental services
provided by non-Plan dentists.

° We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health of
the patient; we do not cover the dental procedure unless it is described below.

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

Dental benefits for High Option Plan
(no coverage for Standard Option Plan) You pay

We cover the preventive and diagnostic dental services shown below for all Nothing
members when provided by Plan dentists. Benefit limits are noted where they apply.

° Routine dental examinations (per Plan dentist's recommendation);
° Teeth cleaning, prophylaxis or periodontal maintenance recall
(limited to twice per year);

° Topical application of fluoride (per Plan dentist's recommendation);
° Oral hygiene instruction (per Plan dentist's recommendation);
° Bitewing x-rays (limited to once per year); and
° Full mouth (panoramic) x-rays (limited to once every three years).

Not covered: other dental services not shown as covered. All charges.

Accidental injury benefit You pay
We cover restorative services and supplies provided by Plan dentists necessary
to promptly repair or replace sound natural teeth, including the cost and
installation of necessary prescription dental prosthetic items or devices.
The need for these services must directly result from an accidental injury,
not including injury from biting or chewing, and the treatment or repair must
be initiated within twelve months of the date of injury.

Emergency dental services for accidental injury, as described above, are covered
when they are provided by non-Plan dentists if the services require immediate
treatment.

Not covered: other dental services not shown as covered. All charges.
2001 HealthPartners Classic 36 Section 5h

You pay the dental laboratory's
actual charge for prescription den-tal
prosthetic items and devices
related to the accident plus any
dental services rendered in con-nection
with previously missing
teeth or for teeth not injured in the
accident.

After you pay a $50 calendar
year deductible, you pay 20% of
the charges, up to a maximum
benefit of $300 per calendar year,
and any charges thereafter. 36
36 Page 37 38
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maxi-mums.

Medicare prepaid plan enrollment Ð This Plan offers Medicare recipients the opportunity to enroll in the Plan
through Medicare without payment of an FEHB premium. As indicated on page xx, certain annuitants and former
spouses who are covered by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later
reenroll in FEHB. Contact your retirement system for information on changing your FEHB enrollment. Contact us at
952/ 883-5600 for information on the Medicare prepaid plan and the cost of that enrollment.

Expanded Provider Network Option
An Expanded Provider Network (EPN) option is available to you as a member of this HealthPartners medical plan.
The EPN option offers a network of allied health care professionals in addition to the network available under your
medical plan. EPN health care professionals include audiologists, chiropractors, home health care providers, mental
health providers, occupational therapists, optometrists, physical therapists, podiatrists and speech therapists.

The EPN option is offered as a rider, or "add-on," to your current medical plan. You have the opportunity to purchase
the EPN rider within 31 days of enrolling in this medical plan and annually at your group's renewal date.

The EPN option does not increase or change the benefits under your current medical plan. The coverage, limitations
and exclusions are the same as your current plan, with a per visit copayment for care received from an EPN provider.
There is a monthly cost to you for enrolling in the EPN option.

For a complete EPN Information Packet, including benefit summary, rates, provider listing and enrollment form,
please call HealthPartners Member Services at 952-883-5000 or the toll-free number at 1-800-883-2177. If you have
additional questions about the EPN option after you receive your packet, please call Member Services.

Benefits on this page are not part of the FEHB Contract.

2001 HealthPartners Classic 37 Section 5i 37
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Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.

We do not cover the following:
° Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
° Services, drugs, or supplies you receive while you are not enrolled in this Plan;
° Services, drugs, or supplies that are not medically necessary;
° Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric prac-tice;

° 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 unless determined medically necessary by the Plan
Medical Director; or

° Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

2001 HealthPartners Classic 38 Section 6 38
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Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coin-surance,
or deductible.

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

Medical, hospital and In most cases, providers and facilities file claims for you. Physicians drug benefits must file on the form HCFA-1500, Health Insurance Claim Form. Facilities

will file on the UB-92 form. For claims questions and assistance, call us at
952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals should call
952/ 883-5127).
When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown below.
Bills and receipts should be itemized and show:

° Covered member's name and ID number;

° Name and address physician or facility that provided the service or supply;
° Dates you received the services or supplies;
° Diagnosis;
° Type of each service or supply;
° The charge for each service or supply;
° A copy of the explanation of benefits, payments, or denial from any pri-mary
payer --such as the Medicare Summary Notice (MSN); and

° Receipts, if you paid for your services.
Submit your claims to: HealthPartners claims
P. O. Box 1289
Minneapolis, MN 55440-1289

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.

