Pages 1--52 from Coventry Health Care of Iowa, Inc.

A Health Maintenance Organization

Serving: The Greater Des Moines, Central Iowa, and Waterloo
Enrollment in this Plan is limited; see page 5 for requirements.
This Plan has a Commendable
accreditation from the NCQA. See the
2001 Guide for more information on

NCQA.

Enrollment codes for this Plan:
SV1 Self Only
SV2 Self and Family

RI-73-186

2001
For changes
in benefits
see page 7. 1
1 Page 2 3
2001 Coventry Health Care of Iowa, Inc. 2 Table of Contents
Table of Contents
IntroductionÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ............................................................... 4
Plain LanguageÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.............................................................. 4
Section 1. Facts about this HMO plan ........................................................................................................................ 5
How we pay providers ................................................................................................................................ 5
Who provides my health care...................................................................................................................... 5
Service Area................................................................................................................................................ 6
Section 2. How we change for 2001ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ................................................................ 7
Program-wide changes................................................................................................................................ 7
Changes to this Plan.................................................................................................................................... 7
Section 3. How you get care ÉÉÉÉ....................................................................................................................... 8
Identification cards...................................................................................................................................... 8
Where you get covered care........................................................................................................................ 8
· Plan providers........................................................................................................................................ 8
· Plan facilities.......................................................................................................................................... 8
What you must do to get covered care........................................................................................................ 8

· Primary care .......................................................................................................................................... 8
· Specialty care ........................................................................................................................................ 8
· Hospital care.......................................................................................................................................... 9
Circumstances beyond our control.............................................................................................................. 9
Services requiring our prior approval ...................................................................................................... 10
Section 4. Your costs for covered services ................................................................................................................ 11
· Copayments.......................................................................................................................................... 11
· Deductible............................................................................................................................................ 11
· Coinsurance.......................................................................................................................................... 11
Your out-of-pocket maximum .................................................................................................................. 11
Section 5. BenefitsÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.............................................................. 12
Overview .................................................................................................................................................. 12
(a) Medical services and supplies provided by physicians and other health care professionals.............. 13
(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 ........................................ 27
(d) Emergency services/ accidents ............................................................................................................ 30
(e) Mental health and substance abuse benefits........................................................................................ 32
(f) Prescription drug benefits.................................................................................................................... 34
(g) Special features.................................................................................................................................... 37
(h) Dental benefits .................................................................................................................................... 38
(i) Non-FEHB benefits available to Plan members.................................................................................. 39 2
2 Page 3 4
2001 Coventry Health Care of Iowa, Inc. 3 Table of Contents
Section 6. General exclusions --things we don't cover ............................................................................................ 40
Section 7. Filing a claim for covered services .......................................................................................................... 41
Section 8. The disputed claims process...................................................................................................................... 43
Section 9. Coordinating benefits with other coverage .............................................................................................. 45
When you haveÉ
· Other health coverage.......................................................................................................................... 45
· Original Medicare................................................................................................................................ 45
· Medicare Managed Care Plan.............................................................................................................. 46
TRICARE/ Workers' Compensation/ Medicaid.......................................................................................... 47
Other Government agencies...................................................................................................................... 48
When others are responsible for injuries .................................................................................................. 48
Section 10. Definitions of terms we use in this brochure............................................................................................ 49
Section 11. FEHB facts................................................................................................................................................ 50
Coverage information................................................................................................................................ 50
· No pre-existing condition limitation.................................................................................................... 50
· Where you get information about enrolling in the FEHB Program.................................................... 50
· Types of coverage available for you and your family ........................................................................ 50
· When benefits and premiums start...................................................................................................... 51
· Your medical and claims records are confidential .............................................................................. 51
· When you retire .................................................................................................................................. 51
When you lose benefits ............................................................................................................................ 51

· When FEHB coverage ends ................................................................................................................ 51
· Spouse equity coverage ...................................................................................................................... 51
· Temporary Continuation of Coverage (TCC)...................................................................................... 51
· Converting to individual coverage ...................................................................................................... 52
· Getting a Certificate of Group Health Plan Coverage ........................................................................ 52
Inspector General Advisory ...................................................................................................................... 52
Department of Defense/ FEHB Demonstration Project .............................................................................................. 53
Index............................................................................................................................................................................ 55
Summary of benefits .................................................................................................................................................. 57
Rates.............................................................................................................................................................. Back cover 3
3 Page 4 5
2001 Coventry Health Care of Iowa, Inc. 4 Introduction/ Plain Language
Introduction
Coventry Health Care of Iowa, Inc.
4600 Westown Parkway, Suite 200
West Des Moines, Iowa 50266-1099

This brochure describes the benefits of Coventry Health Care of Iowa, Inc. under our contract (CS 1983) 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, unless those benefits are also shown in this brochure.

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

Plain Language
The President and Vice President are making the Government's communication more responsive, accessible, and
understandable to the public by requiring agencies to use plain language. In response, a team of health plan
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 Coventry Health Care of
Iowa, Inc.

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 Coventry Health Care of Iowa, Inc. 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, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.

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

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

Who provides my health care
Coventry Health Care of Iowa, Inc. contracts with more than 405 doctors representing specialties in family practice,
pediatrics and internal medicine to serve as primary care physicians. In addition, over 979 specialists and 31 hospitals
participate. Coventry Health Care of Iowa, Inc. has also made arrangements with certain optometrists, ophthalmologists
and pharmacies to provide your eye exams and prescription drugs.

