Pages 1--56 from Intergroup of Arizona

Intergroup of Arizona, Inc. http:// www. intergroupofarizona. com 2001
A Health Maintenance Organization

Serving: Cochise, Coconino, Gila, Maricopa, Pima, Pinal and Santa Cruz counties
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
A71 Self Only A72 Self and Family

RI 73-283

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

For
changes in
benefits
see page 7 1
1 Page 2 3

2001 Intergroup 2 Table of Contents
Table of Contents
Introduction .................................................................................................................................................................. 4
Plain Language .............................................................................................................................................................. 4
Section 1. Facts about this HMO plan .......................................................................................................................... 5
How we pay providers ................................................................................................................................. 5
Patients' Bill of Rights ................................................................................................................................. 5
Who provides my healthcare?...................................................................................................................... 6
Service Area................................................................................................................................................. 6
Section 2. How we changed for 2001 ........................................................................................................................... 7
Program-wide changes................................................................................................................................. 7
Changes to this Plan..................................................................................................................................... 7
Section 3. How you get care ......................................................................................................................................... 8
Identification cards....................................................................................................................................... 8
Where you get covered care......................................................................................................................... 8

· Plan providers........................................................................................................................................ 8
· Plan facilities ......................................................................................................................................... 8
What you must do to get covered care ......................................................................................................... 8

· Primary care........................................................................................................................................... 8
· Specialty care......................................................................................................................................... 8
· Hospital care.......................................................................................................................................... 9
Circumstances beyond our control............................................................................................................... 9
Services requiring our prior approval ........................................................................................................ 10
Section 4. Your costs for covered services ................................................................................................................. 11

· Copayments ......................................................................................................................................... 11
· Deductible ........................................................................................................................................... 11
· Coinsurance ......................................................................................................................................... 11
Your out-of-pocket maximum.................................................................................................................... 11
Section 5. Benefits ...................................................................................................................................................... 12
Overview.................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals ........... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 23
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 27
(d) Emergency services/ accidents......................................................................................................... 30
(e) Mental health and substance abuse benefits.................................................................................... 32
(f) Prescription drug benefits................................................................................................................ 34
(g) Special features ............................................................................................................................... 37
(h) Dental benefits ................................................................................................................................ 38
(i) Non-FEHB benefits available to Plan members.............................................................................. 39 2
2 Page 3 4

2001 Intergroup 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
Section 9. Coordinating benefits with other coverage ................................................................................................ 44
When you have…

·Other health coverage ......................................................................................................................... 44
·Original Medicare............................................................................................................................... 44
·Medicare Managed Care Plan............................................................................................................. 46
TRICARE/ Workers' Compensation/ Medicaid........................................................................................... 46
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............................................................................................................................................... 50

Coverage information ............................................................................................................................. 50
· No pre-existing condition limitation .................................................................................................. 50
· Where you get information about enrolling in the FEHB Program................................................... 50
· Types of coverage available for you and your family........................................................................ 50
· When benefits and premiums start..................................................................................................... 51
· Your medical and claims records are confidential ............................................................................. 51
· When you retire ................................................................................................................................ 51
When you lose benefits.............................................................................................................................. 51

· When FEHB coverage ends............................................................................................................... 51
· Spouse equity coverage .................................................................................................................... 51
· Temporary Continuation of Coverage (TCC) ................................................................................... 51
· Converting to individual coverage.................................................................................................... 52
· Getting a Certificate of Group Health Plan Coverage....................................................................... 52
Inspector General Advisory ....................................................................................................................... 52

Index ................................................................................................................................................................ 53
Summary of benefits.................................................................................................................................................... 54
Rates .................................................................................................................................................. Back cover 3
3 Page 4 5
2001 Intergroup 4 Introduction/ Plain Language
Introduction
Intergroup of Arizona, Inc. 930 North Finance Center Drive, Tucson, Arizona 85710-1362
This brochure describes the benefits of Intergroup of Arizona, Inc. HMO under our contract CS2121 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 54. 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 Intergroup of Arizona, Inc.
HMO.

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

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

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

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

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

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.

· Intergroup has been in existence since 1981 · Intergroup is a for-profit organization

You may review and obtain copies of your medical records on request. If you want copies of your medical records,
ask your health care provider for them. You may ask that a physician amend a record that is not accurate, not relevant
or incomplete. If the physician does not amend your record, you may add a brief statement to it. If they do not
provide you your records, call us and we will assist you.

If you want more information about us, call 1-800-289-2818, or write to Intergroup of Arizona, Inc., ATTN: Member
Inquiry, 930 North Finance Center Drive, Tucson, Arizona 85710-1362. You may also contact us by fax at 1-800-
889-8703 or visit our website at www. intergroupofarizona. com. 5
5 Page 6 7
2001 Intergroup 6 Section 1
Who provides my health care?
There are multiple locations throughout Maricopa County, Pima County, Cochise County, Coconino County, Gila
County, Pinal County and Santa Cruz County serving Intergroup members. When you enroll, you must select a
primary care physician (PCP) for yourself and eligible family members. Each member may choose a different
primary care physician. Intergroup of Arizona sometimes contracts with Medical Groups to provide medical care. In
these cases, the Medical Group determines the group of specialist( s) and hospital( s) that are available.