2001 HealthPartners Classic 39 Section 7 39
39 Page 40 41
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 Ð including a request for preauthorization:

Step Description
1 1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Member Services, P. O. Box 1309, Minneapolis, MN 55440-1309; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific ben-efit
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 2 We have 30 days from the date we receive your request to:
(a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a
copy of our requestÑ go to step 3.

3 3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 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 xx, P. O. Box 436, Washington, D. C. 20044-0436.

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

° Copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms;

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

2001 HealthPartners Classic 40 Section 8 40
40 Page 41 42
Section 8. The disputed claims process (Continued)
Step Description
4 4 Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
The Disputed Claims process (Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as
your representative, such as medical providers, must provide a copy of your specific written consent
with the review request.

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

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

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

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then
call us at 952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127
and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
°° If we expedite our review and maintain our denial, we will inform OPM so that they can give
your claim expedited treatment too, or

°° You can call OPM's Health Benefits Contracts Division IV at 202/ 606-0737 between 8 a. m. and
5 p. m. eastern time.

2001 HealthPartners Classic 41 Section 8 41
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Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is cov-coverage ered 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 sec-ondary
payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners' guide-lines.

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.
8° People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant).

Medicare has two parts:
°° Part A (Hospital Insurance). Most people do not have to pay for Part A.
°° Part B (Medical Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.

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

When you are enrolled in this Plan and Original Medicare, you still need to
follow the rules in this brochure for us to cover your care. You must coordi-nate
your care with your Plan primary care physician, who will authorize
your referrals to Plan specialists and prior authorize services with the Plan,
as specified under Section 3.

We will waive any of our copayments, coinsurance and deductibles.

(Primary payer chart begins on next page.)

2001 HealthPartners Classic 42 Section 9 42
42 Page 43 44
(except for claims
related to Workers'
Compensation.)

2001 HealthPartners Classic 43 Section 9

Then the primary payer isÉ
Section 9. Coordinating benefits with other coverage
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 Ñ or your covered spouse Ñ are age 65 or over and É
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 whenÉ
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 (for other services) 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,

B. When you Ñ or a covered family member Ñ have Medicare based
on end stage renal disease (ESRD) andÉ

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

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

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

C. When you or a covered family member have FEHB andÉ
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee 43
43 Page 44 45
Section 9. Coordinating benefits with other coverage
Claims process ÑYou probably will never have to file a claim form when you have both our plan and Medicare

° When we are the primary payer, we process the claim first.
° When original Medicare is the primary payer, medicare processes your
claim first. In most cases, your claims will be coordinated automatically
and we will pay the balance of covered charges. You will not need to do
anything. To find out if you need to do something about filing your
claims, call us at 952/ 883-5000 or 1-800/ 883-2177 (hearing impaired indi-viduals
should call 952/ 883-5127)

We waive some costs when you have Medicare Ð When Medicare is the pri-mary
payer, we will waive any of our copayments, coinsurance, or deductibles.

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

This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do waive any of our copayments, coinsurance, or deductibles
for your FEHB coverage.

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

Suspended FEHB coverage and a Medicare managed care plan: If you
are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare managed care plan, eliminating your FEHB premium.
(OPM does not contribute to your Medicare managed care plan premium.)
For information on suspending your FEHB enrollment, contact your retire-ment
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+ Choice service area.

° Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be
covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for eligible dependents of military per-sons and retirees of the military. TRICARE includes the CHAMPUS program.

If both TRICARE and this Plan cover you, we pay first. See your TRICARE
Health Benefits Advisor if you have questions about TRICARE coverage.

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

2001 HealthPartners Classic 44 Section 9

Medicare Part B 44
44 Page 45 46
Section 9. Coordinating benefits with other coverage
° 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 treat-ment,
we will cover your benefits. You must use our providers.

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

When others are responsible When you receive money to compensate you for medical or hospital for injuries care for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called sub-rogation.

We will be entitled to immediately collect the present value of subrogation
rights from any recovery payments you receive, whether or not you have
been fully compensated for your losses and damages. Unless we agree, you
may not deduct attorneys' fees and expenses, which you incur in the recov-ery
of monies from a third party, from the subrogation/ reimbursement
amounts.

If you need more information, contact us for our subrogation procedures.

