Pages 1--55 from Humana Medical Plan, Inc.

Serving: South Florida
Enrollment in this Plan is limited; see page 6 for requirements.

This plan has accreditation
from the NCQA. See the 2001 Guide
for more information on NCQA.

Enrollment codes for this Plan:
EE1 Self Only EE2 Self and Family

RI 73-278

2001
Special notice for Humana Enrollees: Enrollment codes 7F, P5, P7, JH, and 9D have been
eliminated. Ft. Myers, including the counties of Charlotte and Lee under enrollment code EE
have been eliminated. Current enrollees in these areas must select another plan during Open
Season. See page 7 for details. 1
1 Page 2 3
2001 Humana Medical Plan, Inc. 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………........................................................................ 4
Plain Language………………………………………………………………....................................................................... 4
Section 1. Facts about this HMO plan...................................................................................................................................... 5-6
How we pay providers................................................................................................................................................. 5
Who provides my health care?…………………………………………………………………………….. 5
Patients' Bill of Rights.............................................................................................................................................. 5-6
Service Area .................................................................................................................................................................. 7
Section 2. How we change for 2001………………………………………......................................................................... 8
Program-wide changes................................................................................................................................................ 8
Changes to this Plan..................................................................................................................................................... 8
Section 3. How you get care ………….................................................................................................................................. 9-11
Identification cards ...................................................................................................................................................... 9
Where you get covered care ....................................................................................................................................... 9

· Plan providers ............................................................................................................................................................ 9
· Plan facilities.............................................................................................................................................................. 9
What you must do to get covered care ................................................................................................................ 9-10

· Primary care ............................................................................................................................................................... 9
· Specialty care ........................................................................................................................................................ 9-10
· Hospital care....................................................................................................................................................... 10-11
Circumstances beyond our control.......................................................................................................................... 11
Services requiring our prior approval..................................................................................................................... 11

Section 4. Your costs for covered services............................................................................................................................... 12

· Copayments ............................................................................................................................................................. 12
· Coinsurance ............................................................................................................................................................. 12
Your out-of-pocket maximum.................................................................................................................................. 12
Section 5. Benefits…………………………………………………………................................................................. 13-39
Overview...................................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals .............. 13-22
(b) Surgical and anesthesia services provided by physicians and other health care professionals .......... 23-26
(c) Services provided by a hospital or other facility, and ambulance services ............................................ 27-29
(d) Emergency services/ accidents ....................................................................................................................... 30-31
(e) Mental health and substance abuse benefits................................................................................................ 32-33
(f) Prescription drug benefits ............................................................................................................................... 34-36
(g) Special features....................................................................................................................................................... 37
(h) Dental benefits ........................................................................................................................................................ 38
(i) Non-FEHB benefits available to Plan members ............................................................................................... 39 2
2 Page 3 4
2001 Humana Medical Plan, Inc. 3 Table of Contents
Section 6. General exclusions – things we don't cover........................................................................................................... 40
Section 7. Filing a claim for covered services .......................................................................................................................... 41
Section 8. The disputed claims process............................................................................................................................... 42-43
Section 9. Coordinating benefits with other coverage ...................................................................................................... 44-47
When you have…

· Other health coverage ....................................................................................................................................... 44-46
· Original Medicare .............................................................................................................................................. 44-43
· Medicare managed care plan ................................................................................................................................. 46
TRICARE/ Workers' Compensation/ Medicaid ................................................................................................ 46-47
Other Government agencies...................................................................................................................................... 47
When others are responsible for injuries ................................................................................................................ 47
Section 10. Definitions of terms we use in this brochure ......................................................................................................... 48
Section 11. FEHB facts............................................................................................................................................................. 49-51
Coverage information................................................................................................................................................. 49

· No pre-existing condition limitation..................................................................................................................... 49
· Where you get information about enrolling in the FEHB Program................................................................ 49
· Types of coverage available for you and your family ....................................................................................... 49
· When benefits and premiums start ....................................................................................................................... 49
· Your medical and claims records are confidential............................................................................................. 50
· When you retire........................................................................................................................................................ 50
When you lose benefits ....................................................................................................................................... 50-51
· When FEHB coverage ends................................................................................................................................... 50
· Spouse equity coverage.......................................................................................................................................... 50
· Temporary Continuation of Coverage (TCC)..................................................................................................... 50
· Converting to individual coverage........................................................................................................................ 51
· Getting a Certificate of Group Health Plan Coverage....................................................................................... 51
Inspector General advisory ....................................................................................................................................... 51
Index.................................................................................................................................................................................................. 52
Summary of benefits ...................................................................................................................................................................... 54
Rates.................................................................................................................................................................................. Back cover 3
3 Page 4 5
2001 Humana Medical Plan, Inc. 4 Introduction/ Plain Language
Introduction
Humana Medical Plan, Inc.
P. O. Box 19080F
Jacksonville, FL 32245-9080

This brochure describes the benefits of Humana Health Plan, under our contract (CS 2110) 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 8. 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 Humana Medical Plan, 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 Humana Medical Plan, 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 and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.

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

How we pay providers
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 and
coinsurance.

Who provides my healthcare?
The Plan's provider directory lists primary care doctors (family practitioners, pediatricians, and internists), with their
locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated
on a regular basis and are available at the time of enrollment or upon request by calling 1-800/ 426-2173; you can also
find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a
specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan
and is accepting new patients. Important note: When you enroll in this plan, services (except for emergency benefits)
are provided through the Plan's delivery system; the continued availability and/ or participation of any one doctor,
hospital, or other provider, cannot be guaranteed.

