Pages 1--52 from HealthAmerica Pennsylvania, Inc.

HealthAmerica Pennsylvania, Inc.
http:// www. healthamerica. cvty. com
A Health Maintenance Organization

Serving: Greater Pittsburgh Area, Central, South Central & Northeast Pennsylvania
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
Greater Pittsburgh Area 261 Self Only
262 Self and Family
Central, South Central & Northeast Pennsylvania SW1 Self Only
SW2 Self and Family

For changes in benefits,
see page 7.

RI 73-255
This Plan has Commendable accreditation from the NCQA.
See the 2001 Guide for more information on NCQA.

2001 1
1 Page 2 3

2001 HealthAmerica Pennsylvania, Inc. 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….............................................................. 4
Plain Language………………………………………………………………............................................................ 4
Section 1. Facts about this HMO plan..................................................................................................................... 5
How we pay providers ........................................................................................................................... 5
Who provides my health care? ............................................................................................................... 5
Patients' Bill of Rights ........................................................................................................................... 5
Service Area .......................................................................................................................................... 6
Section 2. How we change for 2001………………………………………............................................................... 7
Program-wide changes........................................................................................................................... 7
Changes to this Plan............................................................................................................................... 7
Section 3. How you get care …………................................................................................................................... 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 .............................................................................................................................. 8-9
· Hospital care.................................................................................................................................... 9
Circumstances beyond our control........................................................................................................ 10
Services requiring our prior approval.................................................................................................... 10
Section 4. Your costs for covered services ............................................................................................................ 10
· Copayments................................................................................................................................... 10
· Deductible ..................................................................................................................................... 10
· Coinsurance................................................................................................................................... 10
Your out-of-pocket maximum .............................................................................................................. 10
Section 5. Benefits…………………………………………………………............................................................. 11
Overview............................................................................................................................................. 11
(a) Medical services and supplies provided by physicians and other health care professionals...... 12-19
(b) Surgical and anesthesia services provided by physicians and other health care professionals .. 20-23
(c) Services provided by a hospital or other facility, and ambulance services............................... 24-26
(d) Emergency services/ accidents ............................................................................................... 27-28
(e) Mental health and substance abuse benefits ........................................................................... 29-31
(f) Prescription drug benefits ..................................................................................................... 32-34
(g) Special features ......................................................................................................................... 34
(h) Dental benefits........................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members .......................................................................... 36 2
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2001 HealthAmerica Pennsylvania, Inc. 3 Table of Contents
Section 6. General exclusions --things we don't cover ......................................................................................... 37
Section 7. Filing a claim for covered services....................................................................................................... 38
Section 8. The disputed claims process ........................................................................................................... 39-40
Section 9. Coordinating benefits with other coverage ........................................................................................... 41
· When you have…
·· Other health coverage ................................................................................................................ 41
·· Original Medicare................................................................................................................. 41-43
·· Medicare managed care plan...................................................................................................... 43
· TRICARE/ Workers' Compensation/ Medicaid................................................................................. 44
· Other Government agencies ........................................................................................................... 44
· When others are responsible for injuries ......................................................................................... 44
Section 10. Definitions of terms we use in this brochure....................................................................................... 45
Section 11. FEHB facts ....................................................................................................................................... 46
· Coverage information..................................................................................................................... 46
·· No pre-existing condition limitation ......................................................................................... 46
·· Where you get information about enrolling in the FEHB Program............................................. 46
·· Types of coverage available for you and your family ................................................................ 46
·· When benefits and premiums start............................................................................................ 47
·· Your medical and claims records are confidential ..................................................................... 47
·· When you retire ....................................................................................................................... 47
· When you lose benefits ............................................................................................................. 47-48
·· When FEHB coverage ends...................................................................................................... 47
·· Spouse equity coverage............................................................................................................ 47
·· Temporary Continuation of Coverage (TCC)....................................................................... 47-48
·· Converting to individual coverage............................................................................................ 48
· Getting a Certificate of Group Health Plan Coverage ...................................................................... 48
Inspector General Advisory .............................................................................................................. 48
Index ........................................................................................................................................................ 50
Summary of benefits ............................................................................................................................................ 51
Rates ........................................................................................................................................... Back cover 3
3 Page 4 5

2001 HealthAmerica Pennsylvania, Inc. 4 Introduction/ Plain Language
Introduction
HealthAmerica Pennsylvania, Inc.
2575 Interstate Drive
Harrisburg, PA 17110

This brochure describes the benefits of HealthAmerica Pennsylvania, Inc. under our contract (CS 2078) 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 HealthAmerica
Pennsylvania, 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 HealthAmerica Pennsylvania, 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. Our providers are paid on a capitated basis or a fee for service basis according to negotiated contracts.
We do not participate in any withholds/ bonus or incentive programs.

Who provides my health care?
We are a mixed-model HMO with physicians in individual or group practices. You and each covered family member
must choose a Primary Care Physician (PCP) who specializes in family practice, internal medicine, or pediatrics. Your
PCP will provide or coordinate all of your health care needs.

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.

· We are compliant with federal and state licensing requirements; licensed since 1975.
· We have over 25 Years in existence.
· We are a for-profit HMO.
· We have participated with the FEHB program since 1977.

If you want more information about us, call 1-800-735-4404 for the Greater Pittsburgh region, or 1-800-788-8445 in
Central, South Central and Northeast Pennsylvania, or write to 2575 Interstate Drive, Harrisburg, PA 17110. You may
also contact us by visiting our website at www. healthamerica. cvty. com. 5
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2001 HealthAmerica Pennsylvania, Inc. 6 Section 1
Service Area
You must live in our service area to enroll with us. Our service area is where our providers practice. You must enroll
in the code we have designated for your county.

