Pages 1--56 from Prudential HealthCare HMO

RI 73-108
Prudential HealthCare HMO ® Ñ Oklahoma 2001
http:// www. aetnaushc. com/ pruhealthcare
A Health Maintenance Organization
Serving: Oklahoma City and Tulsa, Oklahoma Areas

Enrollment in this Plan is limited; see page 8 for requirements.
Oklahoma City Enrollment code:
RR1 Self only
RR2 Self and family

Tulsa Enrollment code:
RS1 Self only
RS2 Self and family

6/ 99
This plan has commendable accreditation
from the NCQA. See the 2001 Guide
for more information on NCQA.

For changes
in benefits
see page 9. 1
1 Page 2 3

2001 Prudential HealthCare HMO Ñ Oklahoma 2 Table of Contents
Table of Contents
Introduction ........................................................................................................................................................................... 4
Plain Language ...................................................................................................................................................................... 4
Section 1. Facts about this HMO plan.................................................................................................................................. 5
How we pay providers........................................................................................................................................ 5
Who provides my health care?........................................................................................................................... 5
Patients' Bill of Rights ....................................................................................................................................... 6
Service Area........................................................................................................................................................ 8
Section 2. How we change for 2001..................................................................................................................................... 9
Program-wide changes ....................................................................................................................................... 9
Changes to this Plan ........................................................................................................................................... 9
Section 3. How you get care ............................................................................................................................................... 10
Identification cards ........................................................................................................................................... 10
Where you get covered care............................................................................................................................. 10
Plan providers ............................................................................................................................................ 10
Plan facilities.............................................................................................................................................. 10
What you must do to get covered care............................................................................................................. 10

Primary care ............................................................................................................................................... 10
Specialty care ............................................................................................................................................. 10
Hospital care .............................................................................................................................................. 11
Circumstances beyond our control .................................................................................................................. 12
Services requiring our prior approval .............................................................................................................. 12
Section 4. Your costs for covered services......................................................................................................................... 13
Copayments................................................................................................................................................ 13
Coinsurance................................................................................................................................................ 13
Your out-of-pocket maximum ......................................................................................................................... 13
Section 5. Benefits............................................................................................................................................................... 14
Overview........................................................................................................................................................... 14
(a) Medical services and supplies provided by physicians and
other health care professionals.............................................................................................................. 15

(b) Surgical and anesthesia services provided by physicians and
other health care professionals.............................................................................................................. 23

(c) Services provided by a hospital or other facility, and ambulance services......................................... 26
(d) Emergency services/ accidents .............................................................................................................. 28
(e) Mental health and substance abuse benefits......................................................................................... 30
(f) Prescription drug benefits ..................................................................................................................... 32 2
2 Page 3 4

2001 Prudential HealthCare HMO Ñ Oklahoma 3 Table of Contents
(g) Special features...................................................................................................................................... 35
(h) Dental benefits....................................................................................................................................... 36
(i) Non-FEHB benefits available to Plan members .................................................................................. 37
Section 6. General exclusions Ñ things we don't cover ................................................................................................... 38
Section 7. Filing a claim for covered services ................................................................................................................... 39
Section 8. The disputed claims process.............................................................................................................................. 41
Section 9. Coordinating benefits with other coverage ....................................................................................................... 43
When you haveÉ
Other health coverage .............................................................................................................................. 43
Original Medicare .................................................................................................................................... 43
Medicare managed care plan ................................................................................................................... 45
TRICARE/ Workers' Compensation/ Medicaid ............................................................................................... 45
Other Government agencies............................................................................................................................. 46
When others are responsible for injuries ......................................................................................................... 46
Section 10. Definitions of terms we use in this brochure .................................................................................................. 47
Section 11. FEHB facts....................................................................................................................................................... 49
Coverage information....................................................................................................................................... 49
No pre-existing condition limitation ....................................................................................................... 49
Where you get information about enrolling in the FEHB Program....................................................... 49
Types of coverage available for you and your family ............................................................................ 49
When benefits and premiums start .......................................................................................................... 50
Your medical and claims records are confidential ................................................................................. 50
When you retire........................................................................................................................................ 50
When you lose benefits .................................................................................................................................... 50

When FEHB coverage ends..................................................................................................................... 50
Spouse equity coverage ........................................................................................................................... 50
Temporary Continuation of Coverage (TCC)......................................................................................... 51
Converting to individual coverage .......................................................................................................... 51
Getting a Certificate of Group Health Plan Coverage............................................................................ 51
Inspector General Advisory ............................................................................................................................. 51
Index .................................................................................................................................................................................... 53
Summary of benefits ........................................................................................................................................................... 55
Rates....................................................................................................................................................................... Back cover 3
3 Page 4 5
2001 Prudential HealthCare HMO Ñ Oklahoma 4 Introduction/ Plain Language
Introduction
Prudential HealthCare HMO ® Ñ Oklahoma
1425 Union Meeting Road,
P. O. Box 1126, Mail Stop U32A,
Blue Bell, PA 19422

This brochure describes the benefits you can receive from Prudential HealthCare HMO Ñ Oklahoma under our contract
(CS 1939) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure.

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

OPM negotiates benefits and rates with each Plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 9. 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
representatives 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 Prudential HealthCare HMO
Ñ Oklahoma.

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
comparisons easier.

If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback 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. 4
4 Page 5 6
2001 Prudential HealthCare HMO Ñ Oklahoma 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

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

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

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

How we pay providers Provider Compensation 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.

This is a direct contract prepayment Plan, which means that plan
providers are neither agents nor employees of the Plan. Rather, they are
independent doctors and providers who practice in their own offices or
facilities. The Plan arranges with licensed providers and hospitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury for benefits covered under the Plan.

Plan providers in our network have agreed to be compensated in
various ways. Many Plan primary care physicians are paid by capitation
every month. Under capitation, a physician receives payment for a
patient whether he sees that patient that month or not. Specialists,
hospitals, primary care physicians and other providers in our network
are paid in the following ways:

Per individual service (fee-for-service at contracted rates),
Per hospital day (per diem contracted rates), and
Under other capitation methods (a certain amount per member, per month)

You are encouraged to ask your physicians and other providers how
they are compensated for their services. Members should ask their
treating provider about the method by which the provider is
compensated for providing services to the member.

Who provides
my health care? When you first join the Plan, you must choose a primary care doctor for you and each covered member of your family. You may select your

primary care physician from a list of family or general practitioners,
pediatricians or medical internists. For women, open access to Plan
gynecologists is available for the diagnosis and treatment of gynecological
problems and one routine gynecological exam and Pap smear each
calendar year. 5
5 Page 6 7
2001 Prudential HealthCare HMO Ñ Oklahoma 6 Section 1
Patients' Bill of Rights OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's
Commission on Consumer Protections 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 information
that we must make available to you. Some of the required information is listed below.