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.

· Medical case management is a special Humana program that communicates the provision of care and the management of benefit in cases of catastrophic illness or injury, transplant management and disease management.

The program strives to ensure that patients receive the most appropriate, cost-effective care and also derive
maximum advantage from plan benefits.

· Humana has adopted preventative care guidelines based on the United States Preventative Health Task Force and subscribes to their Healthy People 2000 goals. Our Patterns of Preventative Care (POPC) program monitors the

delivery of well care and uses an automated reminder system to help assure that our members schedule routine
preventative services

· Humana provides comprehensive disease management programs to plan members. Key to each program is ongoing education, communication and coordination. Each contracted vendor offers plan members access to a staff of highly

specialized nurses and doctors, experienced in the respective disease field. The programs focus on linking the plan
member with a specialized nurse or interdisciplinary team to ensure an individualized care development approach.
These nurses work closely with the plan member, member's family, member's primary care physician (PCP) and
other involved providers to provide information, education and assistance when needed.

· Nationally, Humana has been in the health care business since 1961. Locally, Humana has been in existence since 1988.

· Humana is a for profit corporation which is publicly traded on the New York Stock Exchange (NYSE). 5
5 Page 6 7
2001 Humana Medical Plan, Inc. 6 Section 1
If you want more information about us, call 1-800/ 426-2173, or write to the Plan at P. O. Box 19080F, Jacksonville,
FL 32245-9080. You may also contact us by fax at 904/ 376-1926 or visit our website at www. humana. com. 6
6 Page 7 8
2001 Humana Medical Plan, Inc. 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our
Service Area is:

The Florida counties of Broward, Dade and Palm Beach.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our Service Area,
we will pay only for emergency care. We will not pay for any other health care services.

If you or a covered family member move outside of our Service Area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8 9
2001 Humana Medical Plan, Inc. 8 Section 2
Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it
easier for you to compare plans.

· This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital

services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and
day and visit limitations when you follow a treatment plan that we approve. Previously, we placed shorter day or
visit limitations on mental health and substance abuse services than we did on services to treat physical illness,
injury, or disease.

· Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our patient

safety activities by calling 1-800/ 4HUMANA, or checking our website, www. humana. 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
· Your share of the non-Postal premium will increase by 25.2% for Self Only and Self and Family.
· Enrollment codes P7-Daytona, P5-Jacksonville, 7F-Orlando/ Gainesville, 9D-Pensacola, and JH-Tampa have been eliminated. Members currently enrolled in these codes must select another plan during Open Season.

· Enrollment code EE has been reduced. Ft. Myers, including the counties of Charlotte and Lee have been eliminated. Members currently enrolled in these counties must select another plan during Open Season.
· There is a $10 copay for specialist visits. 8
8 Page 9 10
2001 Humana Medical Plan, Inc. 9 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/ 426-2173.

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

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

We list Plan providers in the provider directory, which we update periodically.
The list is also on our website at www. humana. com.

· · 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 at www. humana. com.

What you must do to get
covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician by sending a selection form to the
Plan. This decision is important since your primary care physician
provides or arranges for most of your health care. You may choose your
primary care physician from our Provider Directory or our website, or you
may call us for assistance. You may change your doctor selection by
notifying us 30 days in advance.

· · Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

If you are receiving services from a doctor who leaves the Plan, we will
provide payment for covered services until we can make reasonable and
medically appropriate provisions for the assumption of such services by a
participating doctor.

· · Specialty care Your primary care physician will refer you to a specialist for needed care.
However, you may see the following participating providers without a
referral:

· Mental health providers · OB/ GYN providers for your annual well-woman exam 9
9 Page 10 11
2001 Humana Medical Plan, Inc. 10 Section 3
· Podiatrists · Chiropractors
· Dermatologists (for up to five visits each calendar year) · Another doctor your primary care physician has designated to provide
patient care when he or she is not available.
When you receive a referral from your primary care doctor, you must
return to the primary care doctor after the consultation unless your doctor
authorizes additional visits. All follow-up care must be provided or
authorized by the primary care doctor. Do not go to the specialist for a
second visit unless your primary care doctor has arranged for and the
Plan has issued an authorization for the referral in advance.

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

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

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

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

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

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

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

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

If you are in the 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/ 426-2173. 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 10
10 Page 11 12
2001 Humana Medical Plan, Inc. 11 Section 3
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the hospital benefits of the hospitalized
person.

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 Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your
physician must obtain precertification for the following services:

· Growth hormone therapy ·
Organ/ Tissue transplants
· All elective medical and surgical hospitalizations ·
Hysterectomy
· Lumbar laminectomy/ disectomy ·
Lumbar fusion
· MRI of the lumbar and cervical spine ·
Blepharoplasty
· Reduction mammoplasty/ breast reconstruction ·
Septoplasty/ submucous resection (with or without rhinoplasty)
· Rhinoplasty ·
Uvulopalatopharyngoplasty (UPPP)
· Continuous positive airway pressure (CPAP) ·
Gastric bypass
· Scar revisions ·
Mandibular or maxillary osteotomy
· Speech therapy ·
All durable medical equipment (DME) over $500

Your physician must obtain our approval before sending you to a
hospital, referring you to a specialist, or recommending follow-up care
from a specialist. 11
11 Page 12 13
2001 Humana Medical Plan, Inc. 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
· · Copayments A copayment is a fixed amount of money you pay to the provider when
you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit and when you go in the hospital, you
pay nothing.