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

· Coventry Health Care of Iowa, Inc. came together officially on January 1, 2000. Formerly it was known as Principal Health Care of Iowa, Inc.

If you want more information about us, call 800-257-4692, or write to 4600 Westown Parkway, Suite 200 West Des
Moines, Iowa 50266-1099. You may also contact us by fax at 302-283-6786 or visit our website at www. cvty. com. 5
5 Page 6 7
2001 Coventry Health Care of Iowa, Inc. 6 Section 1
Facts about this HMO plan (Continued)
Service Area

To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service
area is: Black Hawk, Boone, Bremer, Clarke, Dallas, Guthrie, Jasper, Lucas, Madison, Marion, Polk, Story, and
Warren counties.

You may also enroll with us if you live in the following places: Hamilton, Mahaska, Marshall, and Poweshiek
counties.

Ordinarily, you must get 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, unless authorized by the Plan.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live outside 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 states. If you or your family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2001 Coventry Health Care of Iowa, Inc. 7 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 deductibles, coinsurance, copays, and
day and visit limitations when you follow a treatment plan that we approve. Previously, we placed shorter day or
visit limitations on mental health and substance abuse services than we did 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 Member Services at 800-257-4692, or checking our website www. cvty. com. You can
find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take
these five steps:

Speak up if you have questions or concerns.
Keep a list of 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

Mental Health/ Substance Abuse benefits are now administered exactly as the medical benefits. What this means to
you is that there will no longer be limits on the number of outpatient visits or inpatient days you can be seen every
calendar year.

Your share of the non-Postal premium will not change for either Self-Only or Self and Family. 7
7 Page 8 9
2001 Coventry Health Care of Iowa, Inc. 8 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 services from a Plan provider, or obtain 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 800-257-4692.

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

Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically.

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

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care.
You choose a primary care physician when you enroll in the plan. You may
change your primary care physician up to twice a year.

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

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

Specialty care Your primary care physician will refer you to a specialist for needed care.
However, you may see either an optometrist or ophthalmologist for a routine
eye exam once per year without a referral. Women in our plan may also see a
gynecologist once per year for a routine check without a referral.

Here are other things you should know about specialty care:
· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with
the specialist and the plan to 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). 8
8 Page 9 10
2001 Coventry Health Care of Iowa, Inc. 9 Section 3
How you get care (Continued)
· 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 s pecialist because we:

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

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800-257-4692. If you are new
to the FEHB Program, we will arrange for you to receive care.

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

· You are discharged, not merely moved to an alternative care center; or
· The day your benefits from your former plan run out; or

· The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. 9
9 Page 10 11
2001 Coventry Health Care of Iowa, Inc. 10 Section 3
How you get care (Continued)
Circumstances beyond our Under certain extraordinary circumstances, such as natural disasters, we
control may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the

necessary care.
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 prior approval. Your physician must
obtain prior approval for the following services such as: hospital inpatient
admissions, outpatient surgeries, home health care, home infusion services,
durable medical equipment, outpatient therapy (physical therapy,
occupational therapy, speech therapy and manipulative services), growth
hormone therapy, and any out of network services. 10
10 Page 11 12
2001 Coventry Health Care of Iowa, Inc. 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when
you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care.

Example: In our Plan, you pay 50% of our allowance for infertility
services and 20% of our allowance for durable medical equipment.

Yo u r out-of-pocket maximum
f o r coinsurance and copayments After your copayments and/ or coinsurance total $750 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 or
coinsurance for dental services do not count toward these limits, and you
must continue to make these payments.

Be sure to keep accurate records of your copayments and coinsurance
since you are responsible for informing us when you reach the maximum. 11
11 Page 12 13
2001 Coventry Health Care of Iowa, Inc. 12 Section 5 (Overview)
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact
us at 800-257-4692 or at our website at www. cvty. com.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . .13-22
· Diagnostic and treatment services · Hearing services (testing, treatment, and
· Lab, X-ray, and other diagnostic tests supplies)
· Preventive care, adult · Vision services (testing, treatment, and
· Preventive care, children supplies)
· Maternity care · Foot care
· Family planning · Orthopedic and prosthetic devices
· Infertility services · Durable medical equipment (DME)
· Allergy care · Home health services
· Treatment therapies · Alternative treatments
· Rehabilitative therapies · Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . .23-26

· Surgical procedures · Oral and maxillofacial surgery
· Reconstructive surgery · Organ/ tissue transplants
· Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . .27-29

· Inpatient hospital · Extended care benefits/ skilled nursing care
· Outpatient hospital or ambulatory surgical facility benefits center
· Hospice care
· Ambulance

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30-31
· Medical emergency · Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32-33
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34-36
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 12
12 Page 13 14
2001 Coventry Health Care of Iowa, Inc. 13 Section 5 (a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

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

° Plan physicians must provide or arrange your care.
° Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

Benefit Description You Pay
Diagnostic and treatment services
Professional services of physicians $10 per office visit to your primary
care physician

· In physician's office $15 per office visit to a specialist

Professional services of physicians
· In an urgent care center Nothing
· During a hospital stay Nothing
· In a skilled nursing facility Nothing
· Initial examination of a newborn child covered under a family $10 per office visit to primary care enrollment physician, or

· Office medical consultations
· Second surgical opinion $15 per office visit to a specialist