Direct Access Ob/ Gyn Program
This program allows female members to visit any Plan gynecologist for a routine well-woman exam, including a Pap
smear (if appropriate) and an unlimited number of visits for gynecologic problems and follow-up care as described in
your benefits plan. Gynecologists may also refer a woman directly for covered gynecologic services without the
patient's having to go back to her Plan primary care physician. If your Ob/ Gyn is part of an Independent Practice
Association (IPA), a Physician Medical Group (PMG) or a similar organization, covered care must be coordinated
through the IPA, the PMG or the similar organization.

Mental Health/ Substance Abuse
Behavioral health care services (e. g., treatment or care for mental disease or illness, alcohol abuse and/ or substance
abuse) are managed by an independently contracted organization. This organization makes initial coverage
determinations and coordinates referrals; any behavioral health care referrals will generally be made to providers
affiliated with the organization, unless your needs for covered services extend beyond the capability of the affiliated
providers. You can receive information regarding the appropriate way to access the behavioral health care services that
are covered under your specific plan by calling Member Services at 1-800-856-0764. As with other coverage
determinations, you may appeal behavioral health care coverage decisions in accordance with the provisions of your
Plan.

Ongoing Reviews
We conduct ongoing reviews of those services and supplies which are recommended or provided by health
professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that
the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such
determination, you may then contact us to seek a review of the determination.

Authorization
Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits
under this Plan.

Patient Management
We have developed a patient management program to assist in determining what health care services are covered under
the health plan and the extent of such coverage. The program assists members in receiving the appropriate health care
and maximizing coverage for those health care services.

Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial
letters delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal
process.

Our patient management staff uses national guidelines and resources to guide the precertification, concurrent review and
retrospective review processes. Using the information obtained from providers, patient management staff utilize
Milliman & Robertson Health Care Management Guidelines when conducting concurrent review. If there is no
applicable Milliman & Robertson Guideline, patient management staff utilizes InterQual ISD criteria. To the extent
certain patient management functions are delegated to integrated delivery systems, independent practice associations or
other provider groups (" Delegates"), such Delegates utilize criteria that they deem appropriate.

Precertification Certain health care services, such as hospitalization or outpatient surgery, require precertification by us to ensure coverage for those services. When

a member is to obtain services requiring precertification through a Plan
provider, this provider should precertify those services prior to treatment. 6
6 Page 7 8
2001 Prudential HealthCare HMO Ñ Oklahoma 7 Section 1
Concurrent Review The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services.
All inpatient services extending beyond the initial certification period will
require Concurrent Review.

Discharge Planning Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge

needs during precertification or concurrent review. The
discharge plan may include initiation of a variety of services/ benefits to be
utilized by the member upon discharge from an inpatient stay.

Retrospective Record Review The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on

quality or utilization issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care services. Our
effort to manage the services provided to members includes the
retrospective review of claims submitted for payment, and of medical
records submitted for potential quality and utilization concerns.

Member Services
Representatives from Member Services are trained to answer your questions and to assist you in using the Prudential
HealthCare plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free
number on the card when you need to:

Ask questions about benefits and coverage.
Notify us of changes in your name, address or telephone number.
Change your primary care physician or office.
Obtain information about how to file a grievance.
Confidentiality
We protect the privacy of confidential member medical information. We contractually require that Plan providers keep
member information confidential in accordance with applicable laws. Furthermore, you have the right to access your
medical records from Plan providers, at any time. Prudential HealthCare (including its affiliates and authorized agents,
collectively "Prudential HealthCare") and Plan providers require access to member medical information for a number of
important and appropriate purposes, including claims payment, fraud prevention, coordination of care, data collection,
performance measurement, fulfilling state and federal requirements, quality management, utilization review, research
and accreditation activities, preventive health, early detection and disease management programs. Accordingly, for these
purposes, members authorize the sharing of member medical information about themselves and their dependents
between Prudential HealthCare and Plan providers and health delivery systems.

Read this entire document carefully. It describes the rights and obligations of you and us.
In some circumstances, certain medical services are not covered or may require preauthorization by us.
This brochure applies to coverage only and does not restrict your ability to receive health care services that are
not, or might not be, covered benefits under this Plan.

If you want more information about us, call 1-800-856-0764, or write to 1425 Union Meeting Road, P. O. Box 1126,
Mail Stop U32A, Blue Bell, PA 19422. You may also contact us by fax at 215-775-6550 or visit our website at
www. aetnaushc. com/ pruhealthcare. 7
7 Page 8 9
2001 Prudential HealthCare HMO Ñ Oklahoma 8 Section 1
Service Area To enroll with us, you must live or work in our service area. This is where our providers practice.
Our Oklahoma City (RR) service area is: Blaine, Caddo, Canadian,
Cleveland, Comanche, Dewey, Garfield, Garvin, Grady, Kingfisher,
Lincoln, Logan, Major, McClain, Oklahoma, Payne, Pontotoc,
Pottawatomie, Seminole, and Woodward counties.

Our Tulsa (RS) service area consists of the following cities and zip codes:
Avant (74001), Beggs (74421), Bixby (74008), Broken Arrow (74011 Ñ
74014), Bryant (74880), Catoosa (74015), Chelsa (74016), Claremore
(74017 Ñ 74018), Cleveland (74202), Chouteau (74337), Collinsville
(74021), Coweta (74431), Dewar (74431), Eram (74422), Foyil (74031),
Gleenpool (74033), Haskell (74436), Henryetta (74437), Inola (74036),
Jenks (74037), Kellyville (74039), Kiefer (74041), Leonard (74043),
Mannford (74044), Morris (74445), Oakhurst (74050), Okmulgee (74447),
Oologah (74053), Osage (74054), Owasso (74055), Porter (74454), Preston
(74456), Prue (74060), Pryor (74361 Ñ 74362), Sand Springs (74063),
Sapulpa (74066 Ñ 74067), Schulter (74460), Skiatook (74070), Sperry
(74073), Talala (74080), Terlton (74080), Tulsa (74101 Ñ 74121,
74125 Ñ 74138, 74145 Ñ 74159, 74169 Ñ 74171), Vera (74082), and
Wagoner (74467, 74477).

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 dependents live out of the area (for
example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO that has agreements
with affiliates in other areas. If you or a family member move, you do not
have to wait until Open Season to change plans. Contact your employing
or retirement office. 8
8 Page 9 10
2001 Prudential HealthCare HMO Ñ Oklahoma 9 Section 2
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. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to coinsurance, copays, and day and visit
limitations when you follow a treatment plan that we approve. Previously, higher cost sharing and shorter day
limitations were placed on mental health and substance abuse services than on services to treat physical illness,
injury, or disease.

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 Customer Service at 1-800-856-0764, or checking our website at
www. aetnaushc. com/ pruhealthcare. 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 performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the language
referenced only women.

Changes to this Plan Code RR Oklahoma City area: your share of the non-postal premium will increase by 9% for Self Only or 9% for Self
and Family.
Code RS Tulsa area: your share of the non-postal premium will increase by 5% for Self Only or 5% for Self and
Family.

Coverage for increased mammogram visits is available for women above a certain age. See page 16.
We have eliminated the outpatient mental health visit limit. We will now treat visits as any other illness based on
medical necessity. See Section 5 (e).