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

Example: In our Plan, you pay 50% of our allowance for infertility
services after the Plan has paid for the first $2,000 in charges.

Your out-of-pocket maximum
for copayments and coinsurance After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for

covered services. However, copayments for the following services do
not count toward your out-of-pocket maximum, and you must continue to
pay copayments for these services:

· Prescription drugs

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Humana Medical Plan, Inc. 13 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this year and page 52 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
1-800/ 426-2173 or at our website at www. humana. com.

(a) Medical services and supplies provided by physicians and other health care professionals ............................... 13-22

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

·Hearing services (testing, treatment, and
supplies)
·Vision services (testing, treatment, and
supplies)

·Foot care
·Orthopedic and prosthetic devices
·Durable medical equipment (DME)
·Home health services
·Alternative treatments
·Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ........................... 23-26
·Surgical procedures
·Reconstructive surgery
·Oral and maxillofacial surgery
·Organ/ tissue transplants
·Anesthesia

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

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

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

(e) Mental health and substance abuse benefits ................................................................................................................ 32-33
(f) Prescription drug benefits................................................................................................................................................ 34-36
(g) Special features ....................................................................................................................................................................... 37
· Services for deaf and hearing impaired ·
High risk pregnancies
· Centers of excellence for transplants/ heart surgery/ etc.
· 24-hour nurse line

(h) Dental benefits......................................................................................................................................................................... 38
(i) Non-FEHB benefits available to Plan members ................................................................................................................ 39
Summary of benefits ...................................................................................................................................................................... 54 13
13 Page 14 15
2001 Humana Medical Plan, Inc. 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these
benefits:

· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when

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

I M
P O
R T
A N
T

Benefit Description
Diagnostic and treatment services You pay
Professional services of physicians
· In physician's office
· In an urgent care center
· Office medical consultations
· At home

$10 per office visit

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

· Second surgical opinion

Nothing

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

Nothing if you receive these services during your
office visit; otherwise, $10 per visit. 14
14 Page 15 16
2001 Humana Medical Plan, Inc. 15 Section 5( a)
Preventive care, adult You pay
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
··Sigmoidoscopy, screening – every five years
starting at age 50

· Prostate Specific Antigen (PSA test) – one annually for men age 40 and older

· Routine pap test – one annually
NOTE: The office visit is covered if pap test is
received on the same day; see Diagnostic and
treatment services, above.

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

· From age 35 through 39, one during this five year period

· From age 40 through 64, one every calendar
year

· At age 65 and older, one every two consecutive calendar years

· When prescribed by the doctor as medically necessary to diagnose or treat illness

Nothing if you receive these services during your
office visit; otherwise, $10 per visit

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

All charges

Routine Immunizations, limited to:
· 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, or in the presence of high risk,

chronic conditions

Nothing if you receive these services during your
office visit; otherwise, $10 per visit . 15
15 Page 16 17
2001 Humana Medical Plan, Inc. 16 Section 5( a)
Preventive care, children You pay
· Childhood immunizations recommended by the
American Academy of Pediatrics
Nothing

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

··Examinations done on the day of immunizations ( through age 22)

· Well-child care charges for routine examinations, immunizations and care
(through age 17)

$10 per office visit.

Maternity care
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care

NOTE: Here are some things to keep in mind:
· 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 for the first pre-natal office visit.
Subsequent visits are provided with no copay
charge.

Not covered: routine sonograms to determine
fetal age, size or sex
All charges 16
16 Page 17 18
2001 Humana Medical Plan, Inc. 17 Section 5( a)
Family planning You pay
· Implantable drugs (such as Norplant)
· Injectable drugs (such as Depo Provera)
· Contraceptive devices
· Oral contraceptive drugs covered under prescription drug benefits. See Section 5 (f).

· Voluntary sterilization

$10 per office visit

Not covered: reversal of voluntary surgical
sterilization
All charges

Infertility services
Diagnosis and treatment of infertility, such as:
· Artificial insemination: ··intravaginal
insemination (IVI)
··intracervical insemination (ICI) ··intrauterine
insemination (IUI)

· Fertility drugs

50% of all charges after the Plan has paid for the
first $2,000 in charges.

Not covered:
· assisted reproductive technology (ART) procedures, such as:

··in vitro fertilization ··embryo
transfer and GIFT

· services and supplies related to excluded ART
procedures

· cost of donor sperm

All charges

Allergy care
· Testing and treatment, including test and treatment materials Nothing if you receive these services during your office visit; otherwise, $10 per visit .

· Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization
All charges 17
17 Page 18 19
2001 Humana Medical Plan, Inc. 18 Section 5( a)
Treatment therapies You pay
· Chemotherapy and radiation therapy
NOTE: High dose chemotherapy in association
with autologous bone marrow transplants is
limited to those transplants listed under
Organ/ Tissue Transplants on page 24.

· Respiratory and inhalation therapy
· Dialysis – Hemodialysis and peritoneal dialysis

$10 per office visit

· Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
· Growth hormone therapy (GHT)
NOTE: We will only cover Growth Hormone
Therapy if the treatment is precertified and there is
a laboratory confirmed diagnosis of Growth
Hormone Deficiency. You will need to call the
precertification telephone number on the back of
your medical ID (identification) card. We will
also ask that your physician submit information
that establishes that the GHT is medically
necessary. GHT must be authorized before you
begin treatment.