2001 HealthPartners Classic 45 Section 9 45
45 Page 46 47
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you receive cov-ered services. See page 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Deductible A deductible is a fixed amount of covered expenses you must incur for cer-tain covered services and supplies before we start paying benefits for those

services. See page 11.
Experimental or The Plan determines if a treatment or procedure is experimental/ investigational services investigative or unproven if it is:

° Not approved by the U. S. Food and Drug Administration (FDA) to be law-fully
marketed for the proposed use; or

° If reliable evidence shows that the drug, device or medical treatment or
procedure is the subject of ongoing Phase I, II, or III Clinical Trials; or

° If reliable evidence shows that the drug, device or medical treatment or
procedure is under study to determine its maximum tolerated dose, its tox-icity,
its safety, and its efficacy as compared with the standard means of
treatment or diagnosis.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their

allowances in different ways. We determine our allowance as follows:
For covered services delivered by Plan providers, or Plan referral providers,
our allowance is the provider's discounted charge for a given medical/ surgi-cal
service, procedure or item, which Plan providers have agreed to accept
as payment in full.

For covered services delivered by non-Plan providers, our allowance is the
provider's charge for a given medical/ surgical service, procedure or item,
according to the fair and reasonable charge amount.

The Fair and Reasonable Charge is the maximum amount we allow when
we calculate the payment for charges incurred for covered services provided
by non-Plan providers. It is consistent with what other providers in the
same community charge for a given service or item, as defined by the
Health Insurance Association of America (HIAA) schedule.

Us/ We Us and we refer to HealthPartners Classic

You You refers to the enrollee and each covered family member.

2001 HealthPartners Classic 46 Section 10 46
46 Page 47 48
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for 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 inca-pable
of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the

child is born or becomes an eligible family member. When you change to
Self and Family because you marry, the change is effective on the first day
of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.

When benefits and The benefits in this brochure are effective on January 1. If you are new
premiums start to this Plan, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. Annuitants' premiums begin on

January 1.

2001 HealthPartners Classic 47 Section 11

for you and your family 47
47 Page 48 49
Section 11. FEHB facts
Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

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

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

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

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

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of

your Federal service. If you do not meet this requirement, you may be eli-gible
for other forms of coverage, such as temporary continuation of cover-age
(TCC).

When you lose benefits
°When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premi-um,
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. But, you
may be eligible for your own FEHB coverage under the spouse equity law.
If you are recently divorced or are anticipating a divorce, contact your ex-spouse's
employing or retirement office to get RI 70-5, the Guide to Federal

Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, or other information about your coverage
choices.

°TCC If you leave Federal service, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you
are not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement
office or from www. opm. gov/ insure.

2001 HealthPartners Classic 48 Section 11 48
48 Page 49 50
Section 11. FEHB facts
° Converting to individual You may convert to a non-FEHB individual policy if:
°° Your coverage under TCC or the spouse equity law ends. If you can
celed 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 cover-age,
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; how-ever,
you will not have to answer questions about your health, and we will not
impose a waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group
Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health

care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the informa-tion
in the certificate, as long as you enroll within 63 days of losing cover-age
under this Plan.

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

Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for every-one. If you suspect that a physician, pharmacy, or hospital has charged you

for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:

° Call the provider and ask for an explanation. There may be an error.

° If the provider does not resolve the matter, call us at 952/ 883-5000 or 1-
800-883-2177 (hearing impaired individuals should call 952/ 883-5127)
and explain the situation.

° If we do not resolve the issue, call THE HEALTH CARE FRAUD HOT-LINEÐ
202/ 418-3300 or write to: The United States Office of Personnel
Management, Office of the Inspector General Fraud Hotline, 1900 E Street,
NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be pros-ecuted for fraud. Also, the Inspector General may investigate anyone who

uses an ID card if the person tries to obtain services for someone who is not
an eligible family member, or is no longer enrolled in the Plan and tries to
obtain benefits. Your agency may also take administrative action against
you.

2001 HealthPartners Classic 49 Section 11

coverage 49
49 Page 50 51
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to enroll
in the FEHB Program. The demonstration will last for three years and
began with the 1999 open season for the year 2000. Open season enroll-ments
will be effective January 1, 2001. DoD and OPM have set up some
special procedures to implement the Demonstration Project, noted below.
Otherwise, the provisions described in this brochure apply.