The first and most important decision each member must make is the selection of a primary care physician. The
decision is important since it is through this doctor that all other health services, particularly those of specialists, are
obtained. It is the responsibility of your primary care physician to obtain any necessary authorizations from the plan
before referring you to a specialist or making arrangements for hospitalization. Services of other providers are
covered only when there has been a referral by the member's primary care physician with the following exceptions: a
woman may see her plan obstetrician/ gynecologist without a referral and a member who is diabetic may see a plan
ophthalmologist for an annual eye examination to detect eye disease without a referral

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: Cochise, Coconino, Gila, Maricopa, Pima, Pinal and Santa Cruz counties.

You may also enroll with us if you live or work in the following places: the Tucson, Phoenix, Sierra Vista, Flagstaff,
Casa Grande and Nogales City areas.

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 unless they are preauthorized.

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. 6
6 Page 7 8
2001 Intergroup 7 Section 2
Section 2. How we changed 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 call our Customer Service Department at 1-800-289-2818 or checking our website at
www. intergroupofarizona. 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 you 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 20.1% for Self Only or 20.1% for Self and Family
· The out of pocket maximums will reflect 200% of the negotiated premium for 2001; we will update these figures in future years to reflect 200% of the negotiated premium for each respective year.

· The member will pay $25 for visits to Plan urgent care centers in 2001. Previously, the member paid $10 for visits to Plan urgent care centers.
· The Plan will cover 12 chiropractic visits per year with a network chiropractor. The member will pay a $10 copay per visit. Previously, the Plan did not cover chiropractic services. 7
7 Page 8 9
2001 Intergroup 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or obtain a
prescription at a Plan pharmacy. Until you receive your ID card, use your
copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 800/ 289-
2818.

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

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

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

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care. You can find a primary care physician by
looking in the provider directory, visiting our website, or calling us at 1-800-
289-2818

·Primary care Your primary care physician can be a Family Practice, General Practice, Internal Medicine, or Pediatrics physician. Your primary care physician

will provide most of your health care, or give you a referral to see a
specialist.

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

· Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a plan obstetrician/ gynecologist and diabetic
members may see a plan opthamologist for an annual eye examination to
detect eye disease without a referral.

Here are other things you should know about specialty care:

· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will work with the specialist and/ or the plan to develop a treatment
plan that allows you to see your specialist for a certain number of
visits without additional referrals. Your primary care physician will 8
8 Page 9 10
2001 Intergroup 9 Section 3
use our criteria when creating your treatment plan (the physician may
have to get an authorization or approval beforehand).

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

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

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

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

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

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

· Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-289-2818. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

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

These provisions apply only to the hospital benefit 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. 9
9 Page 10 11
2001 Intergroup 10 Section 3
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 prior authorization. Your
physician must obtain prior authorization for services such as: hospital
stays, some surgeries, home health care and organ transplants.

When your PCP feels that you may need such a service, he or she will
submit a request for an authorization.

Authorization Made Easy Program
Because we want your healthcare to be easy and convenient, we have
developed an Authorization Made Easy Program. PCPs who are part of
this program can give you a direct written referral or authorization. This
allows you to see certain specialists or get certain tests, without any prior
approval. This could include an initial consultation or evaluation,
diagnostic tests, and same day treatment.

If the specialist you need to see, or the test or procedure you need done
is not eligible for an Authorization Made Easy referral or authorization,
as described above, the following process will occur:

· Your PCP will submit the request to Intergroup. Once we receive the request, our medical staff will review it. They review the
treatment plan, covered benefits, medical history and national
treatment standards.

· If a request is denied, it will automatically proceed to one of our doctors for review. He or she will either support the decision for

denial or approve the care requested.
· If the case or treatment is complex, we may ask for an outside review from non-Intergroup doctors who are experts in the field of

care requested. If these doctors recommend the care, it will be
approved.

· If a case involves new medical technology, our doctors may review current medical literature and/ or consult with medical experts. Our

doctors will use this information to decide if the care requested is
appropriate.

Remember, your PCP must coordinate all your medical care (except
for emergencies). If you need specialty care, your PCP will determine
the most appropriate specialist, based on your medical condition. If
you go to a specialist, or receive a service without prior authorization,
the services you receive will not be covered by your Intergroup health
plan. 10
10 Page 11 12
2001 Intergroup 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
· Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

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

·Deductible We do not have a deductible

·Coinsurance We do not have coinsurance.
Your out-of-pocket maximum After your copayments total $4,992.52 per person or $13,470.72 per family for deductibles, coinsurance, enrollment in any calendar year, you do not have to pay any more for

and copayments 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 · infertility services

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 11
11 Page 12 13
2001 Intergroup 12 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this year and page 55 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 1-800-289-2818 or at our website at www. intergroupofarizona. 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
·Hospice care ·Ambulance

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

(e) Mental health and substance abuse benefits ................................................................................................... 32-33
(f) Prescription drug benefits ............................................................................................................................... 34-36
(g) Special features..................................................................................................................................................... 37
·Flexible benefits option ·Services for deaf and hearing impaired

·Disease Management Services
(h) Dental benefits...................................................................................................................................................... 38
(i) Non-FEHB benefits available to Plan members ................................................................................................... 39

Summary of benefits.................................................................................................................................................... 54 12
12 Page 13 14
2001 Intergroup 13 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 You pay
Diagnostic and treatment services
Professional services of physicians