See Services requiring our prior approval in
Section 3.

$10 per office visit 18
18 Page 19 20
2001 Humana Medical Plan, Inc. 19 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech
therapy on an inpatient or outpatient basis

· Up to two consecutive months per condition for
the services of each of the following if
significant improvement can be expected within
two months:

··qualified physical therapists; ··speech
therapists; and
··occupational therapists.

NOTE: Speech therapy is limited to treatment of
certain speech impairments of organic origin.
Occupational therapy is limited to services that
assist the member to achieve and maintain self-care
and improved functioning in other activities
of daily living.

Nothing

· Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial
infarction, is provided for up to 12 weeks.
Nothing

Not covered:
· long-term rehabilitative therapy
· exercise programs

All charges

Hearing services (testing, treatment, and supplies)
· Screening hearing testing for children through age 17
(see Preventive care, children)
$10 per office visit

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)

· Diagnosis and treatment of diseases of the eye.
· Screening eye exam to determine the need for vision correction for children through age 17

(see preventive care)

$10 per office visit 19
19 Page 20 21
2001 Humana Medical Plan, Inc. 20 Section 5( a)
Vision services (testing, treatment, and supplies)
(Continued) You pay

Not covered:
· eyeglasses or contact lenses and, after age 17, examinations for them

· eye exercises and orthoptics
· radial keratotomy and other refractive surgery

All charges

Foot care
Routine foot care when you are under active
treatment for a metabolic or peripheral vascular
disease, such as diabetes.

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

$10 per office visit

Not covered,:
· cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine

treatment of conditions of the foot, unless
primary medical condition requires such care

· 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
· Orthopedic devices such as braces (except for dental braces) that are custom-fitted or custom-made.

· Externally worn breast prostheses and surgical bras, including necessary replacements,
following a mastectomy
· Internal prosthetic devices, such as artificial joints and pacemakers. 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.

Nothing 20
20 Page 21 22
2001 Humana Medical Plan, Inc. 21 Section 5( a)
Orthopedic and prosthetic devices
(Continued) You pay

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

· prosthetic replacements

All charges

Durable medical equipment (DME)
Rental or purchase, at our option, including repair
and adjustment, of durable medical equipment
prescribed by your Plan physician, such as oxygen
and dialysis equipment. Under this benefit, we
also cover:

· Hospital beds
· Wheelchairs
· Crutches
· Walkers
· Blood glucose monitors
· Insulin pumps

Nothing

Home health services
· 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.

· Services includes intravenous therapy and medications.

$10 per visit

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.

All charges 21
21 Page 22 23
2001 Humana Medical Plan, Inc. 22 Section 5( a)
Alternative treatments You pay
· Chiropractic services $10 per office visit
Not covered:
· acupuncture
· naturopathic services
· hypnotherapy
· biofeedback

All charges

Educational classes and programs
Lifestyle management programs are offered by
Magellan Behavioral Health, e. g. Smoking
cessation, stress management and weight
management. For information call 1-800-741-1017.

Nothing 22
22 Page 23 24
2001 Humana Medical Plan, Inc. 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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A N
T

Here are some important things to keep in mind about these
benefits:

· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when

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

coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section

5( c) for charges associated with the facility (i. e. hospital, surgical
center, etc.).

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

I M
P O
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A N
T

Benefit Description
Surgical procedures You pay
· Treatment of fractures, including casting
· Normal pre-and post-operative care by the surgeon

· 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.

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

device coverage information.
· Surgically implanting of contraceptives such as Norplant, and contraceptive devices.

NOTE: Devices are covered under 5( a).
· Treatment of burns
· Voluntary sterilization

Nothing for inpatient services; $10 per office
visit.

Not covered:
· reversal of voluntary sterilization
All charges 23
23 Page 24 25
2001 Humana Medical Plan, Inc. 24 Section 5( b)
Reconstructive surgery You pay
· Surgery to correct a functional defect
· Surgery to correct a condition caused by injury or illness if:

··the condition produced a major effect on the
member's appearance and
··the condition can reasonably be expected to be corrected by such surgery

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

· All stages of breast reconstruction surgery
following a mastectomy, such as:
··surgery to produce a symmetrical appearance on the other breast;

··treatment of any physical complications, such as lymphedemas;
··breast prostheses and surgical bras and
replacements (see Prosthetic devices)

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

Nothing for inpatient services; $10 copay per
office visit.

Not covered:
· cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily

to improve physical appearance through change
in bodily form, except repair of accidental injury

· Surgeries related to sex transformation

All charges 24
24 Page 25 26
2001 Humana Medical Plan, Inc. 25 Section 5( b)
Oral and maxillofacial surgery
Oral surgical procedures, such as:
· Reduction of fractures of the jaws or facial bones;

· Surgical correction of congenital defects such as
cleft lip, cleft palate or severe functional
malocclusion;

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

· Other surgical procedures that do not involve the
teeth or supporting stuctures;

· Diagnosis and non-dental treatment of temporomandibular joint (TMJ) pain dysfunction

syndrome.

Nothing for inpatient services; $10 copay per
office visit.