We have reduced the mental health outpatient copayment from 20% of the charge to $15. See Section 5 (e).
We have eliminated the inpatient mental health days and copayment. We will now treat inpatient care as any other
illness based on medical necessity. See Section 5 (e).

We have decreased the inpatient mental health care copayment from 20% of the charge to nothing. See Section 5 (e).
Substance abuse will be treated the same as mental health benefits. See Section 5 (e).
Copayments for office visits with specialists have been increased from $10 to $15 per visit. See Sections 5 (a), 5 (b),
5 (d) and 5 (e).

If we deny your claim or services, you may be able to request an External Review. See page 42. 9
9 Page 10 11
2001 Prudential HealthCare HMO Ñ Oklahoma 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you

receive covered services from a plan provider, or fill a prescription at a
plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-856-0764.

Where you get covered care You get covered care from "plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential plan providers according to national standards.
We list plan providers in the provider directory, which
we update periodically. The list is also on our website at
www. aetnaushc. com/ pruhealthcare.

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

facilities in the provider directory, which we update periodically. The list is
also on our website at www. aetnaushc. com/ pruhealthcare.

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

since your primary care physician provides or arranges for most of your
health care.

Primary care Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will

provide or coordinate 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 or visit our website. We will change your
primary care physician to a newly-selected primary care physician.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a network OB/ GYN, chiropractor, Dermatologist

(up to 5 visits annually), or Podiatrist without a referral. 10
10 Page 11 12
2001 Prudential HealthCare HMO Ñ Oklahoma 11 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop

a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what

treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another

specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

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

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 covered 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 1-800-856-0764. If you are
new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefits of the hospitalized
person. 11
11 Page 12 13
2001 Prudential HealthCare HMO Ñ Oklahoma 12 Section 3
Circumstances beyond
our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In

that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from

us. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your Plan
physician must obtain approval for certain services such as hospitalization
or surgery and the following services:

For certain prescription drugs
For covered transplant surgery
For certain diagnostic tests
For ambulance transportation
For coverage of follow-up care by a non-Plan provider 12
12 Page 13 14
2001 Prudential HealthCare HMO Ñ Oklahoma 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay when you receive services.

Example: When you see your primary care physician you pay a copayment
of $10 per office visit or $15 when you see a Plan specialist.

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

Example: In our Plan, you pay 50% of charges for covered infertility
services and allergy testing, 20% of charges for durable medical
equipment, orthopedic devices, prosthetic devices, oxygen and rental
equipment for its use, for diabetic supplies and supplies for injecting
medications.

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

Prescription drugs
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 13
13 Page 14 15
2001 Prudential HealthCare HMO Ñ Oklahoma 14 Section 5
Section 5. Benefits Ñ OVERVIEW (See page 9 for how our benefits changed this year and page 55 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in section 6; they apply to benefits in the following
section. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-856-
0764 or at our website at www. aetnaushc. com/ pruhealthcare.

(a) Medical services and supplies provided by physicians and other health care professionals............................... 15-22
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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ........................... 23-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .......................................................... 26-27
Inpatient hospital Outpatient hospital or ambulatory

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

(d) Emergency services/ accidents................................................................................................................................ 28-30
Medical emergency Ambulance

(e) Mental health and substance abuse benefits .......................................................................................................... 30-31
(f) Prescription drug benefits............................................................................................................................................ 32
(g) Special features ............................................................................................................................................................ 35
High risk pregnancies ........................................................................................................................................... 35 Centers for excellence for transplants/ heart surgery ........................................................................................... 35

(h) Dental benefits ............................................................................................................................................................. 36
(i) Non-FEHB benefits available to Plan members......................................................................................................... 37
Summary of benefits ........................................................................................................................................................... 55 14
14 Page 15 16
2001 Prudential HealthCare HMO Ñ Oklahoma 15 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

medically necessary.
Plan physicians must provide or arrange your care.
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.
Plan physicians must precertify certain diagnostic tests.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical opinion
Initial examination of a newborn child covered under a family enrollment

$10 per PCP visit or
$15 per specialist visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility

$10 per PCP visit or
$15 per specialist visit

At home $10 per PCP visit or
$15 per specialist visit
and nothing for visits by
nurses and health aids

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive
these services during your
office visit; otherwise,
$10 per PCP visit or
$15 per specialist visit 15
15 Page 16 17
2001 Prudential HealthCare HMO Ñ Oklahoma 16 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Periodic check-ups
Blood lead level
Total blood cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening Ñ every five years starting at age 50

$10 per PCP visit
$15 per specialist visit

Nothing for tests if you
receive these services
during your office visit.

Prostate Specific Antigen (PSA test) Ñ one annually for men age 40 and
older
Nothing

Routine pap test
NOTE: Nothing for the pap test if performed on the same day as the
office visit.

$10 per PCP visit or
$15 per specialist visit

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

$10 per PCP visit or
$15 per specialist visit

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

Immunizations and boosters for travel or work-related exposure

All charges

Routine Immunizations $10 per PCP visit or $15 per specialist visit
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if services are provided during the
office visit, otherwise
$10 per PCP visit or
$15 per specialist visit

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)
Well-child visits for routine examinations, immunizations and care (through age 22)

$10 per PCP visit or
$15 per specialist visit 16
16 Page 17 18
2001 Prudential HealthCare HMO Ñ Oklahoma 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

NOTE: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see below for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended
inpatient stay if your Physician determines it is medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an

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

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

benefits (Section 5b).

$10 for the first PCP
office visit only or
$15 for the first specialist
visit only

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
Voluntary sterilization
Injectable contraceptive drugs
Intrauterine devices (IUDs)

$10 per PCP visit
$15 per specialist visit

Surgically implanted contraceptives
NOTE: Amounts you pay are not refundable even if the implanted time-release
medication is removed before the end of its expected lifetime.
Coverage is limited to one implanted time-release medication within the
expected lifetime of the product.

$10 per PCP visit
$15 per specialist visit
and 20% of charges for
the contraceptives

Not covered:
reversal of voluntary surgical sterilization
genetic counseling

All charges 17
17 Page 18 19
2001 Prudential HealthCare HMO Ñ Oklahoma 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Injectable Fertility drugs

NOTE: We cover oral fertility drugs under the prescription drug benefit,
subject to the applicable copays.

50% of charges

Not covered:
the purchase or storage of and/ or manipulation of sperm or eggs;
any charge associated with care of the donor required for donor egg retrievals or transfers;

Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer
embryo freezing
GIFT procedures
ZIFT procedures
Services and supplies related to excluded ART procedures
reversal of sterilization surgery.

All charges 18
18 Page 19 20
2001 Prudential HealthCare HMO Ñ Oklahoma 19 Section 5( a)
Allergy care You pay
Testing and treatment
Allergy injection
50% of charges

Allergy serum Nothing
Treatment therapies
Chemotherapy and radiation therapy
NOTE: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.

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

$15 per visit

Rehabilitative therapies
Physical therapy, occupational therapy and speech therapy Ñ
The greater of 60 consecutive days or 60 visits per condition in a calendar year for outpatient services of each of the following:

qualified physical therapists;
speech therapists; and
occupational therapists.