· In physician's office
· Initial examination of a newborn child covered under a family enrollment

· Office medical consultations
· Second surgical opinions

$10 per visit

· In an urgent care center $25 per visit
· During a hospital stay
· In a skilled nursing facility

Nothing

At home $10 per visit

Diagnostic and treatment services --Continued on next page 13
13 Page 14 15
2001 Intergroup 14 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Not covered: hearing exams to determine extent of hearing loss, if you
are over age 18
All charges

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

If you receive these services
during your office visit, only your
$10 office visit copay will apply

Preventive care, adult
Routine screenings, such as:
· Blood lead level – One annually
· Total Blood Cholesterol – periodic depending on risk factors
· Colorectal Cancer Screening, including
··Fecal occult blood test

$10 per visit

··Sigmoidoscopy, screening – every three to five years starting at age 50 $10 per visit
Prostate Specific Antigen (PSA test) – testing as determined by physician $10 per visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$10 per visit 14
14 Page 15 16
2001 Intergroup 15 Section 5( a)
Preventive care, adult (Continued) You pay
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 49, one every one or two years
· At age 50 and older, one every year

· Other screenings as requested by the Primary Care Physician

Nothing

Not covered: Physical exams 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, ages 19 and over (except as provided for under Childhood immunizations)
$10 per visit

· Influenza/ Pneumococcal vaccines, annually, age 65 and over Nothing when performed by non-physician personnel or an affiliated
flu shot clinic sponsored by your
PCP or Intergroup

Preventive care, children You pay
· Childhood immunizations recommended by the American Academy of Pediatrics $10 per visit

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

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

$10 per visit 15
15 Page 16 17
2001 Intergroup 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:

· You do not need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your baby.

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

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

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

Surgery benefits (Section 5b).

$10 per visit, nothing for prenatal
and postnatal care after the initial
diagnosis of pregnancy

Not covered: Routine sonograms, amniocenteses, ultrasound or any other
procedure to determine fetal age, size or sex; non-medically necessary
circumcision after the newborn period.

All charges

Family planning
· Voluntary sterilization $10 per visit in a physician's office; nothing in inpatient or
outpatient hospital

· Surgically implanted contraceptives 50% of all services, limited to one implant in any 3 consecutive year
period

· Elective removal of surgically implanted contraceptives Nothing, limited to one non-medically necessary removal in
any 3 consecutive year period

· Injectable contraceptive drugs $10 per visit
· Intrauterine devices (IUDs) $10 per visit
· Elective removal of Intrauterine devices (IUDs) $10 per visit, limited to one non-medically necessary removal in
any 3 consecutive year period

Not covered: reversal of voluntary surgical sterilization, genetic
counseling, , diagnostic testing to establish paternity of a child, and
genetic testing

All charges 16
16 Page 17 18
2001 Intergroup 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
· Artificial insemination:
··intravaginal insemination (IVI)
··intracervical insemination (ICI)
··intrauterine insemination (IUI)

50% of all covered services

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 or sperm banking
· Fertility drugs

All charges

Allergy care
Testing and treatment $10 per visit

Allergy injection $10 per visit; nothing if performed
by non-physician personnel

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization, skin titration (Rinkel Method), cytotoxicity testing
(Bryans Test), RAST testing, MAST testing, urine autoinjection

All charges 17
17 Page 18 19
2001 Intergroup 18 Section 5( a)
Treatment therapies You pay
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 26.

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

· Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment.
Call 1-800-863-7847 for preauthorization information. We will ask you
or your doctor to submit information that establishes that the GHT is
medically necessary. You or your doctor must ask us to authorize
GHT before you begin treatment; otherwise, we will only cover GHT
services from the date you submit the information. If you or your
doctor does not ask or if we determine GHT is not medically necessary,
we will not cover the GHT or related services and supplies. See
Services requiring our prior approval in Section 3.

$10 per visit

Not covered: Experimental, investigational or alternative therapies. All charges
Rehabilitative therapies
Physical therapy, occupational therapy, cardiac rehabilitation and
speech and language therapy --

· Up to two consecutive months per condition, for the services of each of the following:

··qualified physical therapists;
··speech therapists; and
··occupational therapists.
Note: We only cover therapy to restore bodily function or speech
when there has been a total or partial loss of bodily function or
functional speech due to illness or injury.

$10 per visit

Not covered:
· long-term rehabilitative therapy
· exercise programs
· therapies provided for the purpose of maintaining physical condition

All charges 18
18 Page 19 20
2001 Intergroup 19 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
· Hearing screening to determine hearing loss and/ or to treat a suspected disease or injury to the ear

· Hearing testing for children through age 17 (see Preventive care, children)

$10 per visit

Not covered:
· all other hearing testing, including hearing exams to determine the extent of hearing loss if you are over age 18

· hearing aids, testing and examinations for them

All charges

Vision services (testing, treatment, and supplies)
· The first pair of contact lenses or corrective lenses following cataract surgery, treatment of keratoconus, aphakia, or corneal transplantation,
including a frame allowance of up to $75

$10 per visit

· Eye exam to determine the need for vision correction for children through age 17 (see preventive care)
· Lenses and/ or frames once every 24 months

$10 per visit

· Annual eye examination for refraction Nothing
· Elective contact lenses once every 24 months
Note: annual eye examination for refraction, lenses and/ or frames and
elective contact lenses benefits are administered by IVS. Call 800/ 443-
4994 x410

$100 allowance provided toward
the cost of contact lenses,
evaluation and fitting

Not covered:
· Eye exercises, orthoptics and any other vision training
· Radial keratotomy, lasik and any 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 visit

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

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

treatment is by open cutting surgery)

All charges 19
19 Page 20 21
2001 Intergroup 20 Section 5( a)
Orthopedic and prosthetic devices You pay
· Artificial limbs and eyes, including the initial purchase and subsequent purchases due to physical growth. Coverage is limited
to limbs that are necessary because of an illness, injury or surgery
causing anatomical functional impairment, or from a congenital
defect.