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

· dental work related to treatment for
temporomandibular joint (TMJ)

All charges 25
25 Page 26 27
2001 Humana Medical Plan, Inc. 26 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
· Cornea
· Heart
· Kidney/ Pancreas
· Liver
· 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; Wiskott-Aldrich syndrome;
severe combined immunodeficiency syndrome;
aplastic anemia; ewings sarcoma; and testicular,
mediastinal, retroperitoneal and ovarian germ
cell tumors.

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

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

Nothing.

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

· implants of artificial organs
· transplants not listed as covered

All charges

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

Professional services provided in –
· Hospital outpatient department
· Skilled nursing facility
· Ambulatory surgical center

Nothing

Professional services provided in –
· Office
$10 per office visit 26
26 Page 27 28
2001 Humana Medical Plan, Inc. 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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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.

· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or

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

I M
P O
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A N
T

Benefit Description
Inpatient hospital You pay

Room and board, such as
· Semiprivate, intensive care or cardiac care accommodations;

· General nursing care;
· Private accommodations when a Plan doctor determines it is medically necessary;

· Private duty nursing when Plan doctor
determines medically necessary; and

· Meals and special diets.

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

Nothing

Other hospital services and supplies, such as:
· Operating, recovery, maternity, and other
treatment rooms

· Prescribed drugs and medicines
· Diagnostic laboratory tests and x-rays
· Administration of blood and blood products
· Dressings, splints, casts, and sterile tray services
· Medical supplies and equipment, including
oxygen

· Anesthetics, including nurse anesthetist services
· Take-home items
· Medical supplies, appliances, medical
equipment, and any covered items billed by a
hospital for use at home

Nothing 27
27 Page 28 29
2001 Humana Medical Plan, Inc. 28 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered:
· custodial care, rest cures, domiciliary or convalescent care

· personal comfort items, such as telephone and
television

· blood and blood derivatives not replaced by the member

All charges

Outpatient hospital or ambulatory
surgical center

· Operating, recovery, and other treatment rooms
· Prescribed drugs and medicines
· Laboratory tests, x-rays, and pathology services
· Administration of blood, blood plasma, and other biologicals

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

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

Nothing

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

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit:
· Up to 100 days per calendar year, including °° bed and board;

°° general nursing care
°° drugs, biologicals, supplies and equipment
provided by the facility

NOTE: Coverage is provided 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 the Plan.

Nothing

Not covered: custodial care, rest cures,
convalescent care
All charges 28
28 Page 29 30
2001 Humana Medical Plan, Inc. 29 Section 5( c)
Ambulance You pay
· Local professional ambulance service when
medically appropriate.
Nothing 29
29 Page 30 31
2001 Humana Medical Plan, Inc. 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M

P O
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A N
T

Here are some important things to keep in mind about these
benefits:

· Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.

· 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
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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:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local
emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to
tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family
member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your
responsibility to ensure that the Plan has been timely notified.

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

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

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

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

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day
following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan
doctor believes 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. 30
30 Page 31 32
2001 Humana Medical Plan, Inc. 31 Section 5( d)
Benefit Description
Emergency within our service area You pay
· Emergency care at a doctor's office
· Emergency care at an urgent care center
$10 per visit

· Emergency care as an outpatient at a hospital, including doctors' services
If the emergency results in an admission to the
hospital, the emergency care copay is waived.

$25 per visit

Not covered: elective care or non-emergency care All charges
Emergency outside our service area
· Emergency care as an outpatient at a hospital, including doctor's services
If the emergency results in admission to a hospital,
the emergency care copay is waived.

25% of charges up to a $50 maximum 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 approved by the Plan. See 5( c) for non-emergency service.

NOTE: Air ambulance is covered only when point
of pick-up is inaccessible by land vehicle; or great
distances or other obstacles are involved in getting
a patient to the nearest hospital with appropriate
facilities when prompt admission is essential.

Nothing 31
31 Page 32 33
2001 Humana Medical Plan, Inc. 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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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.

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

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

I M
P O
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A N
T

Description
Mental health and substance abuse benefits You pay
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

$10 per office visit

· Diagnostic tests Nothing
· 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

Nothing

Mental health and substance abuse benefits – Continued on next page. 32
32 Page 33 34
2001 Humana Medical Plan, Inc. 33 Section 5( e)
Mental health and substance abuse benefits – CONTINUED
Not covered: services we have not approved.
NOTE: OPM will base its review of disputes about
treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us
to pay or provide one clinically appropriate
treatment plan in favor of another.

All charges

.
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all of the following authorization processes.

· Please contact Magellan Behavioral Health at 1-800/ 777-7753 to
obtain Mental Health/ Substance Abuse treatment services.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued
coverage with your provider for up to 90 days under the following
conditions:

· If your mental health or substance abuse professional provider with
whom you are currently in treatment leaves the plan at our request for
other than cause.

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

Limitation We may limit your benefits if you do not follow your treatment plan. 33
33 Page 34 35
2001 Humana Medical Plan, Inc. 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
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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.

· 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
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T
A
N
T

There are important features you should be aware of. These include:
· Who can write your prescription. A licensed physician must write the prescription.
· Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a prescribed maintenance medication. Maintenance medications are drugs that are generally prescribed for the treatment

of long term chronic sicknesses or injuries.
· We use a formulary. Our formulary is a continually updated list of drug products including strengths, dispensing limits and any prior authorization requirements that represent the current clinical judgment of the

members of our Pharmacy and Therapeutics Committee. This committee is comprised of both physicians
and pharmacists. The formulary contains both brand name and generic drugs, all of which have FDA
approval.