Enrollment code 26 (Greater Pittsburgh area) includes the following Pennsylvania counties:
· Allegheny
· Armstrong
· Beaver
· Butler
· Cambria
· Fayette
· Greene
· Indiana
· Lawrence
· Mercer
· Somerset · Washington

· Westmoreland
Enrollment code SW (Central, South Central, Northeast Pennsylvania) includes the following Pennsylvania counties:
· Adams
· Berks
· Blair
· Centre
· Clinton
· Columbia · Cumberland

· Dauphin
· Huntingdon
· Juniata
· Lancaster
· Lebanon
· Luzerne
· Lycoming
· Mifflin
· Northumberland · Perry

· Schuylkill
· Snyder
· Union
· York 6
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2001 HealthAmerica Pennsylvania, 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 higher patient
cost sharing 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 1-800-735-4404 in Greater Pittsburgh; or1-800-788-8445
in Central, South Central, and Northeast Pennsylvania or checking our website www. healthamerica. 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 all the medicines you take.
·· Make sure you get the results of any test or procedure.
·· Talk with your doctor and health care team about your options if you need hospital care.
·· Make sure you understand what will happen if you need surgery.

· We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the

language referenced only women.

Changes to this Plan
· If you are in Enrollment Code 26, your share of the non-postal premium will increase by 6.1% for Self Only or 6.1% for Self and Family. If you are in enrollment code SW, your share of the non-postal premium will increase
by 5% for Self Only or decrease by 7.6% for Self and Family.
· The office visit copay has changed from $10 to $15 for all specialty care visits.
· Your copays have increased under the Prescription Drug Benefits. You now pay $8 for Generic Formulary drugs, $14 for Name Brand Formulary drugs, or $35 for Non-formulary drugs from Plan retail pharmacies. See page 32.

· You may obtain up to a 90-day supply of maintenance medication by Mail order after you pay a $16 copay for Generic Formulary drugs, $28 copay for Name Brand Formulary drugs or a $70 copay for Non-formulary drugs.
· Your Emergency Room copay has increased from $25 to $35 for each emergency room visit or urgent care visit. 7
7 Page 8 9
2001 HealthAmerica Pennsylvania, 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 fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 1-800-735-
4404 in Greater Pittsburgh; or 1-800-788-8445 in Central, South
Central, and Northeast Pennsylvania.

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

· Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

What you must do It depends on the type of care you need. First, you and each family member 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 can complete a PCP Selection Card and
mail it or you can call us.

· 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 coordinate your care 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 If you need to see a specialist, your PCP will coordinate this care. Your PCP has relationships with specialists, hospitals and other medical
providers. Each visit to a specialist must be arranged by your PCP. Your
PCP may be able to provide you with needed follow up care after your
specialist visit. Your primary care physician will refer you to a specialist
for needed care.

Here are other things you should know about specialty care:
· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary 8
8 Page 9 10
2001 HealthAmerica Pennsylvania, Inc. 9 Section 3
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval
beforehand).

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

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

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

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

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

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

· Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise 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 1-800-735-4404 for the
Greater Pittsburgh region, or 1-800-788-8445 in Central, South Central
and Northeast Pennsylvania. 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
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2001 HealthAmerica Pennsylvania, Inc. 10 Section 3/ Section 4
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain medical procedures, tests or when sending you to a hospital

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.

The following are health care services which require precertification:
· inpatient hospital admissions, · outpatient surgeries,
· home health care,
· durable medical equipment,
· out of network referral requests,
· transplant requests,
· complex diagnostic testing such as Magnetic Resonance Imaging,
· chiropractic care,
· rehabilitative service,
· infertility treatment and
· oral surgery.

You must contact Mainstay/ Magellan before seeking mental health and
substance abuse treatment. Mainstay/ Magellan will help develop a
treatment plan that you must follow. We will not cover services that the
have not approved.

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 and when you see a specialist you pay a
$15 copay per office visit.

· Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before benefits are paid. We do not have a
deductible.
· Coinsurance Coinsurance is the percentage of negotiated fee that you pay for your care. In our plan, you pay a $300 copay or 50% of the cost, whichever is
less, for infertility services.

Your out-of-pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments and coinsurance required for some
benefits. 10
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2001 HealthAmerica Pennsylvania, Inc. 11 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this year and page 51 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 1-800-735-4404 for the Greater Pittsburgh region, or 1-800-788-8445 in Central, South Central and Northeast
Pennsylvania or at our website at www. healthamerica. cvty. com.

(a) Medical services and supplies provided by physicians and other health care professionals ........................ 12-19

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

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals...................... 20-23
· Surgical procedures
· Reconstructive surgery
· Oral and maxillofacial surgery
· Organ/ tissue transplants
· Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .................................................. 24-26
· Inpatient hospital
· Outpatient hospital or ambulatory surgical center
· Extended care benefits/ skilled nursing care facility benefits

· Hospice care
· Ambulance

(d) Emergency services/ accidents............................................................................................................ 27-28
· Medical emergency · Ambulance

(e) Mental health and substance abuse benefits........................................................................................ 29-31
(f) Prescription drug benefits ......................................................................................................................... 32-34
(g) Special features ............................................................................................................................................. 34
· High-risk pregnancy, Centers of Excellence, Member Services TDD, Case Management

(h) Dental benefits .............................................................................................................................................. 35
(i) Non-FEHB benefits available to Plan members.............................................................................................. 36

Summary of benefits ............................................................................................................................................ 51 11
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2001 HealthAmerica Pennsylvania, Inc. 12 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

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

· Plan physicians must provide or arrange your care.
· We do not have a calendar year deductible.
· Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

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

$10 per office visit to your Primary
Care Physician

$15 per office visit to a specialist

Professional services of physicians
· During a hospital stay
· In a skilled nursing facility
· Initial examination of a newborn child covered under a family enrollment

Nothing

Professional services of physicians after posted office hours $20 per office visit to your Primary
Care Physician

$30 per office visit to a Specialist

At home $10 per visit by Primary Care
Physician

$15 per visit by Specialist 12
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2001 HealthAmerica Pennsylvania, Inc. 13 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap tests
· Pathology
· X-rays
· Non-routine Mammograms
· Cat Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG

Nothing if you receive these
services during your office visit;
otherwise,

$10 per office visit to your Primary
Care Physician or

$15 per office visit to a Specialist

Preventive care, adult
Routine screenings, such as: Blood lead level – One annually
· Total Blood Cholesterol – once every three years, ages 19 through 64
· Colorectal Cancer Screening, including
·· Fecal occult blood test

Nothing if you receive these
services during your office visit;
otherwise,

$10 per office visit to your Primary
Care Physician or

$15 per office visit to a Specialist

·· Sigmoidoscopy, screening – every five years starting at age 50 Nothing
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

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

· From age 35 through 39, one during this five year period
· One per calendar year age 40 and above

Nothing

Not covered: Physical exams, immunizations or other services required
for obtaining or continuing employment or insurance, attending schools
camp, travel, driver's license, marriage license or obtain a passport.