· Prosthetic devices when determined to be medically necessary and result from an illness, injury or surgery causing anatomical

functional impairment, or from a congenital defect. Coverage
includes the fitting and purchase of a standard model. Replacement
is covered only if determined to be medically necessary and results
from a change in your physical condition.

· Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.

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

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

Nothing

Not covered:
· orthopedic and corrective shoes · arch supports

· foot orthotics · heel pads and heel cups
· lumbosacral supports · corsets, trusses, elastic stockings, support hose, and other supportive
devices
· repairs and/ or replacement of parts or devices worn out due to misuse or abuse

· model upgrades, deluxe, or specialized equipment · over-the-counter items

All charges 20
20 Page 21 22
2001 Intergroup 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, of durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis
equipment. Under this benefit, we also cover:

· manual hospital beds
· standard size manual wheelchairs
· crutches, canes
· walkers
· plan approved standard blood glucose monitors
· insulin pumps
· plan approved peak flow meters
· medical supplies determined by Intergroup to be medically necessary to operate and/ or maintain a covered prosthesis or item of Durable

Medical Equipment, subject to the following exclusions and
limitations

Nothing

Not covered:
· motorized, electric or specialized wheel chairs · scooters or other power operated vehicles

· more than one device to provide essentially the same functional assistance
· deluxe, specialized or customized equipment, model upgrades · Transcutaneous Electrical Nerve Stimulation (TENS) units
· repair or replacement of equipment or parts due to misuse and/ or abuse
· over-the-counter braces and other DME devices, except as listed above
· prophylactic braces · braces used primarily for sports activities
· foot orthotics which are not an integral part of a leg brace

All charges

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 who is part of an
Intergroup contracted Home Health Care Agency.

· Services include oxygen therapy, intravenous therapy and medications.

Nothing

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

· nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication;
· housekeeping services; · services of a person who resides in the patient's home
· custodial care, rest cures, respite care · services performed by the patient's family member

All charges 21
21 Page 22 23
2001 Intergroup 22 Section 5( a)
Alternative treatments
Not covered:
· naturopathic services · hypnotherapy

· acupuncture services · acupressure services
· behavior training · educational, recreational, art, dance, sex, sleep or music therapies
· other forms of holistic treatment or alternative therapies

All charges

Educational classes and programs
Coverage is limited to classes offered by or through Intergroup's Health
Education Department. Recent classes and seminars include:

· Smoking Cessation
· Diabetes self-management
· Stress management
· Parenting
· Health nutrition
· Congestive heart failure counseling
· Lamaze
· Weight management

Nothing
A nominal fee may be required for
classroom materials 22
22 Page 23 24
2001 Intergroup 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan physicians must provide or arrange 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 charge (i. e. hospital,

surgical center, etc.).

I M
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Benefit Description You pay

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

· Correction of amblyopia and strabismus · Endoscopy procedure
· Biopsy procedure · Removal of tumors and cysts
· Correction of congenital anomalies (see reconstructive surgery) · Surgical treatment of morbid obesity --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.

$10 per visit

Surgical procedures continued on next page. 23
23 Page 24 25
2001 Intergroup 24 Section 5( b)
Surgical procedures (Continued) You pay
· Voluntary sterilization

· Treatment of burns

$10 per visit

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

Reconstructive surgery
· Surgery to correct a functional defect

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

··the condition can reasonably be expected to be corrected by such surgery

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

$10 per visit

· 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 this procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

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 Intergroup 25 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
· Reduction or manipulation of fractures of the jaws or facial bones and supporting tissues;

· Surgical correction of 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; and

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

$10 per visit

Not covered:
· Oral implants and transplants · Procedures that involve the teeth or their supporting structures

(such as the periodontal membrane, gingiva, and alveolar bone)
· Routine or general care of teeth or dental structures · Extraction of impacted or abscessed teeth

· Dental splints, dental implants, dental prostheses or dentures · Accidental injury to the teeth or gums caused by chewing

All charges 25
25 Page 26 27
2001 Intergroup 26 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single –Double
· Allogenic (donor) bone marrow transplants
· Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

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

· Donor searches limited to $5,000 per organ per lifetime
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.

$10 per visit

Not covered:
· Donor screening tests and donor search expenses which exceed the maximum lifetime benefit

· Implants of artificial or non-human 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

· Office $10 per visit 26
26 Page 27 28
2001 Intergroup 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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 You pay
Inpatient hospital
Room and board, such as
· ward, semiprivate, or intensive care accommodations; · general nursing care; and

· meals and special diets.