At home $10 per house call by primary care
physician

Lab, X-ray and other diagnostic tests
Tests, such as: Nothing if you receive these
· Blood tests services during your office visit;
· Urinalysis otherwise, $10 per office visit to
· Non-routine pap tests primary care physician, or $15 per
· Pathology office visit to a specialist
· X-rays
· Non-routine Mammograms
· Cat Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG

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2001 Coventry Health Care of Iowa, Inc. 14 Section 5 (a)
Preventive care, adult You Pay
Routine screenings, such as: $10 per office visit to primary care
· Blood lead level Ð One annually physician, or $15 per visit to a
· Total Blood Cholesterol Ð once every three years, ages 19 through 64 specialist
· Colorectal Cancer Screening, including
·· Fecal occult blood test
·· Sigmoidoscopy, screening Ð every five years starting at age 50

Prostate Specific Antigen (PSAtest) Ð one annually for men age $10 per office visit to primary care
40 and older physician, or $15 per visit to a
specialist

Routine pap test $10 per office visit to primary care
physician, or $15 per office visit to a
specialist

Routine mammogram Ðcovered for women age 35 and older, as follows: $10 per office visit to primary care
· From age 35 through 39, one during this five year period physician, or $15 per office
· From age 40 through 49, one every one or two calendar years visit to a specialist
· From age 50 through 64, one every calendar year
· At age 65 and older, one every two consecutive calendar years

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

Routine Immunizations, limited to: $10 per office visit to primary care
· Tetanus-diphtheria (Td) booster Ð once every 10 years, ages19 and physician, or $15 per office over (except as provided for under Childhood immunizations) visit to a specialist

· Influenza/ Pneumococcal vaccines, annually, age 65 and over 14
14 Page 15 16
2001 Coventry Health Care of Iowa, Inc. 15 Section 5 (a)
Preventive care, children You pay
· Childhood immunizations recommended by the American Academy $10 per office visit to primary care of Pediatrics physician, or $15 per office visit to
a specialist

· Examinations, such as: $10 per office visit to primary care
·· Eye exams through age 17 to determine the need for vision physician, or $15 per office visit to correction. a specialist

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

Maternity care
Complete maternity (obstetrical) care, such as: $50 at the time of delivery.
· Prenatal care One copay per pregnancy
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:

· You do not need to precertify your normal delivery; see page xx for other circumstances, such as extended stays for you or your baby.

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

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

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

Surgery benefits (Section 5b).

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
· Voluntary sterilization $10 per office visit to a primary
· Surgically implanted contraceptives care physician, or $15 per office
· Injectable contraceptive drugs visit to a specialist
· Intrauterine devices (IUDs)

Not covered: reversal of voluntary surgical sterilization, genetic All charges.
counseling 15
15 Page 16 17
2001 Coventry Health Care of Iowa, Inc. 16 Section 5 (a)
Infertility services You pay
Diagnosis and treatment of infertility, such as: 50% of the allowable charges
· Artificial insemination:
·· intravaginal insemination (IVI)
·· intracervical insemination (ICI)
·· intrauterine insemination (IUI)
· Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Not covered: All charges.
· Assisted reproductive technology (ART) procedures, such as:
·· in vitro fertilization
·· embryo transfer and GIFT
· Services and supplies related to excluded ART procedures

· Cost of donor sperm

Allergy care
Testing and treatment $10 per office visit to primary care
Allergy injection physician, or $15 per office visit to a specialist

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy All charges.
desensitization

Treatment therapies
· Chemotherapy and radiation therapy $10 per office visit to primary care
Note: High dose chemotherapy in association with autologous bone physician, or $15 per visit to
marrow transplants are limited to those transplants listed under specialist
Organ/ Tissue Transplants on page 27.

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

· Growth hormone therapy (GHT) 25% of allowable charges or a $5
Note: Ð We will only cover GHT for medically necessary conditions copayment per one month supply,
when we have preauthorized the treatment. Such authorization must be whichever is greater
obtained through Health Services at 800-470-6352. See Services
requiring our prior approval in Section 3. 16
16 Page 17 18
2001 Coventry Health Care of Iowa, Inc. 17 Section 5 (a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --$10 per outpatient session; nothing
· 60 visits per condition for the services of each of the following: per inpatient visit
·· qualified physical therapists;
·· speech therapists; and
·· occupational therapists.
Note: These services are covered when determined by the Plan to
be medically necessary and significant improvement can be
expected within two months.

· Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to two

months

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

Hearing services (testing, treatment, and supplies)
· First hearing aid and testing only when necessitated by accidental $10 per office visit to primary care injury physicians or $15 per office visit
to a specialist
· Hearing testing for children through age 17 (see Preventive care, children) physician,

Not covered: All charges.
· all other hearing testing

· hearing aids, testing and examinations for them

Vision services (testing, treatment, and supplies)
· One annual eye refraction (which includes the written lens Nothing to an optometrist; $15 prescription) may be obtained from Plan providers. per visit to an opthalmologist

· One pair of eyeglasses or contact lenses to correct an impairment 20% of allowable charges directly caused by intraocular surgery (such as for cataracts)
· Eye exam to determine the need for vision correction for children Nothing to an optometrist; $15 through age 17 (see preventive care) per visit to an opthalmologist
· Annual eye refractions
Not covered: All charges.
· Eyeglasses or contact lenses and, after age 17, examinations for them
· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery 17
17 Page 18 19
2001 Coventry Health Care of Iowa, Inc. 18 Section 5 (a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic $10 per office visit to primary care
or peripheral vascular disease, such as diabetes. physician, or $15 per office visit to a

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

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

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

treatment is by open cutting surgery)

Orthopedic and prosthetic devices
· Corrective orthopedic appliances for non-dental treatment of 20% of allowable charges and all temporomandibular joint (TMJ) pain dysfunction syndrome. Note: charges over $2,000
There is a combined $2,000 lifetime maximum for the non-surgical
and surgical treatment of TMJ.