All charges

Routine Immunizations, such as:
· Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

· Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist 13
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2001 HealthAmerica Pennsylvania, Inc. 14 Section 5( a)
Preventive care, children You pay
· Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist
· Examinations, such as:
·· Eye exams through age 17 to determine the need for vision correction to diagnose and treat diseases of the eye.

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

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

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

$10 per office visit to your primary care
physician or

$15 per office visit to a specialist
Note: You pay the office visit
copay for your first visit only. We
waive the office visit copay after
your initial maternity care visit.

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

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

Not covered: reversal of voluntary surgical sterilization All charges. 14
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2001 HealthAmerica Pennsylvania, Inc. 15 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
· Artificial insemination:
·· intravaginal insemination (IVI)
·· intracervical insemination (ICI)
·· intrauterine insemination (IUI)

$300 copay or 50% of the cost of
the service, whichever is less

Not covered:
· Fertility drugs
· Assisted reproductive technology (ART) procedures, such as:
·· in vitro fertilization
·· embryo transfer, GIFT, ZIFT and ovum harvest
· Services and supplies related to excluded ART procedures
· Cost of donor sperm

All charges.

Allergy care
Testing and treatment
Allergy injection
$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

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

Treatment therapies
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.

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

· Growth hormone therapy (GHT)
Note: We will only cover GHT when we preauthorize the treatment and
determine that it is medically necessary. Your doctor will need to
submit medical information to support that GHT is medically necessary.
You must obtain authorization for GHT before you begin treatment
because we only cover GHT services from the date we determine it is
medically necessary We do not cover GHT or related services and
supplies if we determine it isn't medially necessary. See Services
requiring our prior approval in Section 3.

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist 15
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2001 HealthAmerica Pennsylvania, Inc. 16 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy —
· Up to two consecutive months per condition, per contract year for the services of each of the following:

·· qualified physical therapists;
·· speech therapists; and
·· occupational therapists.
Note: We only cover therapy to restore bodily function or speech
when there has been a total or partial loss of bodily function or
functional speech due to illness or injury and if significant
improvement can be expected within two consecutive months.

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

consecutive months per condition, per contract year.

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

Not covered:
· long-term rehabilitative therapy or beyond two consecutive months per condition

· exercise programs
· Physical, occupational and speech therapy for developmental delay

All charges.

Hearing services (testing, treatment, and supplies)
· Hearing testing $10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist
Not covered:
· all other hearing testing
· hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment, and supplies)
· One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
Nothing

· Annual eye refractions
Note: You must contact National Vision Administrators (NVA) prior to
your exam. NVA will send you a list of participating eye doctors and a
vision claim form. Call NVA at 800-672-7723.

$15 per office visit

Not covered:
· Eyeglasses or contact lenses
· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery

All charges 16
16 Page 17 18
2001 HealthAmerica Pennsylvania, Inc. 17 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

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

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

Not covered:
· Cutting, trimming or removal of corns, calluses, or the free edge of toenails, reduction of warts, removal of toenails (except medically

necessary surgery for ingrown toenails) and similar routine
treatment of conditions of the foot, except as stated above

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

treatment is by open cutting surgery)

All charges

Orthopedic and prosthetic devices
· Artificial limbs and eyes;
· Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

· Internal prosthetic devices, such as artificial joints, limbs, pacemakers, and surgically implanted breast implant following
mastectomy, when authorized in accordance with the plan's policies
and procedures. Note: See 5( b) for coverage of the surgery to insert
the device.

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

TMJ is caused by acute traumatic dislocation, fractures, neoplasms,
rheumatoid arthritis, ankylosing spondylitis, or disseminated lupus
erythematosus.

Note: You must receive our preauthorization. Call us at 800/ 735-4404
for the Greater Pittsburgh region or 800/ 788-8445 in South Central,
Central and Northeast Pennsylvania as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

Not covered:
· orthopedic and corrective shoes
· arch supports
· foot orthotics (except for diabetics)
· heel pads and heel cups
· corsets, trusses, elastic stockings, support hose, and other supportive devices

· Cochlear implant devices
· Replacement due to neglect
· Any dental care involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome or joint disorders.

· Dental prosthesis
· Lumbar Supports
· Wigs

All charges 17
17 Page 18 19
2001 HealthAmerica Pennsylvania, Inc. 18 Section 5( a)
Durable medical equipment (DME) You pay
· Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician,
such as oxygen and dialysis equipment. Under this benefit, we also
cover: hospital beds;

· wheelchairs; base model necessary to cover the needs of the member

· crutches;
· walkers;
· Diabetes equipment such as blood glucose monitors, insulin infusion devices, and orthotics

Note: You must receive our preauthorization. Call us at 800/ 735-4404
for the Greater Pittsburgh region or 800/ 788-8445 in South Central,
Central and Northeast Pennsylvania as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Nothing

Not covered:
· Disposable items such as incontinent pads, catheters, irrigation kits, electrodes, ace bandages, elastic stockings and dressings

· Air conditioners
· Humidifiers
· Electric air cleaners
· Exercise or fitness equipment
· Elevators
· Hot tubs
· Hoyer lifts
· Shower/ bath bench
· Routine servicing, e. g., testing, cleaning, regulating and checking of equipment.

· Special clothing of any type
· Hearing devices of any type
· Replacement due to neglect.

All charges 18
18 Page 19 20
2001 HealthAmerica Pennsylvania, Inc. 19 Section 5( a)
Home health services You pay
· Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide. In order for us to
cover home health care you must receive preauthorization.

· Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
· 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.
· Homemaker services
· Services or supplies furnished by a person who is the spouse or relative of member or by non home health provider

All charges.

Alternative treatments
Chiropractic Services – 15 visits per member per calendar year. $15 per office visit
Not covered:
· naturopathic services
· acupuncture
· hypnotherapy
· biofeedback

All charges.

Educational classes and programs
Outpatient diabetes self-management training and education (including
nutritional therapy) for persons with diabetes, when prescribed by a
Plan Physician. Coverage includes:

· visits medically necessary upon the diagnosis of diabetes;
· visits where a Plan physician identifies and diagnoses a significant change in the patient's symptoms or conditions that necessitates

changes in a patient's self-management; and
· visits where a licensed physician identifies that a new medication or therapeutic process relating to the person's treatment or diabetes

management is medically necessary.

$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist 19
19 Page 20 21
2001 HealthAmerica Pennsylvania, Inc. 20 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

I M
P O
R T
A N
T

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

· Plan physicians must provide or arrange your care.
· We do not have a calendar year deductible.
· Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including

with Medicare.
· The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital,

surgical center, etc.).
· Your Plan physician must get precertification of some surgical procedures. Please refer to the preauthorization information in Section 3 for a list of services.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
· Treatment of fractures, including casting
· Normal pre-and post-operative care by the surgeon
· Correction of amblyopia and strabismus
· Endoscopy procedure
· Biopsy procedure
· Removal of tumors and cysts
· Correction of congenital anomalies (see reconstructive surgery)
· Surgical treatment of morbid obesity – 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 or Body Mass Index (BMI) is
greater than 40.

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

Nothing

Surgical procedures continued on next page. 20
20 Page 21 22
2001 HealthAmerica Pennsylvania, Inc. 21 Section 5( b)
Surgical procedures (continued) You pay
· Voluntary sterilization such as tubal ligation and vasectomy $50 copay for vasectomy
$100 for tubal ligation

· Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are covered under 5( a).

· Treatment of burns
$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist

Not covered:
· Reversal of voluntary sterilization, surgically– induced sterility
· Routine treatment of conditions of the foot; see Foot care.
· Cosmetic procedures

All charges

Reconstructive surgery
Surgery to correct a functional defect
· Surgery to correct a condition caused by injury or illness if:
·· the condition produced a major effect on the member's appearance and

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

Nothing

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

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

See above.

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

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

All charges 21
21 Page 22 23
2001 HealthAmerica Pennsylvania, Inc. 22 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
· Reduction of fractures of the jaws or facial bones;
· Surgical correction of cleft lip, cleft palate.
· Excision of lesions of the mandible, mouth, lip, or tongue
· Incision of accessory sinuses, mouth, salivary glands or duct;
· Manipulation of dislocations of the jaw
· Reconstruction or repair of the mouth or lips necessary to correct functional impairment caused by congenital condition and birth

abnormalities;
· Treatment of malignant tumors
· Extractions of impacted third molars when partially or totally covered by bone.

· 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.

Nothing

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

· Orthodontia
· Treatment of TMJ if dental related
· Orthognathic or prognathic surgery when it is performed only to improve the appearance of a functioning structure.

All charges 22
22 Page 23 24
2001 HealthAmerica Pennsylvania, Inc. 23 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single– Double
· Pancreas
· Allogeneic (donor) bone marrow transplants
· Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

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

Note: Transplant services must be provided at a participating Center of
Excellence as we determine. All transplants must be performed at
specific hospitals that we approve and designate to perform the specific
transplant procedure.

Note: We cover related medical and hospital expenses of the donor
when the expenses are not covered by the donor's insurance and when
the transplant recipient is a HealthAmerica member approved for
transplant services.

Nothing

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

· Donor expenses related to donating organs or tissue to a non-member recipient
· Implants of artificial organs

All charge

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

Nothing

Professional services provided in –
· Office
$10 per office visit to your Primary
Care Physician

$15 per office visit to a Specialist 23
23 Page 24 25
2001 HealthAmerica Pennsylvania, Inc. 24 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

I M
P O
R T
A N
T

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

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

· We do not have a calendar year deductible.
· Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
· YOUR PLAN PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services

require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
· ward, semiprivate, or intensive care accommodations;
· general nursing care; and
· meals and special diets.
NOTE: We will cover a private room provided when it is medically
necessary. If you want a private room when it is not medically
necessary, you pay the additional charge above the semiprivate room
rate.

Nothing

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

deductible applies.)

Nothing

Inpatient hospital continued on next page. 24
24 Page 25 26
2001 HealthAmerica Pennsylvania, Inc. 25 Section 5( c)
Inpatient hospital (continued) You pay
Not covered:
· 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

All charges

Outpatient hospital or ambulatory surgical center
· Operating, recovery, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services
· Administration of blood, blood plasma
· Blood and blood plasma, if not donated or replaced
· Packed red blood cells, cryoprecipite, Factor VII, and platelets;
· Other clotting factors or blood components such as Factor VIII or Factor IX, whether naturally or artificially derived are covered for

acute traumatic events or Medically Necessary.
· Pre-surgical testing
· Dressings, casts, and sterile tray services
· Medical supplies, including oxygen
· Anesthetics and anesthesia service
Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedure itself.