A generic drug is a drug that is manufactured, distributed and available from several pharmaceutical
manufacturers and identified by the chemical name; or as defined by the national pricing standard.

A brand name drug is a drug that is manufactured and distributed by only one pharmaceutical manufacturer;
or as defined by the national pricing standard.

Proposed additions or deletions to the Formulary are welcomed at any time and will be reviewed by the
Committee.

· These are the dispensing limitations. Prescription drugs dispensed at a Plan pharmacy will be dispensed for up to a 30-day supply. You may receive up to a 90-day supply of a prescribed maintenance medication
through our mail-order program.

Prescription drug benefits begin on the next page. 34
34 Page 35 36
2001 Humana Medical Plan, Inc. 35 Section 5( f)
Benefit Description
Covered medications and supplies You pay
We cover the following medications and supplies
prescribed by a licensed physician and obtained from
a Plan pharmacy or through our mail order program:

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

· Insulin
· Disposable needles and syringes for the administration of covered medications

· Diabetic supplies including testing agents, lancet devices, alcohol swabs, glucose elevating agents,
and insulin delivery devices
· Self administered injectable drugs
· Oral contraceptive drugs

NOTE: Drugs to treat sexual dysfunction are
limited. Contact the Plan for dosage limits. You
pay the applicable drug copay up to the dosage
limits, and all charges after that.

$5 for generic drugs listed on our formulary
$10 for brand name drugs with no generic
equivalent listed on our formulary.

$25 for generic or brand name drugs not listed
on our formulary.

3 applicable copays for a 90-day supply of
prescribed maintenance drugs, when ordered
through our mail-order program.

NOTE: If there is no generic equivalent
available, you will still have to pay the brand
name formulary copay.

Here are some things to keep in mind about our
prescription drug program:

· If generic is available, and you or your doctor
request the brand name, you pay the applicable
generic formulary or non-formulary copay plus
the difference in cost between the brand name
and generic drugs.

· We have an open formulary. If your physician believes a name brand product is necessary or

there is no generic available, your physician may
prescribe a name brand drug from a formulary
list. This list of name brand drugs is a preferred
list of drugs that we selected to meet patient
needs at a lower cost. To order a prescription
drug brochure, call 1-800/ 4HUMANA. 35
35 Page 36 37
2001 Humana Medical Plan, Inc. 36 Section 5( f)
Covered medications and supplies
(Continued) You pay

Not covered:
· drugs available without a prescription, or for which there is a non-prescription equivalent

available
· drugs and supplies for cosmetic purposes
· vitamins, fluoride, nutrients and food
supplements even if a physician prescribes or
administers them

· drugs obtained at a non-Plan pharmacy except for out of area emergencies

· drugs to enhance athletic performance
· smoking cessation drugs and medications, including nicotine patches

· any drug used for the purpose of weight control
· prescriptions that are to be taken by or administered to the member in whole or part,

while a patient in a hospital, skilled nursing
facility, convalescent hospital, inpatient facility
or other facility where drugs are ordinarily
provided by the facility on an inpatient basis

· medical supplies such as dressings and antiseptics

All charges 36
36 Page 37 38
2001 Humana Medical Plan, Inc. 37 Section 5( g)
Section 5 (g). Special Features
Feature Description

Services for deaf and hearing impaired Humana offers telecommunication devices for the deaf (TDD) and Teletype (TTY) phone lines for the hearing impaired. Call
1-800-432-7482 to access the service.

High risk pregnancies HumanaBeginnings is an outreach program that provides high-risk plan members support and educational materials so care can be
actively managed during pregnancy.

Centers of excellence for transplants/ heart
surgery/ etc.

Members can use any facility that is within Humana's contracted
National Transplant Network. This network has over 35 transplant
facilities located in more than 20 states.

24-hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call HumanaFirst ® at 1-800-622-9529 and talk with a registered
nurse who will discuss treatment options and answer your health
questions. 37
37 Page 38 39
2001 Humana Medical Plan, Inc. 38 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these
benefits:

· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when

we determine they are medically necessary.
· 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
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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.

Nothing

Dental benefits
We have no other dental benefits. 38
38 Page 39 40
2001 Humana Medical Plan, Inc. 39 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

· Additional premium of $92.75 per member per year.
· Diagnostic and most preventive services provided at no charge when received from participating general dentists. Other services including

restorative care, endodontics, periodontics, prosthodontics, oral
surgery, as provided by participating general dentists, are offered at
copayments listed in the separate plan description. When you receive
services from a participating specialist, you will receive a 20%
discount off of their charges.

· Administered by HumanaDental 1-800-955-0782

· All dental services at discounted fees as listed in the separate plan description.
· No additional premium required; no application to complete.
· Administered by HumanaDental 1-800-955-0782.

CREDIT CARD PAYMENT NOW AVAILABLE.
See application for details.

· Examinations, glasses and contact lenses are available after copayments.
· No additional premium required.

Contact us for additional information concerning specific benefits, exclusions, limitations, eligible providers and other
provisions of each of the above coverages.

Medicare prepaid plan enrollment – This plan offers Medicare recipients the opportunity to enroll in the Plan
through Medicare. As indicated on page 45, annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area.
They may then later reenroll in the FEHB program. Most Federal annuitants have Medicare Part A. Those without
Medicare Part A may join this Medicare prepaid plan, but will probably have to pay for hospital coverage in addition
to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so, what you
will have to pay. Contact your retirement system for information on dropping your FEHB enrollment and changing to
a Medicare prepaid plan. Contact us at 1-888-393-6765 for information on the Medicare prepaid plan and the cost of
that enrollment.