· Artificial limbs and eyes; stump hose 20% of allowable charges
· Foot orthotics
· Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

· Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery to
insert the device.

Not covered: All charges.
· orthopedic and corrective shoes
· arch supports
· heel pads and heel cups
· lumbosacral supports
· corsets, trusses, elastic stockings, support hose, and other supportive devices

· prosthetic replacements provided less than 3 years after the last one we covered 18
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2001 Coventry Health Care of Iowa, Inc. 19 Section 5 (a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of 20% of allowable charges
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

· manual hospital beds;
· manual wheelchairs;
· crutches;
· walkers;
· blood glucose monitors; and
· insulin pumps.

Not covered: All charges.
· Motorized wheel chairs
· Convenience items

Home health services
· Home health care ordered by a Plan physician and provided by a $10 per visit by primary care registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed physician; nothing by nurse or
vocational nurse (L. V. N.), or home health aide. Services include home health aide
oxygen therapy, intravenous therapy and medications.

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

· nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

Alternative treatments
Chiropractic services; including osteopathic manipulative therapy, when $10 per office visit
authorized by the Plan and primary care physician

Not covered: All charges.
· acupuncture services
· naturopathic services
· hypnotherapy
· biofeedback 19
19 Page 20 21
2001 Coventry Health Care of Iowa, Inc. 20 Section 5 (b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically necessary.

° Plan physicians must provide or arrange your care.
° Be sure to read Section 4, Your costs for covered services for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.

° The 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).

° YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which services require
precertification and identify which surgeries require precertification.

Benefit Descriptions You Pay
Surgical procedures
· Treatment of fractures, including casting $10 per office visit to primary care
· Normal pre-and post-operative care by the surgeon physician, or $15 per office visit
· Correction of amblyopia and strabismus to a specialist
· Endoscopy procedure Nothing as an inpatient visit
· Biopsy procedure
· Removal of tumors and cysts
· Correction of congenital anomalies (see reconstructive surgery)
· Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal

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

· Insertion of internal prosthetic devices, such as pacemakers and 40% of allowable charges artificial joints. See 5( a) Ð Orthopedic braces and prosthetic devices
for device coverage information.

· Voluntary sterilization $10 per office visit to primary care
· Norplant (a surgically implanted contraceptive) when authorized by physician, or $15 per office visit the Plan and primary care physician. to a specialist

· Treatment of burns Nothing as an inpatient
Not covered: All charges.
· Reversal of voluntary sterilization
· Routine treatment of conditions of the foot; see Foot care.

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2001 Coventry Health Care of Iowa, Inc. 21 Section 5 (b)
Reconstructive surgery You Pay
· Surgery to correct a functional defect $10 per office visit to primary care
· Surgery to correct a condition caused by injury or illness if: physician, or $15 per office visit
·· the condition produced a major effect on the member's to a specialist appearance and

·· the condition can reasonably be expected to be corrected by Nothing as an inpatient 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, See above. 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 this procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.

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

through change in bodily form, except repair of accidental injury
· Surgeries related to sex transformation 21
21 Page 22 23
2001 Coventry Health Care of Iowa, Inc. 22 Section 5 (b)
Oral and maxillofacial surgery You Pay
· Surgical treatment of tempromandibular joint (TMJ) syndrome. 20% of allowable charges and all Note: See Section 5( a) for coverage of TMJ appliances. There is a charges above $2,000
combined $2,000 lifetime maximum for the non-surgical and
surgical treatment of TMJ.

Oral surgical procedures, limited to: $10 per office visit to a primary
· Reduction of fractures of the jaws or facial bones; care physician, or $15 per office visit
· Surgical correction of cleft lip, cleft palate or severe functional to a specialist. malocclusion; Nothing as an inpatient

· Removal of stones from salivary ducts;
· Excision of leukoplakia or malignancies;
· Excision of cysts and incision of abscesses when done as independent procedures; and

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

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

Organ/ tissue transplants
Limited to: Nothing as an inpatient
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single ÐDouble
· 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. Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be limited to non-randomized clinical
trials, based on recommendations by the National Cancer Institute.
Transplants are covered when approved by Plan's Medical Director.
Note: Coventry Health Care of Iowa, Inc. utilizes the (URN) for
transplant services. Transplants must be performed in network
facilities. 22
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2001 Coventry Health Care of Iowa, Inc. 23 Section 5 (b)
Organ/ tissue transplants (Continued) You pay
Note: We cover related medical and hospital expenses of the donor Nothing as an inpatient
when we cover the recipient.

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

· Implants of artificial organs
· Transplants not listed as covered

Anesthesia
Professional services provided in Ð Nothing
· Hospital (inpatient)

Professional services provided in Ð Nothing
· Hospital outpatient department
· Skilled nursing facility
· Ambulatory surgical center
· Office 23
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2001 Coventry Health Care of Iowa, Inc. 24 Section 5 (c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).
· YOU MUST GET PRECERTIFICATION OFHOSPITALSTAYS. Please refer to Section 3 to be sure which services require precertification.