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

° You are an active or retired uniformed service member and are eligible for
Medicare;

° You are a dependent of an active or retired uniformed service member and
are eligible for Medicare;

° You are a qualified former spouse of an active or retired uniformed service
member and you have not remarried; or

° You are a survivor dependent of a deceased active or retired uniformed
service member; and

° You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits Program, you are not eligible to enroll under the
DoD/ FEHBP Demonstration Project.

The demonstration areas ° Dover AFB, DE ° Commonwealth of Puerto Rico

° Fort Knox, KY ° Greensboro/ Winston Salem/ High Point, NC
° Dallas, TX ° Humboldt County, CA area
° New Orleans, LA ° Naval Hospital, Camp Pendleton, CA
° Adair County, IA ° Coffee County, GA
When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2000 open season, November 13, 2000, through December 11, 2000. Your

coverage will begin January 1, 2001. DoD has set-up an Information
Processing Center (IPC) in Iowa to provide you with information about how
to enroll. IPC staff will verify your eligibility and provide you with FEHB
Program information, plan brochures, enrollment instructions and forms.
The toll-free phone number for the IPC is 1-877/ DOD-FEHB (1-877/ 363-
3342).

You may select coverage for yourself (Self Only) or for you and your family
(Self and Family) during the 2000 and 2001 open seasons. Your coverage
will begin January 1 of the year following the open season during which
you enrolled.

If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your cover-age
will begin.

DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations and zip code lists at
www. tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2001 Guide to Federal Employees
Health Benefits Plans Participating in the DoD/ FEHB Demonstration
Project," on the OPM web site at www. opm. gov.

2001 HealthPartners Classic 50 DOD/ FEHB Demonstration Project 50
50 Page 51 52
Department of Defense/ FEHB Demonstration Project
TCC eligibility See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the only individual
eligible for TCC is one who ceases to be eligible as a "member of family"
under your self and family enrollment. This occurs when a child turns 22,
for example, or if you divorce and your spouse does not qualify to enroll as
an unremarried former spouse under title 10, United States Code. For these
individuals, TCC begins the day after their enrollment in the DoD/ FEHB
Demonstration Project ends. TCC enrollment terminates after 36 months or
the end of the Demonstration Project, whichever occurs first. You, your
child, or another person must notify the IPC when a family member loses
eligibility for coverage under the DoD/ FEHB Demonstration Project.

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

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project.

2001 HealthPartners Classic 51 DOD/ FEHB Demonstration Project 51
51 Page 52 53
Accidental injury ................................ 36
Allergy tests ........................................ 16
Alternative treatment .......................... 19
Ambulance .......................................... 27
Anesthesia............................................ 24
Autologous bone
marrow transplant................................ 23

Biopsies................................................ 21
Blood and blood plasma .................... 16
Casts .................................................... 21
Catastrophic protection ...................... 54
Changes for 2001 .................................. 7
Chemotherapy .................................... 16
Cholesterol tests .................................. 14
Claims .................................................. 39
Coinsurance ........................................ 11
Colorectal cancer screening ................ 14
Congenital anomalies.......................... 21
Contraceptive devices and drugs ........ 33
Coordination of benefits .................... 42
Covered providers ................................ 8
Crutches .............................................. 18
Deductible............................................ 11
Definitions .......................................... 46
Dental care .......................................... 36
Diagnostic services.............................. 13
Disputed claims review ...................... 40
Donor expenses (transplants).............. 23
Dressings.............................................. 34
Durable medical equipment
(DME).................................................. 18

Educational classes and programs...... 20
Effective date of enrollment .............. 47
Emergency .......................................... 28
Experimental or investigational.......... 46
Eyeglasses............................................ 17
Family planning ................................ 15
Fecal occult blood test ........................ 14
General Exclusions.............................. 38
Hearing services .................................. 17

Home health services .......................... 19
Hospice care ........................................ 26
Home nursing care .............................. 19
Hospital................................................ 25
Immunizations .................................... 14
Infertility .............................................. 15
Inhospital physician care .................... 13
Inpatient Hospital Benefits ................ 25
Insulin .................................................. 32
Laboratory and pathological
services ................................................ 11

Magnetic Resonance
Imagings (MRIs) ................................ 13

Mail Order Prescription Drugs .......... 33
Mammograms...................................... 14
Maternity Benefits .............................. 14
Medicaid .............................................. 45
Medically necessary ............................ 38
Medicare .............................................. 42
Members ................................................ 8
Mental Conditions/ Substance
Abuse Benefits .................................... 30