NOTE: We only cover speech therapy for certain speech impairments
of organic origin.

We only cover occupational therapy services that assist the member to
achieve and maintain self-care and improved functioning in other areas
of daily living.

Physical therapy to treat Temporomandibular Joint (TMJ) pain dysfunction syndrome

$15 per visit

Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction in a Plan facility for up to two months per
condition.

$15 per outpatient visit in
an office setting

Nothing in a non-office
setting

Not covered:
long-term rehabilitative therapy
All charges 19
19 Page 20 21
2001 Prudential HealthCare HMO Ñ Oklahoma 20 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 (see Preventive care, children)

Hearing aids for children up to age 13
$10 per PCP visit or
$15 per specialist visit

Not covered:
all other hearing testing and hearing aids for persons age 13 or older
All charges

Vision services (testing, treatment, and supplies)
Eye exam to determine the need for vision correction for children through age 17 (see preventive care)

Diagnosis and treatment of diseases of the eye
Initial lenses or eyeglasses following cataract surgery

$15 per visit

Not covered:
All other eye examinations, eyeglasses or contact lenses, eye exercises, radial keratotomy and other refractive surgery All charges

Foot care
Coverage for routine foot care when you are under active treatment for a metabolic or peripheral vascular disease or of a neurological
condition.
(See orthopedic and prosthetic devices for information on podiatric
shoe inserts.)

$10 per PCP visit or
$15 per specialist visit

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

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

is by open cutting surgery)

All charges

Orthopedic and prosthetic devices
Internal prosthetic devices, such as artificial joints, pacemakers and surgically implanted breast implant following mastectomy.

NOTE: See 5( b) for coverage of the surgery to insert the device.
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Orthopedic devices, such as braces
Prosthetic devices, such as artificial limbs

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

20% of charges

Not covered
Foot orthotics, when not related to diabetes
All charges 20
20 Page 21 22
2001 Prudential HealthCare HMO Ñ Oklahoma 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, including repair and adjustment not provided under a manufacture's warranty or purchase agreement, of durable medical
equipment prescribed by your Plan Physician, such as hospital beds
and wheelchairs. Coverage is determined in accordance with Medicare
guidelines.

Oxygen and rental of equipment for use of oxygen.
Replacement, repair and maintenance of durable medical equipment not provided under manufacturer's warranty or purchase agreement

20% of charges

Not covered:
Exercise equipment, including, but not limited to exercycle.
All charges

Home health services
Home health care ordered by a Plan Physician and provided by nurses and home health aides. Your Plan Physician will periodically review
the program for continuing appropriateness and need.
Services include intravenous therapy and medications.

Oxygen therapy

Nothing

Not covered:
Homemaker services, Respite Care, services that may be provided in a less costly setting such as a skilled nursing facility
All charges

Alternative treatments
Chiropractic services $10 per PCP visit or
$15 per specialist visit

Not covered:
Any services not shown above
All charges

Educational classes and programs
Diabetes self management training if it is:
Needed upon diagnosis of diabetes or if there is a significant change in the patient's condition;

Supervised by a doctor legally authorized to provide such training and;
Completed by the patient

$10 per PCP visit or
$15 per specialist visit

Not covered:
Services and supplies to the extent that they are determined by us to be educational. "Educational" means:

(a) That the primary purpose of the service or supply is to provide the person
with any of the following: training in the activities of daily living; instruction
in scholastic skills such as reading and writing; preparation for an
occupation; or treatment for learning disabilities; or

(b) That the service or supply is being provided to promote development
beyond any level of function previously demonstrated.

All charges 21
21 Page 22 23
2001 Prudential HealthCare HMO Ñ Oklahoma 22 Section 5( a)
Other Medical Supplies You Pay
Supplies, including needles and syringes needed for injecting prescribed medication and dressings

Colostomy bags
20% of charges 22
22 Page 23 24
2001 Prudential HealthCare HMO Ñ Oklahoma 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange covered care.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health
care professional for your surgical care. Any costs associated with the facility
charge (i. e. hospital, surgical center, etc.) are covered in Section 5 (c).

Plan physicians must get precertification of surgical procedures.

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Benefit Description You pay
Surgical procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity Ñ Surgical treatment of morbid obesity Ñ a condition in which an individual weighs 100 pounds or

100% over his or her normal weight according to current underwriting
standards; eligible members must be age 18 or over. This procedure must
be approved in advance by us.

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

Voluntary sterilization and insertion of IUD's
Treatment of burns

$15 per office visit
Nothing for surgical
procedures

Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs)
NOTE: There is no charge when the device is implanted during a covered
hospitalization. Coverage limited to one (1) implanted time-release
medication within expected lifetime of the product.

$15 per specialist visit
and 20% of the charges
for the implanted
medication

Not covered:
Reversal of voluntary surgically-induced sterilization

Blood and blood derivatives not replaced by the member

All charges 23
23 Page 24 25
2001 Prudential HealthCare HMO Ñ Oklahoma 24 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

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

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

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

Nothing

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

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

All charges

Oral and maxillofacial surgery
Oral surgical procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correction of cleft lip or cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Exclusion of leukoplekia or malignancies;
Excision of tumors, cysts and incision of abscesses done as an independent procedure; and

Other surgical procedures that do not involve the teeth or their supporting structures.

$15 per office visit
Nothing for surgical
procedures

Not covered:
All other procedures involving the teeth or intra-oral areas surrounding the teeth

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

All charges 24
24 Page 25 26
2001 Prudential HealthCare HMO Ñ Oklahoma 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Ñ Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

NOTE: Transplants are covered when approved by the Medical Director.
The Institutes of Quality (IQ) Program Ñ The Institutes of Quality (IQ) Program provides coverage for sophisticated medical treatments

and procedures offered by a network of hospitals and physicians
known for their demonstrated accomplishment in patient outcomes.
The IQ Program includes a nationwide network for organ transplants,
bone marrow transplants, and brain and spinal cord injury
rehabilitation. Under the IQ Program, your primary care physician
initiates a referral to an institute of quality for covered procedures.
You must meet certain pre-screening criteria. Your participation is
strictly subject to approval by Prudential HealthCare. You may contact
us at 1-800-856-0764 for further information about the program.

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

Nothing

Not covered:
Transplants not listed as covered
All charges

Anesthesia
Professional services provided in Ñ
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 25
25 Page 26 27
2001 Prudential HealthCare HMO Ñ Oklahoma 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange your covered 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 covered care. Any

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

Physicians must get precertification of hospital stays.

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

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

Nothing

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent cares
Personal comfort items, such as telephone and, television

All charges 26
26 Page 27 28
2001 Prudential HealthCare HMO Ñ Oklahoma 27 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered:
blood and blood derivatives replaced by or for the member
personal comfort items, such as telephone and television

All charges

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: Up to 100 days per condition for all confinements
which are due to the same or related causes and which are separated by
less than three months.

NOTE: Coverage is provided when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medially
appropriate as determined by a Plan doctor and approved by the Plan. All
necessary services are covered, including;

Bed, board and general nursing care
Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor.