Benefit Descriptions You Pay
Inpatient hospital
Room and board, such as Nothing
· ward, semiprivate, or intensive care accommodations;
· general nursing care; and
· meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
· Operating, recovery, maternity, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests and X-rays
· Administration of blood and blood products
· Blood or blood plasma, if not donated or replaced
· Dressings, splints, casts, and sterile tray services
· Medical supplies and equipment, including oxygen
· Anesthetics, including nurse anesthetist services
· Take-home items
· Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year

deductible applies.)

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2001 Coventry Health Care of Iowa, Inc. 25 Section 5 (c)
Inpatient hospital (Continued) You pay
Not covered: All charges.
· Custodial care
· Non-covered facilities, such as nursing homes, extended care facilities, schools

· Personal comfort items, such as telephone, television, barber services, guest meals and beds
· Private nursing care
Outpatient hospital or ambulatory surgical center
· Operating, recovery, and other treatment rooms Nothing
· Prescribed drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services
· Administration of blood, blood plasma, and other biologicals
· Blood and blood plasma, if not donated or replaced
· Pre-surgical testing
· Dressings, casts, and sterile tray services
· Medical supplies, including oxygen
· Anesthetics and anesthesia service
NOTE: Ð We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care/ skilled nursing care benefit: Nothing
We cover a comprehensive range of benefits up to 62 days per calendar
year when full-time skilled nursing is necessary and confinement in a
skilled nursing facility is medically appropriate as determined by a plan
doctor and approved by the plan.

Not covered: custodial care All charges 25
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2001 Coventry Health Care of Iowa, Inc. 26 Section 5 (c)
Hospice care You Pay
Supportive and palliative care for a terminally ill member is covered in the Nothing
home or hospice facility. Services include inpatient and outpatient care and
family counseling; these 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 approximately six months or less.

Not covered: Independent nursing, homemaker services All charges

Ambulance
· Local professional ambulance service when medically appropriate Nothing 26
26 Page 27 28
2001 Coventry Health Care of Iowa, Inc. 27 Section 5 (d)
Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

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

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

(e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room
personnel that you are a Plan member so they can notify the Plan.

You or a family member must notify the primary care doctor as soon as possible and/ or contact the Plan within 48
hours of the emergency room visit. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it is not reasonable possible to notify the Plan within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically
feasible and any ambulance charges are covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan
provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.
The plan pays reasonable charges for emergency services to the extent the services would have been covered if received
from Plan providers. You pay $50 copayment or 50% of the charges, whichever is less, per hospital emergency room
visit or $30 copayment per urgent care center visit for emergency services which are covered benefits of this Plan.
The copayment or coinsurance will be waived if you are admitted as a result of your condition.

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 within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes that 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 the Plan.
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers. You pay $50 copayment or 50% of covered charges, whichever is less, per hospital
emergency room visit for emergency services received at a non-Plan facility or doctor's office or urgent care center.
The copayment or coinsurance will be waived if you are admitted to the hospital as a result of your condition.

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2001 Coventry Health Care of Iowa, Inc. 28 Section 5 (d)
Benefit Descriptions You Pay
Emergency within our service area
· Emergency care at a doctor's office $10 per office visit to a primary care physician; $15 per office visit
to a specialist
· Emergency care at an urgent care center $30 per visit

· Emergency care as an outpatient at a hospital $50 per visit or 50% of allowable charges,
whichever is less

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

Emergency outside our service area
· Emergency care at a doctor's office $50 per visit or 50% of
· Emergency care at an urgent care center allowable charges,
· Emergency care as an outpatient at a hospital whichever is less

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

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

Ambulance
Professional ambulance service when medically appropriate. Nothing
See 5( c) for non-emergency service. 28
28 Page 29 30
2001 Coventry Health Care of Iowa, Inc. 29 Section 5 (e)
Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve
"parity" with other benefits. This means that we will provide mental health and substance
abuse benefits differently than in the past.

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

Here are some important things to keep in mind about these benefits:
· 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.
· YOU MUST GET PREAUTHORIZATION OFTHESE SERVICES. See the instructions after the benefits description below.

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

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

· Professional services, including individual or group therapy by $15 per office visit providers such as psychiatrists, psychologists, or clinical social
workers
· Medication management

· Diagnostic tests $10 per office visit or test by a primacy care physician, or $15
per office visit or test by a
specialist

· Services provided by a hospital or other inpatient facility Nothing
Not covered: Services we have not approved. All charges.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor
of another.

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Your cost sharing
responsibilities are no
greater than for other illness
or conditions. 29
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2001 Coventry Health Care of Iowa, Inc. 30 Section 5 (e)
Mental health and substance abuse benefits (Continued)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

All mental conditions/ substance abuse services are coordinated by American
Psych Systems (APS). To access your mental conditions/ substance abuse
benefits, call APS directly at 1-800-752-7242. A primary care physician
referral is not required.

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.

Limitation We may limit your benefits if you do not follow your treatment plan. 30
30 Page 31 32
2001 Coventry Health Care of Iowa, Inc. 31 Section 5 (f)
Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the chart beginning on the next page.

· All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

There are important features you should be aware of. These include:
· Who can write your prescription. A licensed plan or referral physician must write the prescription.
· Where you can obtain them. You must fill the prescription at a plan pharmacy.