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

Nothing

Inpatient hospital continued on next page. 27
27 Page 28 29
2001 Intergroup 28 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
· Operating, recovery, maternity, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests and X-rays
· Administration of blood and blood products
· Blood or blood plasma, if not donated or replaced
· Dressings, splints, casts, and sterile tray services
· Medical supplies and equipment, including oxygen
· Anesthetics, including nurse anesthetist services

Nothing

Not covered:
· Custodial care · Non-covered facilities

· Personal comfort or convenience items, such as telephone, television, barber services, guest meals and beds, travel expenses
and take-home supplies
· Private nursing care · Collection and/ or storage of blood products for any unscheduled or

non-covered medical procedure

All charges

Outpatient hospital or ambulatory surgical center
· Operating, recovery, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services
· Administration of blood, blood plasma, and other biologicals
· Blood and blood plasma, if not donated or replaced
· Pre-surgical testing
· Dressings, casts, and sterile tray services
· Medical supplies, including oxygen
· Anesthetics and anesthesia service

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

Nothing

Not covered: collection and/ or storage of blood products for any
unscheduled or non-covered medical procedure
All charges 28
28 Page 29 30
2001 Intergroup 29 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF):
Coverage is provided when full-time skilled nursing care is medically
necessary and confinement in a SNF is medically appropriate as
determined by a plan doctor and approved by Intergroup. Covered
services include:

· Bed, board and general nursing care
· Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the SNF when prescribed by a plan doctor.

Nothing

Not covered: custodial care, domiciliary care, or convalescent care All charges
Hospice care
Members who are diagnosed as having an illness giving them a life
expectancy of 6 months or less, may request Hospice care. All Hospice
care must be provided by a licensed participating Hospice and include
inpatient and outpatient care related to the condition

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when medically appropriate
· Air ambulance when prior authorized or if the member's condition is an emergency and the location of the accidental injury and/ or

illness is inaccessible by ground vehicles, or transport by ground
ambulance would be detrimental to the member's health

Nothing 29
29 Page 30 31
2001 Intergroup 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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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
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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.

What to do in case of emergency:
If you are faced with a medical emergency, call 911 or go to the nearest emergency room.

Please notify your Primary Care Physician with 48 hours following emergency services, or as soon as
reasonably possible.

Emergency services do not include the use of a hospital emergency room or other emergency medical
facility for routine medical care, or follow-up or continuing care unless prior authorization has been given
by your Primary Care Physician or Intergroup.

Emergencies within our service area: : call 911 or go to the nearest emergency room
Emergencies outside our service area: : call 911 or go to the nearest emergency room 30
30 Page 31 32
2001 Intergroup 31 Section 5( d)
Benefit Description You pay
Emergency within our service area

· Emergency care at a doctor's office $10 per visit
· Emergency care at an urgent care center $25 per visit
· Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit

Not covered: Elective care or non-emergency care, continuing, routine
or follow-up care without prior authorization
All charges

Emergency outside our service area
· Emergency care at a doctor's office $10 per visit

· Emergency care at an urgent care center $25 per visit
· Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit

Not covered:
· Elective care or non-emergency care, continuing, routine or follow-up care without prior authorization

· Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
· Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Ambulance
Professional ambulance service when medically appropriate and in an
emergency situation. Air ambulance when prior authorized or if the
member's condition is an emergency and the location of the accidental
injury and/ or illness is inaccessible by ground vehicles, or transport by
ground ambulance would be detrimental to the member's health

See 5( c) for non-emergency service.

Nothing 31
31 Page 32 33
2001 Intergroup 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 INPATIENT SERVICES. See the instructions after the benefits description below.

I M
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T

Benefit Description You pay
Mental health and substance abuse benefits

All diagnostic and treatment services recommended
by a Plan provider and contained in a treatment plan
that we approve. The treatment plan may include
services, drugs, and supplies described elsewhere in
this brochure.

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

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

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

$10 per 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 32
32 Page 33 34
2001 Intergroup 33 Section 5( e)
Mental health and substance abuse benefits You pay
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 mental health and substance abuse benefits you must follow your treatment plan and all the following
authorization processes. These include:
To access Mental Health and/ or Substance Abuse benefits, you must contact
Catalina Behavioral Health Services at 1-800-977-0281. Services are
covered as necessary for the diagnosis and treatment of acute conditions
and as outlined above.

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 network 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. The transitional period
will last for up to 90 days from the date you receive notice of the change.
You may receive this notice prior to January 1, 2001, and the 90 day period
begins with receipt of the notice.

Network limitation We may limit your benefits if you do not follow your treatment plan. 33
33 Page 34 35
2001 Intergroup 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M P

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T

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

· All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are 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 maintenance medication

· We use a Preferred Drug List (formulary). Drugs are prescribed by plan doctors in accordance with the plan's Preferred Drug List. The plan's Preferred Drug List offers a variety of drug choices
in each therapeutic category. However, due to individual patient variability, a non-preferred drug
may be required at times. When a non-preferred drug is required, a simple process exists where a
doctor may request a patient specific authorization. Each request for a non-preferred drug is
evaluated to determine if it meets standard approval criteria established by the Intergroup Pharmacy
and Therapeutics Committee

To order a Preferred Drug List call 1-800-289-2818 or visit our website at
www. intergroupofarizona. com

These are the dispensing limitations. Prescription drugs obtained at a plan pharmacy will be dispensed for up to a 31-day supply. Mail order prescriptions are limited to Intergroup's mail order

provider and will be dispensed for up to a 93-day supply. Some medications may be dispensed in
quantities less than those stated due to prepackaging by the pharmaceutical manufacturer. Insulin,
diabetic supplies and inhalers have quantity per copayment limitations, as stated below. Refills are
only covered when authorized by a plan physician. You will be financially liable for the cost of
medications obtained after you are no longer eligible for coverage under this plan.