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care
Personal comfort items, such as telephone and television

All charges

Hospice care
Supportive and palliative care for a terminally ill member in the home or
hospice facility. Covered services include inpatient and outpatient care
and family counseling. Hospice services are provided under the direction
of a Plan doctor who certifies that the patient is in the terminal stages of
illness with a life expectancy of six months or less.

NOTE: Counseling must be provided within three months after the death
of the patient.

All charges over :
$7,400 per period of care,
$200 for counseling

Ambulance
Ambulance service ordered or authorized by a Plan doctor Nothing 27
27 Page 28 29
2001 Prudential HealthCare HMO Ñ Oklahoma 28 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, call you primary care doctor. In extreme emergencies or if you are unable to contact your doctor, contact the local emergency system (e. g. the

911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room
personnel that you are a Plan member so they can notify your primary care doctor. You or a family member must
notify your primary care doctor as soon as possible after receiving emergency care. It is your responsibility to
ensure that your primary care doctor has been timely notified.

If you need to be hospitalized, the Plan must be notified as soon as possible. If you are hospitalized in non-Plan
facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by us or
provided by plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified as soon as possible. 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.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by us
or provided by plan providers.

Portability
If you are away from home and require medical care other than routine physicals, immunizations and non-emergency
maternity care, you can use any Plan facility in the area you are visiting. You will receive this care at
a maximum benefit level as if you were at home, free of bills and claim forms.

To obtain these benefits you must do one of two things:
Contact your primary care doctor at home to obtain permission for out-of-area care. In life-threatening emergencies, we recommend that you seek appropriate treatment immediately. However, you or a family

member must notify your primary care doctor within 48 hours concerning the emergency care you received. 28
28 Page 29 30
2001 Prudential HealthCare HMO Ñ Oklahoma 29 Section 5( d)
Contact the Prudential HealthCare office in the city you are visiting or the National Hotline (1-800-526-2963) to obtain a referral to a local Plan doctor. This toll free number is also located on the back of your member ID
card and is answered 24 hours a day.
Your home plan is responsible for reimbursing the providers in the out-of-area Prudential HealthCare HMO
plan. You should not be asked to make payments, except applicable copays, or file a claim form unless you
receive authorized treatment from a non-Plan provider.

Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per PCP visit or $15 per specialist visit

Emergency care at an urgent care center $25 per visit
Emergency care in a hospital emergency room, including doctors' services
NOTE: If the emergency results in admission to a hospital, we waive the
copay.

$50 per visit

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

Emergency outside our service area
Emergency care at a doctor's office $10 per PCP visit or $15 per specialist visit

Emergency care at an urgent care center
NOTE: Urgent care services rendered outside our service area must
be coordinated through the Prudential National Service Hotline
(1-800-526-2963) for the $25 copay to apply.

$25 per visit

Emergency care in a hospital emergency room, including doctors' services
NOTE: If the emergency results in admission to a hospital, we waive the
copay.

$50 per visit

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

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

All charges

Ambulance
Ambulance service approved by the Plan. See 5( c) for non-emergency
service.
Nothing

Not covered: air ambulance All charges 29
29 Page 30 31
2001 Prudential HealthCare HMO Ñ Oklahoma 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Network Benefit

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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 description below.

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

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

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

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

$15 per visit

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

based intensive outpatient treatment.

Nothing

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

All charges 30
30 Page 31 32
2001 Prudential HealthCare HMO Ñ Oklahoma 31 Section 5( e)
Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits you must follow your treatment plan and all of our network
authorization processes. These include:
You must obtain access to mental health/ substance abuse services by calling Merit Behavioral Care at 1-800-553-3009 prior to receiving

services if you live or work in the Oklahoma City area (RR).
You must obtain access to mental health/ substance abuse services by calling Columbia Tulsa Regional Medical Center at 918-599-5880 or

Laureate Psychiatric Clinic at 918-491-5600 if you live or work in the
Tulsa area (RS).

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
coverage 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
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating 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 you
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. 31
31 Page 32 33
2001 Prudential HealthCare HMO Ñ Oklahoma 32 Section 5( f)
Section 5 (f). Prescription drug benefits
I
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T
A
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T

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

I
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T
A
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T

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 for up to a 30-day supply, or by mail for a 30-90 day supply of medication (if authorized by your physician). Please call Member

Services at 1-800-856-0764 for more details on how to use the mail order program. In an emergency or
urgent care situation, you may fill your covered prescription at any retail pharmacy. If you obtain your
prescription at a non-Plan pharmacy, you will need to pay the pharmacy the full price of the prescription
and submit a claim for reimbursement subject to the terms and conditions of the Plan.

We use a formulary. The plan uses a formulary. A formulary is a list of medications generally available under the plan subject to applicable terms and conditions. Coverage under the plan is not limited to

medications included on the formulary, however a higher copayment may apply. Non-formulary drugs
will be covered when prescribed by a licensed physician or dentist, but at the highest copay level. Visit our
website at www. aetnaushc. com/ pruhealthcare to review our Formulary Guide or call 1-800-856-0764.

Precertification. Your pharmacy benefits plan includes our precertification program. Precertification helps encourage the appropriate and cost-effective use of certain drugs. These drugs must be pre-authorized by

our Pharmacy Management Precertification Unit before they will be covered. Only your physician or
pharmacist in the case of an antibiotic or analgesic can request prior authorization for a drug.

The precertification program is based upon current medical findings, manufacturer labeling, FDA
guidelines and cost information.

The drugs requiring precertification are subject to change. Visit our website for the current Precertification
List.

These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day supply or one commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin) or up to a 90-

day supply by mail order, when permitted by a licensed physician or dentist. We follow FDA dispensing
guidelines. For example, Diflucan VC is FDA indicated as a single-dose treatment and a copay will be
charged for each tablet. The treatment usage for many antibiotics will be for a 10-day supply or less for
which one copay would apply. If no generic equivalent is available, you will still have to pay the brand
name copay.

Only maintenance medications and contraceptives can be obtained by mail order. Maintenance drugs are
used for the treatment of the following chronic medical conditions: chronic obstructive pulmonary disease;
clotting drugs; congestive heart failure; coronary artery disease (angina); diabetes; glaucoma;
hypertension; thyroid disease; and seizure disorders. We may also include other conditions.

When you have to file a claim. Call us at 1-800-856-0764 to obtain a claim form. Mail the completed claim form with your itemized bills to: Prudential HealthCare Pharmacy Services,

Member Reimbursement Department, P. O. Box 34860, Louisville, KY 40232-4860.

Prescription drug benefits Ñ Begin on the next page. 32
32 Page 33 34
2001 Prudential HealthCare HMO Ñ Oklahoma 33 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a licensed
physician or dentist, which can be obtained from a Plan pharmacy, (a non-Plan
pharmacy can be used in an emergency or urgent care situation), or
through our mail order program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded below.

Insulin with a copay applied to each vial
Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Limited Benefits on page 34)
Oral contraceptive drugs and devices
Oral fertility drugs (injectables are covered under Medical Services and Supplies. See Section 5( a).)