Nothing

Not covered:
· blood and blood derivatives replaced by the member All charges

Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF) or Extended care benefits:
Up to 100 days per calendar year when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by us. Services
include:

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

doctor

Nothing

Not covered: custodial care, rest cures, domiciliary or convalescent
care
All charges 25
25 Page 26 27
2001 HealthAmerica Pennsylvania, Inc. 26 Section 5( c)
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered in
the home or a hospice facility. Services include inpatient and outpatient
care, and family counseling. Hospice services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when medically appropriate Nothing 26
26 Page 27 28
2001 HealthAmerica Pennsylvania, Inc. 27 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

· We do not have a calendar year deductible
· Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

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

What to do in case of emergency within or outside our service area:
If you experience the sudden onset of a medical condition or injury with symptoms that you think may
result in serious impairment, please go to the nearest emergency room or call 911. Otherwise if your
symptoms allow , call your Primary Care Physician. Your primary care physician is available to advise
you about an urgent or emergency situation 24 hours a day, seven days a week by phone. Your PCP's
phone number is on your ID card. Be sure to call your Primary Care Physician before going to a hospital
emergency room or urgent care center whenever possible. If it is not possible, go straight to the nearest
hospital emergency room or call 911 or the local emergency phone number. Be sure to tell the emergency
room personnel that you are a HealthAmerica Plan member. Please be sure that you contact your PCP
within 24 hours of being treated or admitted. Your PCP will make sure that:

· Medical information about you is given to the hospital emergency room doctor;
· Your care continues without delay; and
· Your follow-up care is coordinated.
If you are outside the service area and a Plan doctor believes that your 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 or provided by Plan providers. 27
27 Page 28 29
2001 HealthAmerica Pennsylvania, Inc. 28 Section 5( d)
Benefit Description You pay
Emergency within our service area
· Emergency care at a doctor's office $10 per office visit during posted office hours or
$20 after posted office
hours

· Emergency care at a Specialist office $15 during posted office hours or
$30 copay after posted
hours

· Hospital emergency room or urgent care center treatment $35 copay per visit
Not covered: Elective care or non-emergency care All charges

Emergency outside our service area
· Emergency care at a doctor's office $10 per office visit during posted office hours or
$20 after posted office
hours

· Emergency care at a specialist's office $15 during posted office hours or
$30 after posted hours
· Hospital emergency room or urgent care center treatment $35 copay per visit
Not covered:
· Elective care or non-emergency care
· Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance
See 5( c) for non-emergency service.

Nothing 28
28 Page 29 30
2001 HealthAmerica Pennsylvania, Inc. 29 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve
"parity" with other benefits. This means that we will provide mental health and substance abuse
benefits differently than in the past.

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

Here are some important things to keep in mind about these benefits:
· All benefits are subject to the definitions, limitations, and exclusions in this brochure.
· We do not have a calendar year deductible.
· Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.
· YOU CAN COORDINATE YOUR CARE THROUGH YOUR PRIMARY CARE PHYSICIAN OR DIRECTLY THROUGH MAINSTAY/ MAGELLAN. See the
instructions after the benefits description below.

I M
P O
R T
A N
T

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

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

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

· Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social
workers
· Medication management
Note: Psychiatrists, Psychologists, or clinical social workers are
specialty providers. The office visit copay for specialists applies to
services from these providers.

$10 per office visit to your
Primary Care Physician

$15 per office visit to a
Specialist

Nothing for inpatient services

Mental health and substance abuse benefits continued on next page. 29
29 Page 30 31
2001 HealthAmerica Pennsylvania, Inc. 30 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
· Diagnostic tests $10 per office visit to your Primary Care Physician
$15 per office visit to a
Specialist

Nothing for inpatient services

· Services provided by a hospital or other facility
· Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day

hospitalization, facility based intensive outpatient treatment

$10 per office visit to your
Primary Care Physician

$15 per office visit to a
Specialist

Nothing for inpatient services

Not covered:
· Services we have not approved.
· Evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and

appropriate.
· Testing for learning disabilities, school related issues, or for the purposes of obtaining or maintaining employment.

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

All charges

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes.
We have a comprehensive network of professionals and facilities available
for mental health and chemical dependency treatment. Please refer to the
list of providers in the Mental Health/ Chemical Dependency section of your
Provider Directory. If you need a directory or assistance with finding a
provider call Western Pennsylvania (800)-735-4404 or Eastern
Pennsylvania (800)-788-8445 or (717) 540-6315.

Mainstay/ Magellan Behavior Health coordinates your Mental Health and
Substance Abuse services. If you need help, call your Primary Care
Physician. Your doctor will coordinate your referral through Mainstay/
Magellan. You may also call Mainstay/ Magellan directly without referral
from your primary care physician.

Mainstay/ Magellan is available to you 24 hours a day. Their normal
business hours are from 8: 30 am to 4: 00 pm. You can reach
Mainstay/ Magellan at (800)-669-7452 in Western Pennsylvania and
(800)-332-1024 in Eastern Pennsylvania. 30
30 Page 31 32
2001 HealthAmerica Pennsylvania, Inc. 31 Section 5( e)
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
condition:

· 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. 31
31 Page 32 33

2001 HealthAmerica Pennsylvania, Inc. 32 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the chart beginning on the next page.

· We do not have a calendar year deductible.
· 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.

I M
P O
R T
A N
T

There are important features you should be aware of. These include:
· Who can write your prescription. A licensed physician or referral plan doctor must write the prescription.

· Where you can obtain them. You may fill the prescription at a Plan participating pharmacy or by mail for a maintenance medication. Our Plan pharmacies are listed in our directory.
· We use a formulary. It is a list of approved medications. Our Prescription Drug Formulary is a list of drugs and other items that we approve for your use and which will be dispensed through
Participating pharmacies to members. We periodically review and modify our formulary. The list of
approved drugs is available for review in the participating physician's office. You may also obtain
them formulary list by contacting the Plan's Member Services Department or our web site at
www. healthamerica. cvty. com.

· These are the dispensing limitations. You may obtain up to a 31-day supply or 100-unit supply; whichever is less, at a Plan Participating retail pharmacy. For commercially prepackaged drugs such as

topicals, inhalers, and vials, you will pay one copay for each container. Selected products or prescription
drugs may require prior approval from the Plan. Sexual dysfunction drugs have pill limitations. When
generic substitution is permissible, but you or your doctor request the name brand drug, you pay the
price difference between the generic drug and name brand drug as well as the appropriate copay per
prescription unit or refill. Your prescription drug copay will never exceed the retail price of the drug.