· When you have to file a claim. If you are required to pay for a prescription in an out-of-area emergency situation, you must submit an itemized statement to Intergroup for the charges you paid,

along with a completed claim form. Claims forms can be obtained by calling Intergroup at 1-800-
289-2818. Proof of payment must accompany the request for reimbursement.

Claims should be addressed to:
Intergroup of Arizona, Inc.
Attn: Pharmacy Department
930 N. Finance Center Drive
Tucson, Arizona 85710-1362

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

· Drugs for which a prescription is required by Federal law
· Drugs for sexual dysfunction require prior authorization and have dispensing limitations. Contact plan for details.

· Oral contraceptive drugs and contraceptive diaphragms
· Insulin – limited to 2 vials per copayment
· Disposable needles and syringes for the administration of covered medications – limited to 100 per copayment

· Diabetic supplies, including lancets, glucose test strips, visual reading testing strips, and urine testing strips – limited to 100 per
copayment
· Insulin cartridges for the legally blind – limited to the equivalent of 2 vials of insulin per copayment

· Automatic lancing devices – limited to one every six months per copayment
· Insulin aids (insulin pen) – limited to one every six months per copayment
· Glucogon (requires prior authorization) – limited to one per copayment
· Spacers and holding chambers for inhaled medications – limited to one per six months per copayment
· Inhalers – up to 2 (nasal or oral), or up to a 31-day supply, whichever is less, per copayment

$5 per generic prescription or refill
obtained from a plan pharmacy

$10 per brand name prescription or
refill obtained from a plan
pharmacy

$15 per generic prescription or
refill obtained through our mail
order program

$30 per brand name prescription or
refill obtained through our mail
order program

Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay. 35
35 Page 36 37
2001 Intergroup 36 Section 5( f)
Covered medications and supplies (continued) You pay
· Self-injectable drugs require prior authorization. (brand name copayment applies to insulin) $10 per prescription or refill, up to a 31-day supply. Quantity
limitations may apply to specific
drugs.

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

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

· 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 preferred drug (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 preferred drug list, call
1-800-289-2818.

Determination of whether a drug is classified as a Generic or Brand Name
Drug is made by a nationally recognized drug database management
company.

Not covered:
· Drugs and supplies for cosmetic purposes

· Nonprescription medicine
· drugs obtained at a non-plan pharmacy, except for out-of-area emergencies

· anorexiants, appetite suppressants, diet aids, weight loss medications, and drugs used to treat obesity
· fertility drugs
· vitamins (except prenatal)
· drugs to enhance athletic performance
· any drug consumed at the place where it is dispensed or that is dispensed or administered by the physician

· drugs prescribed for non-covered services
· take home drugs; drugs prescribed for use after discharge from a hospital, nursing home, skilled nursing facility or other inpatient

facility must be obtained from a plan pharmacy
· replacement prescriptions

All Charges 36
36 Page 37 38
2001 Intergroup 37 Section 5( g)
Section 5 (g). Special Features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
· We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative
benefit.
· Alternative benefits are subject to our ongoing review.
· By approving an alternative benefit, we cannot guarantee you will get it in the future.

· The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
· Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

Services for deaf and hearing impaired We provide a TTY line for the deaf and hearing impaired 1-800-977-6757.
Disease Management Services We help our members and the community learn how to stay healthy and how to manage chronic conditions. Intergroup offers AsthmaWise
Education and Management, Senior Outreach Programs, Diabetes
Management, Depression Management, Maternity Care, Congestive Heart
Failure Management, Migraine Management, Secondary Prevention
Following A Heart Attack, and Smoking Cessation Programs. 37
37 Page 38 39
2001 Intergroup 38 Section 5( h)
Section 5 (h). Dental benefits
I M
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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
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T
Accidental injury benefit You Pay

We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth, the jawbone and supporting tissues
(does not include injury caused by the act of chewing). 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 Intergroup 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.

Intergroup has added the WellRewards Program – a discount program offered to all Intergroup members.
Intergroup has been able to negotiate reduced prices and excellent values on a number of products and services,
including:

· Eyewear Discounts · Chiropractic Care · Health Club Discounts · Hearing Aids
· Home Fitness Products · Home Medical Equipment & Supplies · Member Classes and Seminars · Home Protection Service
· Mom & Baby Basics Program · Emergency Medical Record Service · Routine Podiatry

Sports Helmet Rebates. Heads up! Intergroup will rebate up to $25 for sports helmets of all kinds. Now bicyclists, rock-climbers, motorcyclists, horseback riders and other sports enthusiasts can buy industry-approved
protective helmets and receive an Intergroup rebate.
Car Seat Rebates. Helping you keep your child safe while riding in the car is our concern, as well as yours. Intergroup offers a rebate of up to $25 on the purchase of a child car seat for each child UNDER AGE 5 covered

by your Intergroup plan.