The following are examples of what a copay applies to:
Up to a 30-day supply of tablets, capsules and liquids to be taken orally; or as indicated for use by the Food and Drug Administration

(FDA). For example, Diflucan VC is FDA indicated as a single-dose
treatment and copay will be charged for each tablet. The treatment
usage for many antibiotics will be for a 10-day supply or less for
which one copay would apply.

a manufacturer's standard 10 milliliter vial of insulin;
insulin syringes, a copay applies to each package of 100;
a package of no more than 15 milliliters of any optic or ophthalmic product;

a manufacturer's smallest standard package of nasal or oral inhaler;
a manufacturer's smallest standard package of nebulizer solution;
1 manufacturer's smallest standard package of liquid or solid rectal or vaginal medication;

1 manufacturer's smallest standard package containing no more than 60 milliliters of topical solutions or lotions;
1 manufacturer's smallest standard package containing no more than 60 grams of topical ointments or creams;
Up to a 30 day supply of patches, a copay applies to each manufacturer's standard package;
1 package of oral contraceptives;
1 diaphragm unit;
Diabetic supplies (except insulin), disposable needles and syringes, contraceptive devices other than diaphragms, intravenous fluids and

medications for home use, implantable drugs (such as Norplant ), and
injectable drugs (such as Depo Provera or some fertility drugs) are
covered under the Medical Benefits.

For a 30-day supply or one
commercially prepared unit
obtained at a Plan pharmacy:

$5 per prescription unit/ refill
for generic formulary drugs

$15 per prescription unit/ refill
for brand name formulary
drugs

$25 per prescription unit/ refill
for non-formulary drugs

For a 90-day supply obtained
through our mail-order
pharmacy for maintenance
drugs and contraceptives

$5 per prescription unit/ refill
for generic formulary drugs

$15 per prescription unit
/refill for brand name
formulary drugs

$25 per prescription unit/ refill
for non-formulary drugs

Covered medications and supplies Ñ Continued on next page 33
33 Page 34 35
2001 Prudential HealthCare HMO Ñ Oklahoma 34 Section 5( f)
Benefit Description You pay
Covered medications and supplies (Continued)
Limited benefits
Sexual dysfunction drugs have dispensing limitations. For complete details call Customer Service at 1-800-856-0764.

Smoking cessation aids: Smoking cessation therapy that requires a prescription is covered. Lifetime coverage is limited to one 90-day
course of treatment to be administered through a Plan doctor.

Not covered:
Drugs available without prescription or for which there is a nonprescription equivalent available;

Drugs obtained at a non-Plan pharmacy except out-of-area emergencies;
Vitamins and nutritional substances which can be obtained without a prescription;
Drugs to enhance athletic performance;
Drugs for cosmetic purposes;
Non-prescription smoking cessation drugs and medication;
Drug, services and supplies provided in connection with any weight loss program or food supplements used to achieve weight loss, unless

the member is morbidly obese or the obesity is shown to have an
adverse effect on a concurrent sickness.

All charges 34
34 Page 35 36
2001 Prudential HealthCare HMO Ñ Oklahoma 35 Section 5( g)
Section 5 (g). Special Features
Feature Description
High risk pregnancies Prudential HealthCare's Starting Right Program includes components for both low-risk and high-risk maternity care. We have refined processes to
make educational materials for low-risk members even more easy to
access and member-satisfying. For high-risk members, we work closely
with Plan obstetricians on providing case management by our registered
nurses.

Centers of excellence
for transplants/ heart
surgery, etc.

The Institutes of Quality (IQ) Program provides coverage for
sophisticated medical treatments and procedures offered by a network of
hospitals and physicians known for their demonstrated accomplishment in
patient outcomes. The IQ Program includes a nationwide network for
organ transplants, bone marrow transplants, and brain and spinal cord
injury rehabilitation. Under the IQ Program, your primary care physician
initiates a referral to an institute of quality for covered procedures. You
must meet certain pre-screening criteria. Your participation is strictly
subject to approval by Prudential HealthCare. You may contact us at
1-800-856-0764 for further information about the program. 35
35 Page 36 37
2001 Prudential HealthCare HMO Ñ Oklahoma 36 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

medically necessary.
Plan dentists must provide or arrange your care.
We 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.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair or replace
sound natural teeth. The need for these services must result from an accidental injury.
$15 per visit

Not covered:
Other dental services not shown as covered
All charges

Dental benefits
We have no other dental benefits. All charges 36
36 Page 37 38
2001 Prudential HealthCare HMO Ñ Oklahoma 37 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Dental Program The comprehensive Dental Program has no claim forms or deductibles. It is not insurance; it's a discount dental program, with more than 10,000
participating dentists across the country. These dentists have agreed to
provide services to program participants at reduced rates Ñ including
periodic exams, cleanings É even orthodontia care.

For as little as $5.00 per month ($ 6.00 for families), you will have access
to a full range of dental services at a substantial discount. The schedule of
benefits has changed for 2001. You can enroll by submitting a completed
application and a full year's premium, $60.00 for an individual and $72.00
for a family. (Please note, this is not a payroll deducted plan.) Applications
and more details about the Dental Program are included in your Prudential
HealthCare open enrollment packet. Please note that the schedule of
benefits has changed. You may contact Benefit Network Systems at 1-800-
391-9721 for more information.

Bike Helmet Program The Prudential HealthCare Bike Helmet Program makes quality bicycle helmets available to people of all ages Ñ even non-plan members Ñ for as
little as $10. Call 1-800 MY HEALTH.

The Vitamin Advantage Program is no longer available. 37
37 Page 38 39
2001 Prudential HealthCare HMO Ñ Oklahoma 38 Section 6
Section 6. General exclusions Ñ things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury or condition.

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

Procedures, services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services and supplies provided by you, your spouse, or a child, brother, sister or parent of you or your spouse. 38
38 Page 39 40
2001 Prudential HealthCare HMO Ñ Oklahoma 39 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.

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

file on the UB-92 form. For claims questions and assistance, call us at 1-
800-856-0764.

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

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

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer Ñ such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Prudential Healthcare, P. O. Box 4084, Houston,
TX 77210-4084

Mental health and
substance abuse benefits For Oklahoma City (Code RR) members, call us at 1-800-862-8276 to obtain a claim form. Mail the completed claim form with your itemized

bills to: Merit Behavioral Care Corporation, Prudential Oklahoma, P. O.
Box 2096, St. Louis, MO 63043.

For Tulsa (Code RS) members, call us at 1-800-856-0764 to obtain a claim
form. Mail the completed claim form with your itemized bills to:
Prudential Healthcare, P. O. Box 4084, Houston, TX 77210-4084

Prescription drugs Call 1-800-856-0764 to obtain a claim form. Send the completed claim form and the original pharmacy receipt (no cash register receipts) which
includes the pharmacy name, address and telephone number, drug name
strength, number of units dispensed and the amount you paid.