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

Expanded dental benefits · · DEN-988
Vision care · · VIS-920
· · DEN-997 39
39 Page 40 41
2001 Humana Medical Plan, Inc. 40 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;

· 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. 40
40 Page 41 42
2001 Humana Medical Plan, Inc. 41 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-800/ 426-2173.

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: Humana Medical Plan, Inc.
P. O. Box 19080F
Jacksonville, FL 32245-9080

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. 41
41 Page 42 43
2001 Humana Medical Plan, Inc. 42 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: Humana Medical Plan, Inc., P. O. Box 19080F, Jacksonville, FL
32245-9080; 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 III,
P. O. Box 436, Washington, D. C. 20044-0436.

The disputed claims process – Continued on next page 42
42 Page 43 44
2001 Humana Medical Plan, Inc. 43 Section 8
Step Description
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
1-800/ 426-2173 and we will expedite our review; or

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

··You can call OPM's Health Benefits Contracts Division III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 43
43 Page 44 45
2001 Humana Medical Plan, Inc. 44 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under
another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

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

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

° What is Medicare? Medicare is a Health Insurance Program for:
·· People 65 years of age and older.
·· Some people with disabilities, under 65 years of age.
·· People with end-stage renal disease (permanent kidney failure
requiring dialysis or a transplant).

Medicare has two parts:
·· Part A (Hospital Insurance). Most people do not have to pay for
Part A.

·· Part B (Medical Insurance). Most people pay monthly for Part B.

If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare managed care plan 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 this Plan and Original Medicare, you still need to follow the
rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP.

We will not waive any of our copayments or coinsurance.
Tell us if you or a family member is enrolled in Medicare Part A or B.
Medicare will determine who is responsible for paying medical services
and we will coordinate the payments. On occasion, you may need to file
a Medicare claim form.

(Primary payer chart begins on next page.) 44
44 Page 45 46
2001 Humana Medical Plan, Inc. 45 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, ü

b) Or 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,
a) Are an annuitant, or ü

b) Are an active employee ü 45
45 Page 46 47
2001 Humana Medical Plan, Inc. 46 Section 9
Claims process – You probably will never have to file a claim form
when you have both our Plan and Medicare.

· When we are the primary payer, we process the claim first.
· When Original Medicare is the primary payer, Medicare processes your
claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something
about filing your claims, contact us at 1-800/ 426-2173.

We will not waive costs when you have Medicare – When Medicare is
the primary payer, we will not waive out-of-pocket costs.

° Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health

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

This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments, coinsurance,
or deductibles for your FEHB coverage.

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

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

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

TRICARE TRICARE is the health care program for eligible dependents of mi litary 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. 46
46 Page 47 48
2001 Humana Medical Plan, Inc. 47 Section 9
Workers' Compensation We do not cover services that:
· you need because of a workplace-related disease or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

· OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.

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

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies 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. 47
47 Page 48 49
2001 Humana Medical Plan, Inc. 48 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services provided to you such as assistance with dressing, bathing, preparation and feeding of special diets, walking, supervision of

medication which is ordinarily self-administered, getting in and out of
bed, and maintaining continence and are not likely to improve your
condition.

Experimental or investigational services A drug, biological product, device, medical treatment, or procedure is

determined to be experimental or investigational if reliable evidence
shows it meets one of the following criteria:

· when applied to the circumstances of a particular patient is the
subject of ongoing phase I, II or III clinical trials, or

· when applied to the circumstances of a particular patient is under study
with written protocol to determine maximum tolerated dose, toxicity,
safety, efficacy, or efficacy in comparison to conventional alternatives,
or

· is being delivered or should be delivered subject to the approval and
supervision of an Institutional Review Board as required and defined
by the USFDA or Department of Health and Human Services

· is not generally accepted by the medical community

Reliable evidence means, but is not limited to, published reports and
articles in authoritative medical scientific literature or regulations and
other official actions and publications issued by the USFDA or the
Department of Health and Human Services.

Medical necessity Services necessary for the treatment or product that a licensed Physician or licensed healthcare provider would provide his or her patient for the

purpose of diagnosing, treating a sickness, illness, disease or its
symptoms.

Us/ We Us and we refer Humana Medical Plan, Inc.
You You refers to the enrollee and each covered family member. 48
48 Page 49 50
2001 Humana Medical Plan, Inc. 49 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.