· These are the dispensing limitations. Prescriptions may be obtained from a participating retail pharmacy, and you pay one copayment per 31-day supply. If a brand name drug is dispensed and an equivalent

generic drug is available, you will pay the difference between the two in addition to the copayment.
· When you have to file a claim. Participating pharmacies will file your claim for you.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan $ 5 copayment or 25% of the cost
physician and obtained from a Plan pharmacy: of the drug, whichever is greater,

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

· Insulin Ð one copayment per vial Note: If there is no generic
· Disposable needles and syringes for the administration of covered equivalent available, you will still medications have to pay the brand name copay.

· FDA approved contraceptive drugs and devices
· Maintenance drugs Ð one copayment per 30-day supply
· Smoking cessation drugs, limited to Prostep, Habitrol, and Nicoderm patches. Call us for benefit restrictions and guidelines.

· Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, and acetone test
tablets
· Drugs to treat sexual dysfunction are limited to four tablets per month. $5 copayment per dosage limit and Prior approval is required by the Plan all charges thereafter

· Fertility drugs Ð Note: See Section 5( b) for coverage of Norplant 50% of the cost of the drugs implantation and removal

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2001 Coventry Health Care of Iowa, Inc. 32 Section 5 (f)
Covered medications and supplies (Continued) You Pay
Here are some things to keep in mind about our prescription drug program:
· A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name

brand drug when a Federally-approved generic drug is available, and
your physician has not specified Dispense as Written for the name
brand drug, you have to pay the difference in cost between the name
brand drug and the generic.

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

· Nonprescription medicines 32
32 Page 33 34
2001 Coventry Health Care of Iowa, Inc. 33 Section 5 (g)
Section 5 (g). Special Features
Feature Description
Services for deaf and
hearing impaired 1-877-843-1942 extension 6979

High risk pregnancies Members identified as having high risk pregnancies will be assigned to a nurse within our organization who will work with them to monitor their care.

Centers of excellence
for transplants/ heart
surgery/ etc

Coventry Health Care of Iowa, Inc. does utilize a network of centers of
excellence for transplant care.

Travel benefit/ services Anytime you are outside of the service area, you and your covered
overseas dependents are always covered for true emergency situations. 33
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2001 Coventry Health Care of Iowa, Inc. 34 Section 5 (h)
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Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan dentists must provide or arrange your care.
· The calendar year deductible is: $25 per person. The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to show when the calendar

year deductible does not apply.
· We cover hospitalization for dental procedures only when a non-dental 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.

Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The
need for these services must result from an accidental injury. Before restorative services are rendered for accidental den-tal
benefits, prior authorization is required through your primary care physician and the Plan. You pay 20% of allowable
charges, no deductible.

Dental Benefits
Service You pay

The following preventive and diagnostic dental Nothing after the $25 deductible per person per
services are covered when provided by a participating calendar year
plan dentist.

· Oral examinations
· X-rays
· Pulp vitality tests
· Diagnostic casts
· Prophylaxis (cleaning)

· Fluoride treatments 34
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2001 Coventry Health Care of Iowa, Inc. 35 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.

Discounts on eyeglasses and contacts: Coventry Health Care of Iowa, Inc. members receive a discount on their contacts
or eyeglasses at the following participating optometric locations: J. C. Penney Optical, Sears Optical, Montgomery Ward
Optical, Target, and Pearle Vision.

The Baby Beeper Program: During the last four weeks of pregnancy, Coventry Health Care of Iowa, Inc. members in the
Des Moines area are provided a free baby beeper so that husbands or birthing coaches can be contacted immediately
when labor begins.

Health Club Discount Program: Fitness World West waives the enrollment fee and offers a reduced monthly rate to
Coventry Health Care of Iowa, Inc. members. 35
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2001 Coventry Health Care of Iowa, Inc. 36 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.

We do not cover the following:
· Care by non-Plan 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;
· Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

· Services, drugs, or supplies related to sex transformations; or
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 36
36 Page 37 38
2001 Coventry Health Care of Iowa, Inc. 37 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,
coinsurance, or deductible.

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

Medical 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
800-257-4692.

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

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

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

· Receipts, if you paid for your services.
Submit your claims to: Coventry Health Care of Iowa, Inc.
P. O. Box 7709
London, KY 40742

Prescription drugs In most cases, participating pharmacies will file claims for you. However, if you should need to file a claim for reimbursement (if you have to obtain a
prescription out of the area), receipts should be itemized and show:
· Covered member's name and ID number;
· Name and address of the dispensing pharmacy;
· Date the prescription was obtained; and
· Receipt reflecting that you paid for your prescription.
Submit your claims to: Caremark Inc.
P. O. Box 686005
San Antonio, TX 78268-6005 37
37 Page 38 39
2001 Coventry Health Care of Iowa, Inc. 38 Section 7
Filing a claim for covered services (Continued)
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. 38
38 Page 39 40
2001 Coventry Health Care of Iowa, Inc. 39 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 Ð including a request for pre-authorization:

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: 4600 Westown Parkway, Suite 200 West Des Moines, Iowa 50266-1099; 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: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
requestÑ go to step 3.

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

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

We will write to you with our decision.

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

· 90 days after the date of our letter upholding our initial decision; or
· 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division II,
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. 39
39 Page 40 41
2001 Coventry Health Care of Iowa, Inc. 40 Section 8
The disputed claims process (Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your rep
resentative, such as medical providers, must provide a copy of your specific written consent with the review
request.