Newborn care ...................................... 15
Non-FEHB Benefits............................ 37
Licensed Practical Nurse .................... 19
Nurse Anesthetist ................................ 25
Registered Nurse ................................ 25
Nursery charges .................................. 15
Obstetrical care.................................... 14
Occupational therapy .......................... 16
Office visits.......................................... 13
Oral and maxillofacial surgery .......... 22
Orthopedic devices.............................. 18
Out-of-pocket expenses ...................... 11
Outpatient facility care........................ 26
Oxygen ................................................ 18
Pap test ................................................ 14
Physical examination .......................... 14
Physical therapy .................................. 16
Physician................................................ 8

Preventive care, adult .......................... 14
Preventive care, children .................... 14
Prescription drugs................................ 32
Preventive services.............................. 14
Prior approval ...................................... 10
Prostate cancer screening.................... 14
Prosthetic devices .............................. 18
Psychologist ........................................ 30
Radiation therapy ................................ 16
Rehabilitation therapies ...................... 16
Room and board .................................. 25
Second surgical opinion...................... 13
Skilled nursing facility care ................ 26
Smoking cessation .............................. 20
Speech therapy .................................... 16
Splints .................................................. 25
Sterilization procedures ...................... 21
Subrogation.......................................... 45
Substance abuse .................................. 30
Surgery ................................................ 21
° Anesthesia ........................................ 24
° Oral.................................................... 22
° Outpatient.......................................... 26
° Reconstructive .................................. 22
Syringes .............................................. 33
Temporary continuation
of coverage .......................................... 48

Transplants .......................................... 23
Treatment therapies ............................ 16
Vision services .................................... 17
Well child care .................................... 14
Wheelchairs ........................................ 18
Workers' compensation ...................... 44
X-rays .................................................. 13

2001 HealthPartners Classic 52 Index

Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage. 52
52 Page 53 54
NOTES:
2001 HealthPartners Classic 53 Notes 53
53 Page 54 55
Summary of benefits for the HealthPartners Classic Plan -2001
° Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.

° If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.

° We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits High Option Page Standard Option Page
You Pay You Pay
Medical services provided by physicians:
° Diagnostic and treatment services provided in the office $10 per office visit. 13 $15 per office visit. 13
Services provided by a hospital:
° Inpatient Nothing. 25 25

° Outpatient $10 per office visit. 26 $15 per office visit. 26
Emergency benefits:
° In-area 28 28

° Out-of-area 29 29
Mental health and substance abuse treatment Nothing. 30 Nothing. 30
Prescription drugs 32 32

Dental Care
Preventive dental Nothing. 36 No Coverage. 36

Accidental injury Dental Laboratory Dental Laboratory
charges Charges

Vision Care Nothing for 17 Nothing for 17
preventive care. preventive care.

Special features: ° CareLine nurse line, 35
° BabyLine Service,
° Partners for Better Health Phone Line,
° Services for deaf and hearing impaired.
Protection against catastrophic costs
(your out-of-pocket maximum) 11 11

2001 HealthPartners Classic 54 Summary of Benefits

$200 per admission
plus 20% of the next
$3,500 of charges per
calendar year.

$40 Emergency
Room visit
$10 Urgent Care
Center visit

$40 Emergency
Room visit
$10 Urgent Care
Center visit

20% of the first
$2,500; then 100%

$8 per prescription
unit or refill (mail
order benefit is two
copays per 90-day
supply).

$3,000 per single,
$5,000 per family
per calendar year.

$3,000 per single,
$5,000 per family
per calendar year.

20% of the first
$2,500; then 100%

$10 per prescription
unit or refill (mail
order benefit is two
copays per 90-day
supply). 54
54 Page 55 56
55
55 Page 56
2001 Rate Information for HealthPartners Classic
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category,
refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.

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

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

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

Minneapolis Ð St. Paul Ð St. Cloud Ð West Central Wisconsin
High Option
Self Only 531 $86.59 $43.51 $187.61 $94.27 $102.22 $27.88

High Option
Self and Family 532 $195.82 $116.43 $424.28 $252.26 $231.17 $81.08

Standard Option
Self Only 534 $81.93 $27.31 $177.52 $59.17 $96.95 $12.29

Standard Option
Self and Family 535 $195.82 $66.36 $424.28 $143.78 $231.17 $31.01 56

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