An Indemnity dental plan is now available to all eligible members. This insurance plan helps you cover the costs of
dental care. Covered dental services include exams, cleanings, filings and extractions as well as crowns, bridges, and
dentures. This plan reimburses you for covered dental expenses based upon a percentage of the reasonable and
customary (R & C) fee for those covered expenses. This plan allows you to select your own dentist and it is
affordable for you and your family. Premiums may be paid monthly (automatic deduction from your checking
account) or on either a quarterly or semi-annual basis.

Medicare Prepaid Plan Enrollment
This Plan offers Medicare recipients the opportunity to enroll in the plan through Medicare. As indicated on page 44,
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 re-enroll in the FEHB
Program. Contact your retirement system for information on dropping your FEHB enrollment and changing to a
Medicare prepaid plan. Contact us at 1-800-289-2818 for information on the Medicare prepaid plan and the cost of
that enrollment.

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored in this Plan without
dropping your enrollment in this Plan's FEHB plan, call the numbers above for information on the benefits available
under the Medicare HMO. 39
39 Page 40 41
2001 Intergroup 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 and we agree, as discussed under What Services Require Our

Prior Approval on page 10.
We do not cover the following:

· Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

· Services, drugs, or supplies you receive while you are not enrolled in this Plan;
· Services, drugs, or supplies that are not medically necessary;
· Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

· Experimental or investigational procedures, treatments, drugs or devices;
· Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or

incest ;
· Services, drugs, or supplies related to sex transformations; or
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 40
40 Page 41 42
2001 Intergroup 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,
coinsurance, or deductible.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-800-289-2818.

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: Intergroup of Arizona, Inc. Attn: Claims Department
930 N. Finance Center Drive
Tucson, Arizona 85710-1362

Prescription drugs Follow the process as stated above, but send your request for reimbursement to the following address.
Submit your claims to: Intergroup of Arizona, Inc. Attn: Pharmacy Department
930 N. Finance Center Drive
Tucson, Arizona 85710-1362

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 Intergroup 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

 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: Intergroup of Arizona, Inc.
Attn: Member Inquiry Department
930 N. Finance Center Drive
Tucson, Arizona 85710-1362; 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.

 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.

 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.

 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 3,
P. O. Box 436, Washington, D. C. 20044-0436. 42
42 Page 43 44
2001 Intergroup 43 Section 8
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.

 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.

 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-
289-2818 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 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 43
43 Page 44 45
2001 Intergroup 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 + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare managed care plan
you have.

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

When you are enrolled in this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. Your care
must continue to be authorized by your Plan PCP and prior authorized as
required.

We will not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.) 44
44 Page 45 46
2001 Intergroup 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), 9

2) Are an annuitant, 9
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB………………………………… ……….. 9

b) Or, the position is not excluded from FEHB………………………….
Ask your employing office which of these applies to you.
……………………..……… 9

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),
9

5) Are enrolled in Part B only, regardless of your employment status, 9 (for Part B
services)

9
(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,

9
(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, 9

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, 9

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, 9

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability,
a) And are an annuitant………………………………………………… ………. 9
b) And are an active employee………………………………………… …………………….. ……. 9

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare 45
45 Page 46 47
2001 Intergroup 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, call us at 1-800-289-2818.

When Medicare is the primary payer, we do not waive any out-of-pocket
costs.

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

This Plan and 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 for your
FEHB coverage.

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

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

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

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage. 46
46 Page 47 48
2001 Intergroup 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 for injuries medical or hospital care for injuries or illness caused by another person,
you must reimburse us for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 47
47 Page 48 49
2001 Intergroup 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 Room and board, nursing care (except for skilled nursing care), and personal care designed to assist a member who has reached the maximum
level of recovery

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 11.

Experimental or investigational services Our parent company, Foundation Health Systems (FHS), has a technology assessment policy committee whose sole function is to
evaluate if a drug, device, medical treatment or procedure is
experimental or investigational. FHS bases its determination on one or
more of the following:

· Is it broadly accepted in the medical community as standard, safe and effective for the illness or injury being treated;

· Is it approved for use by the appropriate governmental regulatory bodies, including the FDA:
· It is attainable in the U. S. outside of a research institution, program or protocol;
· Does it clearly improve the net health outcome as evaluated against non-experimental or non-investigational health care services using
credible and accepted medical evidence.

Group Health Coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies. 48
48 Page 49 50
2001 Intergroup 49 Section 10
Medical necessity Services required to identify or treat an illness that is either diagnosed or reasonably suspected. Medically Necessary services must, in the
judgement of Intergroup:
1. be required to treat an illness or injury; and
2. be consistent and appropriate for the diagnosis and treatment of
the Member's conditions; and
3. be in accordance with the standards of accepted principles of
medical practice in the United States; and
4. be performed at the most appropriate level of care for the
Member as determined by the Member's medical condition and
not the Member's financial or family situations, or the distance
the Member lives from the Hospital, or any other non-medical
factor; and
5. not be for the convenience of the Member, nor the Member's
family, support network, Physician or another Health
Professional; and
6. not be Experimental, Unproved or Investigational or furnished
in connection with medical or other research.