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

5 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 pre-authorization/ prior approval, then call us at
800-257-4692 and we will expedite our review; or

(b) We denied your initial request for care or pre-authorization/ 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 II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 40
40 Page 41 42
2001 Coventry Health Care of Iowa, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you are covered or a family member is covered under health coverage 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+ Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with

Medicare, depending on the type of Medicare managed care plan you have.

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

(Primary payer chart begins on next page.) 41
41 Page 42 43
2001 Coventry Health Care of Iowa, Inc. 42 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you --or your covered spouse --are age 65 or over and É Then the primary payer isÉ

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 3
disability),

2) Are an annuitant, 3
3) Are a re-employed annuitant with the Federal government when ............
a) The position is excluded from FEHB, or............................................ 3

b) The position is not excluded from FEHB .......................................... 3
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 3
covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, 3 3
(for Part B (for other
services) services)

6) Are a former Federal employee receiving Workers'Compensation and 3
the Office of Workers'Compensation Programs has determined that (except for claims
you are unable to return to duty, related to Workers'
Compensation.)

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

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, 3

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, 3

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

C. When you or a covered family member have FEHB andÉ

1) Are eligible for Medicare based on disability, and
a) Are an annuitant ................................................................................ 3
b) Are an active employee .................................................................... 3 42
42 Page 43 44
2001 Coventry Health Care of Iowa, Inc. 43 Section 9
Coordinating benefits with other coverage (Continued)
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 Part 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.

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 c a r e
plan is primary, but we will not waive any of our copayments or coinsurance.

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

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

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If
both TRICARE and this Plan cover you, we pay first. See your TRICARE
Health Benefits Advisor if you have questions about TRICARE coverage.

Workers' Compensation We do not cover services that:
· you need because of a workplace-related 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.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State, or Federal
are responsible for your care Government agency directly or indirectly pays for them.

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

exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 43
43 Page 44 45
2001 Coventry Health Care of Iowa, Inc. 44 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 page 11

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care such as help in walking, getting in and out of bed, bathing, dressing, shopping, preparing meals, or performing general household services.

Experimental or Any treatment, procedure, facility, equipment, drug or drug usage, device or
Investigational services supply that is not accepted as standard medical practice by the general medical community or us, or does not have federal government agency,

approval for its use or application.

The Plan's experimental/ investigational determination process is based on
authoritative information obtained from medical literature, medical
consensus bodies, health care standards, database searches, evidence from
national medical organizations, State and Federal government agencies and
research organizations. The review and approval process for medical policies
and clinical practice guidelines includes clinical input from doctors with
specialty expertise in the subject.

Medical necessity A service or supply for prevention, diagnosis or treatment that, as determined by us, is consistent with the illness or injury and is consistent with the
approved, and generally accepted medical or surgical practice.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Providers that participate with us agree to
accept our Plan allowance as payment in full, minus any copayment or
coinsurance.

Us/ We Us and we refer to Coventry Health Care of Iowa, Inc.
You You refers to the enrollee and each covered family member. 44
44 Page 45 46
2001 Coventry Health Care of Iowa, Inc. 45 Section 11
Section 11. FEHB Facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

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

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

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

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 45
45 Page 46 47
2001 Coventry Health Care of Iowa, Inc. 46 Section 11
FEHB Facts (Continued)
When benefits and The benefits in this brochure are effective on January 1. If you are new to this
premiums start 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 We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

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

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

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

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

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

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

Spouse equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's enrollment. But, you may
be eligible for your own FEHB coverage under the spouse equity law. If you
are recently divorced or are anticipating a divorce, contact your ex-spouse's
employing or retirement office to get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other information about your coverage choices.

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. 46
46 Page 47 48
2001 Coventry Health Care of Iowa, Inc. 47 Section 11
FEHB Facts (Continued)
Converting to You may convert to an individual policy if:
individual coverage ·· Your coverage under TCC or the spouse equity law ends. If you

canceled your coverage or did not pay your premium, you cannot
convert;

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

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

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

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

care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the
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 800-257-4692 and explain the situation.

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

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 they try to obtain services for a person who is not an
eligible family member, or are no longer enrolled in the Plan and try to obtain
benefits. Your agency may also take administrative action against you. 47
47 Page 48 49
Department of Defense/
2001 Coventry Health Care of Iowa, Inc. 48 FEHB Demonstration Project

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

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

The demonstration areas · Dover AFB, DE · Commonwealth of Puerto Rico
· Fort Knox, KY · Greensboro/ Winston Salem/ High Point, NC
· Dallas, TX · Humboldt County, CA area
· New Orleans, LA · Naval Hospital, Camp Pendleton, CA
· Adair County, IA area · Coffee County, GA area

When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2000 open season, November 13, 2000, through December 11, 2000. Your
coverage will begin January 1, 2001. DoD has set-up an Information
Processing Center (IPC) in Iowa to provide you with information about how
to enroll. IPC staff will verify your eligibility and provide you with FEHB
Program information, plan brochures, enrollment instructions and forms. The
toll-free phone number for the IPC is 1-877/ DOD-FEHB (1-877/ 363-3342).

You may select coverage for yourself (Self Only) or for you and your family
(Self and Family) during the 2000 and 2001 open seasons. Your coverage
enrolled.