Submit your claims to: Prudential HealthCare Pharmacy Services, Member
Reimbursement Department, P. O. Box 34860, Louisville, KY 40232-4860. 39
39 Page 40 41
2001 Prudential HealthCare HMO Ñ Oklahoma 40 Section 7
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received
the service, unless timely filing was prevented by administrative operations
of Government or legal incapacity, provided the claim was submitted as
soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 40
40 Page 41 42
2001 Prudential HealthCare HMO Ñ Oklahoma 41 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies Ñ including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Prudential HealthCare HMO Ñ Oklahoma, P. O. Box 4084, Houston, TX
77210; and

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

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

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

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

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us Ñ 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 III,
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.

NOTE: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim.

NOTE: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must 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. 41
41 Page 42 43
2001 Prudential HealthCare HMO Ñ Oklahoma 42 Section 8
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs or supplies. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
1-800-856-0764 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 III at 202-606-0755 between 8 a. m. and 5 p. m. eastern time.

External Review
You can seek an independent external review if:
The amount of your claim or service is more than $500; and
We denied your claim because we did not consider the treatment medically necessary or considered it experimental or investigational.

The independent external review will use a neutral, independent physician with related expertise to conduct the review.
We will cover the professional fee for the review and you will pay the cost to compile and send your submission to the
Plan.

To request an External Review Form, call 1-800-856-0764 within 60 days after receiving our written notification that
we will uphold our original decision to deny your claim.

The external reviewer will make a decision within 30 days after you send us all the necessary information with the
External Review Request Form. Your primary care physician can request an expedited review in cases of "clinical
urgency" where your health would be seriously jeopardized if you waited the full 30 days. In this case, the external
review organization or physician will make a decision within 72 hours.

To request a detailed description of the external review requirements, call us at 1-800-856-0764. 42
42 Page 43 44
2001 Prudential HealthCare HMO Ñ Oklahoma 43 Section 9
Section 9. Coordinating benefits with other coverage
When you have other
health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health

care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

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

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

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.
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 managed care 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
covered 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 benefits. Your care must
continue to be authorized by your Plan PCP, or precertified as required.

We will not waive any of our copayments or coinsurance.
(Primary payer chart begins on next page.) 43
43 Page 44 45
2001 Prudential HealthCare HMO Ñ Oklahoma 44 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer isÉ 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 when É
a) The position is excluded from FEHB, or............................................................. .................. !! ! !

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

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C.
(or if your covered spouse is this type of judge),

!! ! !

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

!! ! !
(for other
services)

6) Are a former Federal employee receiving Workers' Compensation and
the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

!! ! !
(except for claims
related to Workers'
Compensation.)

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

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

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

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

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

b) Are an active employee ........................................................................................ ....................................... ............ !! ! !

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 44
44 Page 45 46
2001 Prudential HealthCare HMO Ñ Oklahoma 45 Section 9
Claims process Ñ You 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 1-800-856-0764.

We waive some costs when you have Medicare Ñ When Medicare is the
primary payer, we do not waive any out-of-pocket costs.

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
managed 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 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 or coinsurance.

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
premium.) For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you
involuntarily lose coverage or move out of the Medicare manage care plan
service area.

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

Medicare.

TRICARE TRICARE is the health care program for members, eligible dependents of military persons, and retirees of the military. TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover you, we pay
first. See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage. 45
45 Page 46 47
2001 Prudential HealthCare HMO Ñ Oklahoma 46 Section 9
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
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed

under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

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

When others are responsible
for injuries When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for

any expenses we paid. However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 46
46 Page 47 48
2001 Prudential HealthCare HMO Ñ Oklahoma 47 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on

December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See pages 9 and 13.

Coinsurance Coinsurance is the percentage of expenses that you must pay for your care. See pages 9 and 13.
Covered services Services we provide benefits for, as described in this brochure.
Custodial care Any type of care provided in accordance with Medicare guidelines, including room and board, that a) does not require the skills of technical or
professional personnel; b) is not furnished by or under the supervision of
such personnel or does not otherwise meet the requirements of post-hospital
Skilled Nursing Facility care; or c) is a level such that you have
reached the maximum level of physical or mental function and such person
is not likely to make further significant improvement. Custodial Care
includes, but is not limited to, any type of care where the primary purpose
of the type of care provided is to attend to your daily living activities which
do not entail or require the continuing attention of trained medical or
paramedical personnel. Examples of this includes, but is not limited to,
assistance in walking, getting in and out of bed, bathing, dressing, feeding,
using the toilet, changes of dressings of non infected, post operative or
chronic conditions, preparation of special diets, supervision of medication
which can be self-administered by the you, general maintenance care of
colostomy or ileostomy, routine services to maintain other service which,
in the sole determination of us, based on medically accepted standards, can
be safely and adequately self-administered or performed by the average
non-medical person without the direct supervision of trained medical or
paramedical personnel, regardless of who actually provides the service,
residential care and adult day care, protective and supportive care including
educational services, rest cures, convalescent care.

Detoxification The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate
regulatory authority, through the period of time necessary to eliminate, by
metabolic or other means, the intoxicating alcohol or drug, alcohol or drug
dependent factors or alcohol in combination with drugs as determined by a
licensed Physician, while keeping the physiological risk to the patient at a
minimum. 47
47 Page 48 49
2001 Prudential HealthCare HMO Ñ Oklahoma 48 Section 10
Experimental or
investigational services We do not cover procedures, services, or supplies that are experimental or investigational. In order to determine whether or not a procedure, service, or

supply is experimental or investigational, we gather appropriate information
for a decision that will be made by medical professionals. The information
we collect may include medical records, current reviews of medical
literature and scientific evidence, results of current studies or clinical trials,
research protocols, reports or opinions of authoritative medical bodies,
opinions of independent outside experts and approvals granted by
regulatory bodies. Your provider may sometimes ask that you sign a form
acknowledging that the procedure, service, or supply is experimental or
investigational. This form and any related protocol may also be part of the
information we consider. After reviewing all pertinent information, we
make our determination and notify you of our decision. Please contact
customer service at 1-800-856-0764 for more specific information.

Medical necessity Also known as medically necessary or medically necessary services. Services that are appropriate and consistent with the diagnosis in
accordance with accepted medical standards as described in this document.
Medical Necessity, when used in relation to services, shall have the same
meaning as Medically Necessary Services. This definition applies only to
the determination by us of whether health care services are Covered
Benefits under this Plan.

Reasonable Charge The charge for a Covered Benefit which is determined by us to be the prevailing charge level made for the service or supply in the geographic
area where it is furnished. We may take into account factors such as the
complexity, degree of skill needed, type or specialty of the Provider, range
of services provided by a facility, and the prevailing charge in other areas
in determining the Reasonable Charge for a service or supply that is
unusual or is not often provided in the area or is provided by only a small
number of providers in the area.

Referral Specific directions or instructions from your PCP, in conformance with our policies and procedures, that direct you to a Plan provider for medically
necessary care.

Respite Care Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to the your needs.

Urgent Care Covered benefits required in order to prevent serious deterioration of a your health that results from an unforeseen illness or injury if you are
temporarily absent from the our service area and receipt of the health care
service cannot be delayed until your return to the service area.