· · Prescriptions by Mail-Order. You can order up to a 3-month supply of approved maintenance medications through the mail and pay just two times the retail pharmacy copay. For commercially

prepackaged drugs such as topicals, inhalers, and vials, you will pay one mail order copay for each three
(3) containers. Maintenance medications are those that you must take for long-term conditions.
(Examples of such conditions are high blood pressure or an estrogen hormone imbalance. Simply ask
your doctor to write your maintenance medication prescription for up to a 90-day supply. You will need
to complete a mail order envelope (which you can obtain from Member Services) and mail it to the
address on the front of the envelope. Unfortunately, all maintenance medications are not available by
mail-order. If you have questions, please contact us at 800/ 735-4404 for the Greater Pittsburgh region or
800/ 788-8445 in South Central, Central and Northeast Pennsylvania.

Prescription drug benefits begin on the next page. 32
32 Page 33 34
2001 HealthAmerica Pennsylvania, Inc. 33 Section 5( f)
Benefit Description You Pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

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

· Full range of FDA approved birth control, including but not limited to oral contraceptives, Depo Provera, and contraceptive diaphragms
· Insulin with a charge and copay for each vial
· Plan approved diabetic supplies and pharmacological agents, or devices used to assist in insulin injection (injection aids) including

insulin syringes and needles, blood glucose test strips and lancets
· Selected injectables as specified by the Plan (Imitrex, Glucagon and Bee Sting Kits)

· Disposable needles and syringes for the administration of covered medications
· Contraceptive drugs and devices
· Norplant
· Potassium Supplement to prevent/ treat low potassium (prescription only)

Note: Please check section 5( a) when checking coverage for intravenous
fluids and medications for home use, some injectable drugs, diabetic
equipment (glucose monitor) and some FDA approved contraceptive
devices.

At a Plan Retail Pharmacy:
$8 copay for generic formulary,
$14 copay for name brand
formulary,

$35 copay non-formulary

or
Through our Mail Order Pharmacy:
$16 copay for generic,
$28 copay brand,
$70 copay for non-formulary
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.

Note: For commercial containers
thru mail order, you pay the
appropriate copay for each (3)
containers.

· Sexual dysfunction drugs have dispensing limitations and require prior approval. For complete details, please call Member Services using the
phone number shown on your ID card.
Note: These drugs are not available by mail-order.

At a Plan Retail Pharmacy:
$8 copay for generic formulary,

$14 copay for name brand
formulary,

$35 copay non-formulary

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 FDA-approved generic drug is available, and you or
your physician request the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.

· We have an open formulary. If your physician believes a non-formulary product is necessary, your physician may prescribe it. You

must pay the non-formulary copay.

Covered medications and supplies continued on next page. 33
33 Page 34 35
2001 HealthAmerica Pennsylvania, Inc. 34 Section 5( g)
Covered medications and supplies (continued) You pay
Not covered:
· Drugs and supplies for cosmetic purposes
· Vitamins, and minerals (both OTC and legend), except legend prenatal vitamins and liquid or chewable legend pediatric vitamins.

· Supplies such as dressings and antiseptics
· Drugs to enhance athletic performance
· Drugs to aid in smoking cessation
· Drugs used for the primary purpose of treating infertility, including those given in connection with artificial insemination

· Oral dental preparations and fluoride rinses
· Drug therapy for weight loss (e. g. Xenical)
· Nonprescription medicines
· Drugs obtained at non-par pharmacies except for out of area emergency

All Charges

Section 5 (g). Special Features
Feature Description
Member Services TDD for deaf and hearing

impaired

Telecommunications Device for the Deaf and hearing impaired
members who have access to a TDD-Compatible telephone. Members
call 800-207-1262 from 7 am –6 pm Monday-Friday or from 9 am-
1 pm on Saturday

Complex Case Management Complex Case Management programs promote quality of care to reduce the likelihood of extended, more costly health care. Our
specially trained nurse case managers work directly with the patients
and their doctors. Some of the programs include Cardiovascular,
Endocrinology, Oncology, Trauma/ Medical-Surgical.

High risk pregnancies This program is set up to identify women at risk for developing complications that may affect their pregnancy. The program promotes
quality of care to reduce the likelihood of extended, more costly health
care and focus on patients at risk, early intervention, coordination of
care between patient and health care team, continuing education and
regular follow up to ensure the patient is following the plan of care
properly. For more information call 800-735-4404 in Western PA and
800-788-8445 in Eastern PA.

Centers of excellence for transplants/ heart
surgery/ etc

HealthAmerica has a nationally recognized organ transplant network
(referred to a s Centers of Excellence) to coordinate care for members
who may need a transplant. The network provides you and your family
with access to the hospitals across the country, which specialize in
specific transplant procedures. For information and access of, these
Centers of Excellence call Member Services. Care provided outside the
Centers of Excellence network will not be covered. 34
34 Page 35 36
2001 HealthAmerica Pennsylvania, Inc. 35 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

· Plan dentists must provide or arrange your care.
· We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not

cover the dental procedure unless it is described below.
· Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury. Covered services must be rendered
within 24 hours of the accident.

Note: We do not cover services rendered more than 24 hours after the
accidental injury whether or not the treatment is a continuation or
completion of a treatment plan initiated at time of injury.

Nothing

Not covered:
· Services provided after the initial 24 hours post
· Orthodontia and all other dental related services
· Services provided by non-participating dentists

Other dental services shown as not covered.

All charges 35
35 Page 36 37

2001 HealthAmerica Pennsylvania, Inc. 37 Section 6
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.

HealthAmerica Dental Plan –
HealthAmerica has partnered with Dominion Dental Services, Inc. to provide HealthAmerica Federal Government
members with discounted dental services. You Pay a $10 office visit copay for cleanings and exams and you receive
discounts on other dental procedures. To receive these benefits you must use a participating dentist.

This dental benefit is an optional dental benefit and is available at no additional premium when you choose
HealthAmerica's HMO medical option. To apply for federal HealthAmerica dental coverage, you must be enrolled in
the HealthAmerica HMO medical option and you must complete a dental enrollment form.
If you have any questions or need additional information simply call Dominion Dental Services at (888)-518-5338. Or
you can access their web site at www. DominionDental. com/ ha.