Us/ We Us and we refer to Intergroup of Arizona, Inc.
You You refers to the enrollee and each covered family member. 49
49 Page 50 51
2001 Intergroup 50 FEHB Facts
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. 50
50 Page 51 52
2001 Intergroup 51 FEHB Facts
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

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

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

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

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

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

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

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

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

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

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or
retirement office or from www. opm. gov/ insure. 51
51 Page 52 53
2001 Intergroup 52 FEHB Facts
·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 800/ 289-2818
and explain the situation.
· If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of

Personnel Management, Office of the Inspector General Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate
anyone who uses an ID card if the person tries to obtain services for
someone who is not an eligible family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 52
52 Page 53 54
2001 Intergroup 53 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 24, 25, 29, 31, 38 Allergy tests 17
Alternative treatment 18, 22, 32 Ambulance 29, 31
Anesthesia 26, 28 Autologous bone marrow
transplant 18, 26 Biopsies 23
Blood and blood plasma 14, 21, 28
Casts 28 Catastrophic protection 56

Changes for 2001 7 Chemotherapy 18
Childbirth 16, 50 Cholesterol tests 14
Circumcision 16 Claims 34, 41, 46, 51
Coinsurance 11, 48 Colorectal cancer screening 5, 14
Congenital anomalies 23, 24 Contraceptive devices and drugs 16, 35
Coordination of benefits 44 Covered charges 46
Crutches 21
Deductible 11, 48 Definitions 48

Dental care 20, 24, 25, 28, 38 Diagnostic services 13, 16, 28, 32
Disputed claims review 42 Donor expenses (transplants) 26
Dressings 28 Durable medical equipment
(DME) 21
Educational classes and programs 22 Effective date of enrollment 51

Emergency 6, 30 Experimental or investigational 48
Eyeglasses 19 Family planning 16
Fecal occult blood test 14

General Exclusions 40 Hearing services 14, 19
Home health services 21 Hospice care 29
Hospital 27
Immunizations 15 Infertility 17

In hospital physician care 23, 27 Inpatient Hospital Benefits 27
Insulin 21, 34, 35 Laboratory and pathological
services 14, 28 Magnetic Resonance Imagings
(MRIs) 14 Mail Order Prescription Drugs 35
Mammograms 14, 15 Maternity Benefits 16
Medicaid 46 Medically necessary 49
Medicare 44, 46 Members 4
Mental Conditions/ Substance Abuse Benefits 32
Newborn care 13, 16 Non-FEHB Benefits 39
Nurse Licensed Practical Nurse 21
Nurse Anesthetist 28 Registered Nurse 21
Nursery charges 16 Obstetrical care 8, 16
Occupational therapy 18 Office visits 11, 13, 14 16, 55
Oral and maxillofacial surgery 24 Orthopedic devices 20, 23
Out-of-pocket expenses 11 Outpatient facility care 28, 31
Oxygen 20, 21, 28 Pap test 14
Physical examination 14

Physical therapy 18 Physician 8, 23, 27 54
Preventive care, adult 14 Preventive care, children 15
Preventive services14, 15 Prescription drugs 34
Prior approval 10, 43 Prostate cancer screening 14
Prosthetic devices 20, 34 Psychologist 32
Radiation therapy 18 Rehabilitation therapies 18
Renal dialysis 18, 21 Room and board 27, 48
Second surgical opinion 13 Skilled nursing facility care
13, 29, 48 Smoking cessation 22, 37
Speech therapy 18 Splints 25, 27
Sterilization procedures16, 24
Subrogation 47 Substance abuse 7, 32
Surgery 23 · Anesthesia 23, 25, 28
· Oral 25 · Outpatient 28
· Reconstructive 24 Syringes 35
Temporary continuation of coverage 51
Transplants 25, 26 Treatment therapies 18
Vision services 15, 19 Well child care 15
Wheelchairs 21 Workers' compensation 46
X-rays 14,28 53
53 Page 54 55
2001 Intergroup 54 Summary
Summary of Benefits – for Intergroup of Arizona HMO
· 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

27
28

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

$50 per visit
$50 per visit
31
31

· Mental health and substance abuse treatment Regular cost sharing. 32
Prescription drugs Drugs prescribed by a Plan doctor
and obtained at a Plan pharmacy.
You pay a $5 copay per generic
prescription unit or refill; $10
copay per brand name
prescription unit or refill; $10
copay per self-injectable (except
for insulin) prescription unit or
refill.

34

Dental Care Accidental injury benefit. You
pay nothing. 38

Vision Care Comprehensive examination once every 12 months – you pay nothing

Lenses and/ or frames once every
24 months – you pay $10 copay for
materials

Elective contact lenses once every
24 months -$100 allowance
provided toward cost of contacts,
evaluation and fitting

19 54
54 Page 55 56
2001 Intergroup 55 Summary
Special features: Flexible benefits option, services for deaf and hearing impaired, Disease Management
Services
37

Protection against catastrophic costs
(your out-of-pocket maximum)

Nothing after $4,992.52/ Self Only
or $13,470.72/ Family enrollment
per year

Some costs do not count toward
this protection

11 55
55 Page 56
2001 Intergroup 56 Rates
2001 Rate Information for
Intergroup of Arizona, 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 A71 $72.01 $24.00 $156.02 $52.00 $85.21 $10.80
Self and Family A72 $194.29 $64.76 $420.96 $140.32 $229. 91 $29.14 56

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