Us/ We Us and we refer to Prudential HealthCare HMO Ñ Oklahoma
You You refers to the enrollee and each covered family member. 48
48 Page 49 50
2001 Prudential HealthCare HMO Ñ Oklahoma 49 Section 11
Section 11. FEHB facts
No pre-existing condition
limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition

before you enrolled.

Where you can get information about enrolling in the
FEHB Program See www. opm. gov/ insure. Also, your employing or retirement office can answer your questions, and give you a Guide to Federal Employee 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
for you and your family Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22,

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

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

Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age
22 marries or turns 22. 49
49 Page 50 51
2001 Prudential HealthCare HMO Ñ Oklahoma 50 Section 11
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

premiums start The benefits in this brochure are effective on January 1. If you are new 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.

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

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

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

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

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

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

Spouse equity 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. 50
50 Page 51 52
2001 Prudential HealthCare HMO Ñ Oklahoma 51 Section 11
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.

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

Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse equity law; or

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

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

Getting a Certificate of
Group Health Plan Coverage If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with

us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting
periods, limitations, or exclusions for health related conditions based on
the information in the certificate, as long as you enroll within 63 days of
losing coverage under this Plan.

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

Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-856-0764 and explain the situation. 51
51 Page 52 53
2001 Prudential HealthCare HMO Ñ Oklahoma 52 Section 11
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE Ñ 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 prosecuted for fraud. Also, the Inspector General may investigate anyone

who uses an ID card if the person tries to obtain services for someone who
is not an eligible family member, or is no longer enrolled in the Plan and
tries to obtain benefits. Your agency may also take administrative action
against you. 52
52 Page 53 54
2001 Prudential HealthCare HMO Ñ Oklahoma 53 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury, 24, 36, 55
Alternative treatment, 21
Ambulance, 12, 26, 27, 28, 29
Anesthesia, 23, 25, 27
Autologous bone marrow
transplant, 19, 25

Blood and blood plasma, 27
Casts, 26, 27
Chemotherapy, 19
Claims, 7, 10, 14, 39, 41, 42, 44,
45, 50

Coinsurance, 5, 9, 10, 13, 39, 43,
45, 47

Colorectal cancer screening, 16
Congenital anomalies, 23, 24
Covered charges, 45
Definitions, 15, 23, 26, 28, 30,
32, 36, 47, 55

Dental care, 24, 55
Dressings, 22, 26, 27, 47
Durable medical equipment
(DME), 13, 21

Educational clas s es and pr ogr ams ,
21

Emergency, 5, 8, 28, 29, 32, 33,
38, 39, 55

Experimental or investigational,
38, 42, 48

Eyeglasses, 20
Family planning, 17
Fecal occult blood test, 16

General exclusions, 14, 38
Hearing services, 20
Home health services, 21
Hospice care, 27
Hospital, 5, 9, 11, 15, 17, 21, 23,
24, 25, 26, 27, 28, 29, 30, 39,
43, 46, 51, 55

Immunizations, 5, 16, 28
Infertility, 13, 18
Insulin, 32, 33
Mammograms, 15
Medicaid, 46
Medically necessary, 12, 15, 17,
23, 26, 28, 36, 38, 42, 48

Medicare, 15, 21, 23, 26, 28, 30,
32, 36, 39, 43, 44, 45, 47

Members, 5, 6, 7, 10, 23, 35, 37,
39, 45, 49, 50, 56

Non-FEHB Benefits, 37
Nurse, 26
Nurse Anesthetist, 26
Registered Nurse, 35
Occupational therapy, 19

Office visits, 5, 9
O r al and maxillof acial s ur ger y, 24
Orthopedic devices, 13, 20
Oxygen, 13, 21, 26, 27
Pap test, 15, 16
Physical therapy, 19
Physician, 5, 6, 7, 10, 11, 12, 13,
15, 17, 21, 23, 25, 32, 33, 35,
39, 42, 44, 47, 51, 55

Precertification, 6, 7, 12, 23, 26,
32

Prescription drugs, 12, 13, 32, 39,
43, 45, 55

Preventive care, adult, 16
P r eventive car e, childr en, 16, 20
Prior approval, 12, 42
Prosthetic devices, 13, 20, 23, 24
Radiation therapy, 19
Room and board, 26, 47
Second surgical opinion, 15
Smoking cessation, 34
Speech therapy, 19
Splints, 26
Subrogation, 46
Substance abuse, 6, 9, 30, 31, 39,
55

Surgery, 9, 12, 17, 18, 19, 20, 23,
24, 26, 35, 55

Oral, 24
Outpatient, 6
Reconstructive, 23, 24
Syringes, 22, 33

Temporary continuation of
coverage, 50, 51

Transplants, 19, 25, 35, 55
Treatment therapies, 19
Vision services, 20, 55
Wheelchairs, 21
X-rays, 15, 26, 27 53
53 Page 54 55
2001 Prudential HealthCare HMO Ñ Oklahoma 54
NOTES: 54
54 Page 55 56
2001 Prudential HealthCare HMO Ñ Oklahoma 55 Summary of Benefits
Summary of benefits for the Prudential HealthCare HMO Ñ Oklahoma Ñ 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 You Pay Page

Medical services provided by physicians:
Diagnostic and treatment services provided in the office ...................
Maternity ..............................................................................................

Office visit copay: $10 primary
care; $15 specialist

First visit only

15

Services provided by a hospital:
Inpatient ................................................................................................
Extended care (up to100 days per condition) ......................................
Outpatient..............................................................................................

Nothing 26
27
27

Emergency benefits:
In-area ..................................................................................................
Out-of-area...........................................................................................

$50 per ER visit
$25 per Urgent Care Center or
physician visit

28
28

Mental health and substance abuse treatment .......................................... Same as hospital and medical
benefits
30

Prescription drugs...................................................................................... $5 per prescription for generic
formulary drugs, $15 per
prescription for brand name
formulary drugs, or $25 per
prescription for non-formulary
drugs

32

Dental Care................................................................................................ Accidental Injury benefit only,
$15 copay per visit 36

Vision Care................................................................................................ Eye exam to determine the need
for vision correction for children
to age 17. Office visit copay: $10
primary care, $15 specialist

20

Protection against catastrophic costs
(your out-of-pocket maximum) ................................................................
Nothing after $500/ Self Only or
$1,500/ Family enrollment per
year.
Prescription drug costs do not
count toward this protection.

13

Special Features:
High Risk pregnancies and Centers of Excellence for transplants/ heart
surgery etc. ............................................................................................

Contact Plan 35 55
55 Page 56
2001 Prudential HealthCare HMO Ñ Oklahoma 56 Rates
2001 Rate Information for Prudential HealthCare HMO ® Ñ Oklahoma
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

Oklahoma City Area

Self Only RR1 $71.69 $23.89 $155.32 $51.77 $84.83 $10.75

Self and Family RR2 $190.80 $63.60 $413.40 $137.80 $225.78 $28.62
Tulsa Area
Self Only RS1 $77.96 $25.99 $168.92 $56.31 $92.26 $11.69

Self and Family RS2 $172.63 $57.54 $374.03 $124.67 $204.28 $25.89

RRD# 8104859A 15993-9/ 00 56

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