Other Benefits and Services:
Vision Coverage -All HealthAmerica members automatically qualify for a "20/ 20" vision benefit, which provides a 20% discount off the normal retail price for lenses, frames and contact lenses at Plan participating vision providers.

Health Education Classes -Classes include Weight Management, Diabetic Education, Prenatal Education, Stress Management and Smoking Cessation.
Health Club Discounts -HealthAmerica members are eligible for discounted initiation fees and discounted monthly membership fees at Plan participating health clubs.
American Specialties Health Network (ASHN)-A discount program offering complimentary and alternative care for members to broaden their health care options. Some services include massage therapy, acupuncture, nutritional
supplements and vitamins and discounts on health club memberships.
To obtain an approved listing of programs available or request a provider directory or call our customer service
department at 800/ 735-4404 for the Greater Pittsburgh region or 800/ 788-8445 in South Central, Central and
Northeast Pennsylvania. Or you can receive additional information regarding any of our programs by accessing the
HealthAmerica web site at www. healthamerica. cvty. com.

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 36
36 Page 37 38
2001 HealthAmerica Pennsylvania, Inc. 37 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. 37
37 Page 38 39
2001 HealthAmerica Pennsylvania, Inc. 38 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 1-800-735-4404 for the greater Pittsburgh region or
1-800-788-8445 in South Central, Central and Northeast Pennsylvania.

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: Harrisburg HealthAmerica Attn: Member Services Department
2575 Interstate Drive
Harrisburg PA 17110-9339

Pittsburgh-HealthAmerica Attn: Member Services Department

Cranberry Business Park
120 East Kensinger
Cranberry Township PA 16066

Prescription drugs Submit your claims to: Must complete a claim reimbursement form. Contact the plan in the Harrisburg Area at (717)-540-4260 or 800-788-8445

or in the Pittsburgh Area at (412)-553-7300 or 800-735-4404.

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 HealthAmerica Pennsylvania, 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 – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: South Central, Central, Northeast Region; HealthAmerica, Attn: Member
Services Department, 2575 Interstate Drive, Harrisburg PA 17110-9339 or Greater Pittsburgh Region-HealthAmerica,
Attn: Member Services Department, Cranberry Business Park, 120 East Kensinger,
Cranberry Township PA 16066 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
request— go to step 3.

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
· 90 days after the date of our letter upholding our initial decision; or
· 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division,
P. O. Box 436, Washington, D. C. 20044-0436. 39
39 Page 40 41
2001 HealthAmerica Pennsylvania, Inc. 40 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
· A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

· Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
· Copies of all letters you sent to us about the claim;
· Copies of all letters we sent to you about the claim; and
· Your daytime phone number and the best time to call.

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

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must 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 preauthorization/ prior approval, then call us at
800/ 735-4404 for the Greater Pittsburgh region; or 800/ 788-8445 in South Central, Central and Northeast
Pennsylvania. and we will expedite our review; or

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

·· You can call OPM's Health Benefits Contracts Division xx at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 40
40 Page 41 42
2001 HealthAmerica Pennsylvania, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

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

When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit, whichever is less. 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. Tell us if
you are enrolled in Medicare Part A or B. Medicare will determine who
is responsible for paying first for medical services. If Medicare pays first,
we coordinate our payment for covered services. Under your FEHB
coverage, we do not waive any of the copayments.

(Primary payer chart begins on next page.) 41
41 Page 42 43
2001 HealthAmerica Pennsylvania, 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
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability), ü

2) Are an annuitant, ü
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or ü

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

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

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

ü
(for other
services)

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

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

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

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

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

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

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

b) Are an active employee ü 42
42 Page 43 44

2001 HealthAmerica Pennsylvania, Inc. 43 Section 9
Claims process – You should not have to file a claim form when you have both our Plan and Medicare as long as you use our providers. In
some cases, you may need to file a claim form when you have both our
Plan and Medicare.

· When we are the primary payer, we process the claim first.
· When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. It is
possible that you will have to provide us with the Explanation of
Medicare Benefits. To find out if you need to do something about
filing your claims, call us at 1-800-735-4404 in the Greater Pittsburgh
region or at 1-800-788-8445 in South Central, Central and Northeast
Pennsylvania.

We do not waive your FEHB copays or coinsurance when you have Medicare.

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

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

Suspended FEHB coverage and a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium.) (OPM does not contribute to your Medicare managed
care 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 Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare. 43
43 Page 44 45
2001 HealthAmerica Pennsylvania, Inc. 44 Section 9
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. You must use our providers

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

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 44
44 Page 45 46
2001 HealthAmerica Pennsylvania, Inc. 45 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 10.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 10.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided by non-medical personnel that does not attempt to cure your condition but will help you perform daily living activities. Some
examples of custodial care include helping you walk, dress, bathe, eat or
take your medication.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 10.

Experimental or We gather appropriate information to determine whether a procedure, Investigational service, or supply is experimental or investigational. The gathered
information includes all appropriate medical records, reviews of current
medical and scientific evidence publications, as well as information from
government regulatory bodies. Appropriate medical professionals
participate in the extensive evaluation process to determine whether a
procedure is/ is not considered experimental or investigational. After the
determination is made, you will be notified of our decision. You can
obtain a copy of our Experimental Procedures Determinations Policy by
contacting HealthAmerica's Member Services Department.

Group Health Coverage Group Health Coverage is protection that provides payment of benefits for covered sickness or injury.

Medical Necessity A service or treatment which is appropriate and consistent with diagnoses, and which, in accordance with accepted standards of practice
in the medical community of the area in which the health services are
rendered, could not have been omitted without adversely affecting the
member's condition or the quality of medical care rendered.

Primary Care Physician Primary Care Physician (PCP) is a family practitioner, internist or a pediatrician. Your PCP provides all routine care and will manage your
preventive care, hospital care, and referrals to Specialists.

Specialist Care Physician-A medical doctor other than your primary care physician (PCP) whose education and work experience focus on a particular area of medicine.
For example, a cardiologist sees patients with heart disease and a
neurologist deals with disorders that affect our central nervous system.