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. 49
49 Page 50 51
2001 Humana Medical Plan, Inc. 50 Section 11
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. 50
50 Page 51 52
2001 Humana Medical Plan, Inc. 51 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/ 426-2173 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 are no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 51
51 Page 52 53
2001 Humana Medical Plan, Inc. 52 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Allergy care ..................................... 16
Alternative treatment ..................... 21 Ambulance................................. 27, 29

Anesthesia .......................... 24, 25, 26
Autologous bone marrow transplant................................. 24

Blood and blood plasma.......... 25, 26
Blood glucose monitor.................. 20 Breast cancer screening........... 13, 14

Casts ........................................... 25, 26
Changes for 2001.............................. 7 Chemotherapy................................. 17

Chiropractic services ..................... 21 Cholesterol tests ............................. 14
Claims ............................................... 39
Coinsurance............................... 11, 46 Colorectal cancer screening.......... 14

Congenital anomalies .................... 23
Contraceptive devices and drugs ........................... 16, 33

Coordination of benefits ......... 42-45
Copayment................................. 11, 46 Covered services ............................ 46

Covered providers ........................ 5, 8
Crutches ........................................... 20 Definitions....................................... 46

Dental care ....................................... 36 Diagnostic services ........... 13, 25, 26
Dialysis ...................................... 17, 20
Disputed claims review........... 40-41 Donor expenses (transplants)....... 24

Dressings................................... 25, 26
Durable medical equipment (DME) ...................................... 20

Effective date of enrollment......... 47
Emergency................................. 28-29 Experimental or investigational... 46

Eyeglasses ................................. 18-19
Family planning.............................. 16 Fecal occult blood test................... 14

Foot care .......................................... 19
General Exclusions........................ 38 Growth hormone therapy.............. 17

Hearing services ............................. 18
Home health services............... 13, 20 Home nursing care ......................... 20

Hospital...................................... 25-26

Immunizations .......................... 14-15
Infertility .......................................... 16 Inhospital physician care ........ 13, 22

Inpatient Hospital Benefits ..... 25-26
Insulin ............................................... 33 Insulin pumps.................................. 20

Laboratory and pathological
services................. 13, 14, 25, 26 Machine diagnostic

tests ....................... 13, 14, 25, 26
Magnetic Resonance Imagings (MRIs)...................................... 13

Mail-order prescription
drugs................................... 32-33 Mammograms ........................... 13, 14

Maternity Benefits ........... 8-9, 15, 25
Medicaid........................................... 44 Medical necessity........................... 46

Medicare..................................... 42-44
Members........................................... 47 Mental Conditions/ Substance

Abuse Benefits .................. 30-31
Newborn care................................... 15 Non-FEHB Benefits ....................... 37

Nurse
Licensed Practical Nurse............. 20 Licensed Vocational Nurse......... 20

Nurse Anesthetist......................... 25
Registered Nurse.......................... 20 Obstetrical care.......... 8-9, 15, 25

Occupational therapy............. 18 Office visits ..................................... 13
Oral and maxillofacial
surgery...................................... 23
Orthopedic devices................... 19-20 Out-of-pocket expenses................. 11

Outpatient facility care................... 26
Oxygen ...................................... 25, 26 Pap test...................................... 13, 14

Physical examination .............. 14, 15
Physical therapy.............................. 18 Physician............................................ 8

Preventive care, adult ..................... 14
Preventive care, children ............... 15 Prescription drugs..................... 32-34

Preventive services................... 14-15
Prior approval.................................. 10
Prostate cancer screening.............. 14

Prosthetic devices .................... 19-20
Psychologist.................................... 30 Radiation therapy........................... 17

Rehabilitation therapies................. 18
Room and board ....................... 25, 26 Second surgical opinion................ 13

Skilled nursing facility care .......... 26
Smoking cessation ......................... 21 Speech therapy ............................... 18

Splints .............................................. 25
Sterilization procedures ................ 16 Stress management......................... 21

Subrogation..................................... 45
Substance abuse....................... 30-31 Surgery ....................................... 22-24

° Anesthesia ................. 24, 25, 26
° Oral.......................................... 23 ° Outpatient............................... 26

° Reconstructive....................... 23
Syringes ........................................... 33 Temporary continuation

of coverage.............................. 48
Transplants ...................................... 24 Treatment therapies ....................... 17

Vision services.......................... 18-19
Walkers ............................................ 20 Weight management ...................... 21

Well child care ................................ 15
Wheelchairs..................................... 20 Workers' compensation................ 44

X-rays ......................... 13, 25, 26 52
52 Page 53 54
2001 Humana Medical Plan, Inc. 53
NOTES: 53
53 Page 54 55
2001 Humana Medical Plan, Inc. 54 Rates
Summary of benefits for Humana Medical Plan, 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;
$10 specialist
13

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

· Outpatient ...........................................................................................
Nothing
Nothing
25-26
26

Emergency benefits:
· In-area..................................................................................................
· Out-of-area..........................................................................................
$25 per visit
25% of charges up to a $50
maximum per visit.

29
29

Mental health and substance abuse treatment .................................. Regular cost sharing 30-31
Prescription drugs:
· Generic formulary drugs ..................................................................

· Brand name formulary drugs
· Non formulary drugs…………………………………………
· Maintenance drugs (90-day supply) when ordered through
our mail-order program.....................................................................

$5 copay
$10 copay
$25 copay
3 applicable copays

33
33
33

33
Dental Care
· Accidental injury benefit .................................................................. Nothing 36

Vision Care ............................................................................................. No benefit
Special features: TDD and TTY phone lines; HumanaBeginnings; National Transplant Network; and
HumanaFirst ®
35

Out-of-pocket maximum...................................................................... Nothing after $1,500/ per person or
$3,000/ Family enrollment per year.

Some costs do not count toward
this maximum.

11 54
54 Page 55
2001 Humana Medical Plan, Inc. 55 Rates
2001 Rate Information for
Humana Medical Plan, Inc.

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

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

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

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

Self Only EE1 $76.10 $25.36 $164.87 $54.96 $90.05 $11.41
Self and Family EE2 $190.25 $63.41 $412.20 $137.40 $225.12 $28.54 55

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