If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your
coverage will begin. 48
48 Page 49 50
Department of Defense/
2001 Coventry Health Care of Iowa, Inc. 49 FEHB Demonstration Project

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

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

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

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project. 49
49 Page 50 51
2001 Coventry Health Care of Iowa, Inc. 50 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

General Exclusions ...................... 40
Hearing services............................ 19
Home health services.................... 21
Hospice care.................................. 29
Home nursing care........................ 21
Hospital ........................................ 27
Immunizations .............................. 15
Infertility........................................ 17
In-hospital physician care ............ 13
Inpatient Hospital Benefits............ 28
Insulin............................................ 35
Laboratory and pathological
services .................................. 14
Magnetic Resonance Imagings
(MRIs).................................... 14
Mammograms................................ 15
Maternity Benefits ........................ 16
Medicaid........................................ 47
Medically necessary...................... 49
Medicare........................................ 45
Mental Conditions/ Substance Abuse
Benefits.................................. 32
Non-FEHB Benefits...................... 39
Obstetrical care ............................ 16
Occupational therapy .................... 19
Office visits .................................. 13
Oral and maxillofacial surgery...... 25
Orthopedic devices........................ 20
Ostomy and catheter supplies ...... 21
Out-of-pocket expenses ................ 11
Outpatient facility care.................. 28
Pap test.......................................... 14
Physical examination .................... 13
Physical therapy............................ 19
Physician ........................................ 8
Preventive care, adult.................... 14

Preventive care, children ............ 15
Prescription drugs.......................... 34
Preventive services........................ 14
Prior approval................................ 10
Prostate cancer screening.............. 14
Prosthetic devices.......................... 20
Psychologist .................................. 32
Psychotherapy .............................. 32
Radiation therapy.......................... 18
Rehabilitation therapies ................ 19
Room and board............................ 27
Second surgical opinion................ 13
Skilled nursing facility care.......... 13
Speech therapy.............................. 19
Sterilization procedures ................ 16
Subrogation .................................. 48
Substance abuse ............................ 32
Surgery.......................................... 23
Anesthesia .................................... 26
Oral................................................ 25
Outpatient...................................... 28
Syringes ........................................ 35
Temporary continuation of
coverage ................................ 51
Transplants .................................... 25
Treatment therapies ...................... 18
Vision services.............................. 19
Well child care.............................. 16
Wheelchairs .................................. 21
Workers'compensation ................ 47
X-rays............................................ 14

Accidental injury .......................... 38
Allergy tests .................................. 17
Alternative treatment.................... 22
Ambulance .................................... 29
Anesthesia .................................... 26
Autologous bone marrow
transplant................................ 25
Biopsies ........................................ 23
Blood and blood plasma................ 28
Breast cancer screening ................ 24
Casts.............................................. 29
Changes for .......................... 2001 7
Chemotherapy .............................. 18
Childbirth ...................................... 16
Cholesterol tests............................ 14
Claims............................................ 41
Coinsurance .................................. 11
Colorectal cancer screening.......... 14
Congenital anomalies.................... 23
Coordination of benefits................ 45
Covered charges............................ 49
Crutches ........................................ 21
Definitions .................................... 49
Dental care .................................... 38
Diagnostic services........................ 13
Disputed claims review ................ 43
Donor expenses (transplants)........ 25
Dressings ...................................... 28
Durable medical equipment
(DME).................................... 21
Effective date of enrollment ........ 50
Emergency .................................... 30
Experimental or investigational.... 49
Eyeglasses .................................... 19
Family planning............................ 16
Fecal occult blood test .................. 14 50
50 Page 51 52
2001 Coventry Health Care of Iowa, Inc. 51 Summary
Summary of benefits for the Coventry Health Care of Iowa, Inc. Plan -2001
· Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;

for more detail, look inside.
· If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

· We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
· Diagnostic and treatment services provided in the office........................ Office visit copay: $10 primary 13 care; $15 specialist

Services provided by a hospital:
· Inpatient.................................................................................................... Nothing 27
· Outpatient.................................................................................................. Nothing 28

Emergency benefits:
· In-area ...................................................................................................... $50 or 50% of charge, whichever 31 is less per emergency room visit;

$30 per urgent care visit

· Out-of-area................................................................................................ $50 or 50% of charge, whichever 31 is less per emergency room visit

Mental health and substance abuse treatment................................................ In-Network: Regular cost sharing 32
Out-of-Network: No benefit

Prescription drugs .......................................................................................... $5 copayment or 25% of the cost 34
of the drug, whichever is greater

Dental Care .................................................................................................... Accidental injury: 20% of 38
allowable charges; Preventive
dental care: $25 dental deductible
per member per year

Vision Care .................................................................................................... One refraction annually. Nothing 19
to an optometrist, $15 copay to an
opthalmologist

Special features: High risk pregnancy program, Centers of Excellence for transplants, Emergency benefits 37
out-of-network

Protection against catastrophic costs ............................................................ Nothing after $750/ Self Only or
(your out-of-pocket maximum) $1,500/ Family enrollment per year

Some costs do not count toward 11
this protection 51
51 Page 52
2001 Rate Information for
Coventry Health Care of Iowa, Inc.

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category,
refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.

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

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

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

The Greater Des Moines, Central Iowa, and Waterloo areas
High Option
Self Only SV1 $62.99 $20.99 $136.47 $45.49 $74.53 $9.45

High Option
Self and Family SV2 $170.09 $56.70 $368.54 $122.84 $201.28 $25.51 52

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