Us/ We Us and we refer to HealthAmerica
You You refers to the enrollee and each covered family member. 45
45 Page 46 47
2001 HealthAmerica Pennsylvania, Inc. 46 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. 46
46 Page 47 48
2001 HealthAmerica Pennsylvania, Inc. 47 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

· OPM, this Plan, and subcontractors when they administer this contract;
· This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when coordinating benefit payments and subrogating claims;
· Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

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

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

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

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

· Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you

may be eligible for your own FEHB coverage under the spouse equity
law. If you are recently divorced or are anticipating a divorce, contact
your ex-spouse's employing or retirement office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.

· 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. 47
47 Page 48 49
2001 HealthAmerica Pennsylvania, Inc. 48 Section 11
· Converting to You may convert to a non-FEHB individual policy if: individual coverage
·· Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot
convert;
·· You decided not to receive coverage under TCC or the spouse equity law; or

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

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

Getting a Certificate of 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 1-800-735-4404 in the Greater Pittsburgh region or at 1-800-788-8445 in South

Central, Central and Northeast Pennsylvania 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 the person tries to obtain services for someone
who is not an eligible family member, or is no longer enrolled in the Plan
and tries to obtain benefits. Your agency may also take administrative
action against you. 48
48 Page 49 50
2001 HealthAmerica Pennsylvania, Inc. 49 Section 11
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 HealthAmerica Pennsylvania, Inc. 50 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury 35 Allergy tests 15
Alternative treatment 19 Ambulance 26
Anesthesia 23 Autologous bone marrow
transplant 23 Biopsies 20
Blood and blood plasma 25 Breast cancer screening 13
Catastrophic protection 10 Changes for 2001 7
Chemotherapy 15 Cholesterol tests 13
Claims 38 Coinsurance 10, 45
Colorectal cancer screening 13 Congenital anomalies 20
Contraceptive devices and drugs 14 Copayments 10, 45
Coordination of benefits 41 Covered charges 45
Covered providers 5, 8
Crutches 18
Deductible 10 Definitions 45

Dental care 36 Diagnostic services 13
Disputed claims review 39 Donor expenses (transplants) 23
Dressings 25 Durable medical equipment
(DME) 18 Educational classes and programs 36
Effective date of enrollment 47 Emergency 27
Experimental or investigational 37, 45
Eye exams 14 Family planning 14
Fecal occult blood test 13

General Exclusions 36 Hearing services 16
Home health services 19 Hospice care 26
Home nursing care 19 Hospital 9
Immunizations 13 Infertility 15
Inhospital physician care 24 Inpatient Hospital Benefits 24
Insulin 33 Laboratory and pathological
services 13 Machine diagnostic tests 13
Magnetic Resonance Imagings (MRIs) 13
Mail Order Prescription Drugs 32 Mammograms 13
Maternity Benefits 14 Medicaid 44
Medically necessary 45 Medicare 41
Mental Conditions/ Substance Abuse Benefits 29
Newborn care 12, 14 Non-FEHB Benefits 36
Nurse Licensed Practical Nurse 19
Registered Nurse 19 Nursery charges 14
Occupational therapy 16 Ocular injury 17
Office visits 12 Oral and maxillofacial surgery 22
Orthopedic devices 17 Ostomy and catheter supplies 19
Out-of-pocket expenses 10 Outpatient facility care 25
Oxygen 19, 24 Pap test 13
Physical examination 13

Physical therapy 16 Physician 8
Pre-admission testing 25 Precertification 8-10
Preventive care, adult 13 Preventive care, children 14
Prescription drugs 32 Preventive services 13, 14
Prior approval 10 Prostate cancer screening 13
Prosthetic devices 17 Psychologist 29
Psychotherapy 29 Radiation therapy 15
Rehabilitation therapies 16
Renal dialysis 15 Room and board 24

Second surgical opinion 12 Skilled nursing facility care 25
Smoking cessation 36 Speech therapy 16
Splints 24 Sterilization procedures 21
Subrogation 44 Substance abuse 29
Surgery 20 · Anesthesia 23
· Oral 22 · Outpatient 25
· Reconstructive 21 Syringes 33
Temporary continuation of coverage 47
Transplants 23 Treatment therapies 15
Vision services 16 Well child care 14
Wheelchairs 18 Workers' compensation 44
X-rays 13 50
50 Page 51 52
2001 HealthAmerica Pennsylvania, Inc. 51 Summary of Benefits
Summary of benefits for the HealthAmerica Pennsylvania, Inc. – 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 care; $15 specialist 12

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

Nothing

24

25

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

$35 per urgent care center or
emergency room visit

$35 per urgent care center or
emergency room visit

27
27
Mental health and substance abuse treatment.................................... Regular cost sharing 29
Prescription drugs:
Up to a 31-day supply from a Plan Retail Pharmacy...........................

Up to a 90-day supply from Plan Mail Order Pharmacy .....................

$8 Formulary Generic,$ 14 Name
Brand, $35 Non-Formulary per
prescription unit or refill

$16 Generic Formulary $28 Name
Brand Formulary, $70 Non-Formulary
per prescription unit or
refill

32

Dental Care:
Accidental injury benefit only ....................................................... Nothing 36
Vision Care:
Limited to one annual eye refraction.............................................. $15 office visit copay 16
Special features: High Risk Pregnancy, Centers of Excellence, Member Services TDD, Complex Case
Management
35

Protection against catastrophic costs Stated copays and coinsurance 10 51
51 Page 52
2001 HealthAmerica Pennsylvania, Inc. 52 Rate Information
2001 Rate Information for
HealthAmerica Pennsylvania

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

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

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

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

Greater Pittsburgh
Self Only 261 $69.71 $23.23 $151.03 $50.34 $82.48 $10.46

Self and Family 262 $181.25 $60.41 $392.70 $130.90 $214.47 $27.19
Central, South Central, and Northeast Pennsylvania
Self Only SW1 $74.45 $24.82 $161.32 $53.77 $88.10 $11.17

Self and Family SW2 $193.56 $64.52 $419.38 $139.79 $229.05 $29.03 52

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