Pages 1--48 Preferred Plus of Kansas

Preferred Plus of Kansas http:// www. phsystems. com
2001 A Health Maintenance Organization

Serving: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley, and Chautauqua Counties, in Kansas
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
VA1 Self Only VA2 Self and Family

RI 73-604 1
1 Page 2 3
2001 Preferred Plus of Kansas Table of Contents 2
Table of Contents
Introduction…………………………………………………………………........................................................................ 4
Plain Language………………………………………………………………....................................................................... 4
Section 1. Facts about this HMO plan......................................................................................................................................... 5
How we pay providers................................................................................................................................................. 5
Who provides my health care?................................................................................................................................... 5
Patients' Bill of Rights................................................................................................................................................. 5
Service Area .................................................................................................................................................................. 6
Section 2. How we change for 2001………………………………………......................................................................... 6
Program-wide changes................................................................................................................................................ 6
Changes to this Plan..................................................................................................................................................... 6
Section 3. How you get care …………....................................................................................................................................... 7
Identification cards ...................................................................................................................................................... 7
Where you get covered care ....................................................................................................................................... 7

· Plan providers ........................................................................................................................................................ 7
· Plan facilities.......................................................................................................................................................... 7
What you must do to get covered care ..................................................................................................................... 7
· Primary care ........................................................................................................................................................... 7
· Specialty care ......................................................................................................................................................... 7
· Hospital care........................................................................................................................................................... 8
Circumstances beyond our control............................................................................................................................ 8
Services requiring our prior approval....................................................................................................................... 9
Section 4. Your costs for covered services................................................................................................................................. 9

· Copayments ........................................................................................................................................................... 9
· Coinsurance ........................................................................................................................................................... 9
Your out-of-pocket maximum.................................................................................................................................... 9
Section 5. Benefits…………………………………………………………....................................................................... 10
Overview...................................................................................................................................................................... 10
(a) Medical services and supplies provided by physicians and other health care professionals ............ 11
(b) Surgical and anesthesia services provided by physicians and other health care professionals ........ 19
(c) Services provided by a hospital or other facility, and ambulance services .......................................... 23
(d) Emergency services/ accidents ..................................................................................................................... 25
(e) Mental health and substance abuse benefits.............................................................................................. 27
(f) Prescription drug benefits ............................................................................................................................. 29
(g) Dental benefits ................................................................................................................................................ 32
Section 6. General exclusions --things we don't cover.......................................................................................................... 33
Section 7. Filing a claim for covered services ......................................................................................................................... 34
Section 8. The disputed claims process .................................................................................................................................... 35 2
2 Page 3 4
2001 Preferred Plus of Kansas Table of Contents 3
Section 9. Coordinating benefits with other coverage ........................................................................................................ 37
When you have…
·Other health coverage ...................................................................................................................................... 37
·Original Medicare ............................................................................................................................................. 37
·Medicare managed care plan........................................................................................................................... 39
TRICARE/ Workers' Compensation/ Medicaid .................................................................................................. 40
Other Government agencies.................................................................................................................................. 40
When others are responsible for injuries ............................................................................................................ 40
Section 10. Definitions of terms we use in this brochure ................................................................................................... 41
Section 11. FEHB facts ............................................................................................................................................................ 42
Coverage information........................................................................................................................................... 42
· No pre-existing condition limitation......................................................................................................... 42
· Where you get information about enrolling in the FEHB Program.................................................... 42
· Types of coverage available for you and your family ........................................................................... 42
· When benefits and premiums start ........................................................................................................... 43
· Your medical and claims records are confidential................................................................................. 43
· When you retire........................................................................................................................................... 43
When you lose benefits ....................................................................................................................................... 43
· When FEHB coverage ends....................................................................................................................... 43
· Spouse equity coverage ............................................................................................................................. 43
· Temporary Continuation of Coverage (TCC)........................................................................................ 43
· Converting to individual coverage........................................................................................................... 44
· Getting a Certificate of Group Health Plan Coverage.......................................................................... 44
Inspector General advisory:.................................................................................................................................. 44
Index ................................................................................................................................................................................ 45
Summary of benefits .................................................................................................................................................................. 47
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2001 Preferred Plus of Kansas 4 Introduction/ Plain Language
Introduction
Preferred Plus of Kansas 8535 E. 21 st North
Wichita, KS 67206
This brochure describes the benefits of Preferred Plus of Kansas under our contract (CS 2667) 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 6. 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 Preferred Plus of Kansas.

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

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

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

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

Preferred Plus of Kansas is an individual practice prepayment (IPP) model HMO. As a member of Preferred Plus of Kansas, you will select a primary care doctor for yourself and each member of your family. Each member may
designate his or her own primary care doctor. You will be able to choose from a list of doctors located throughout the service area. Preferred Plus of Kansas has more than 300 primary care doctors in its Kansas service area and more than
1,100 referral specialists.
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.

· Preferred Plus of Kansas is licensed under the laws or Kansas, as a Health Maintenance Organization
· Preferred Plus of Kansas was incorporated in 1991. ·
Preferred Plus of Kansas is a for-profit company.

If you want more information about us, call (316) 609-2390 or (800) 990-0345, or write to Preferred Health Systems,
8535 E. 21 st North, Wichita, KS 67206. You may also contact us by fax at (316) 609-2483, or visit our website at www. phsystems. com. 5
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2001 Preferred Plus of Kansas Section 2 6
Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is
the following counties in Kansas: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley and Chautauqa.

You may also enroll with us if you live or work in the following places:
The Kansas counties of Saline, Dickenson, Morris, McPherson, Chase, Reno, Harper, Greenwood and Elk.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do

not have to wait until Open Season to change plans. Contact your employing or retirement office.

Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

· This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and
day and visit limitations when you follow a treatment plan that we approve. Previously, we placed higher patient cost sharing on mental health and substance abuse services than we did on services to treat physical illness, injury,

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

safety activities by calling (316) 609-2390, or checking our website www. phsystems. com. You can find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare, take these five steps:

·· Speak up if you have questions or concerns.
·· Keep a list of all the medicines you take.
·· Make sure you get the results of any test or procedure.
·· Talk with your doctor and health care team about your options if you need hospital care.
·· Make sure you understand what will happen if you need surgery.

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

language referenced only women.
Changes to this Plan
· Your share of the non-Postal premium will increase by 9.4% for Self Only or 6.1% for Self and Family.

· This Plan will pay for the following limited dental services; see Section 5 (g) Dental benefits:
··Services relating to the trauma of sound natural teeth caused directly by an accidental injury (not from biting or chewing), including replacement of teeth.

··We will cover the administration of general anesthetic and the facility charges for dental care provided for special conditions. We will determine the medical necessity for these services.
· This Plan will cover one pair of orthopedic shoes per calendar year for diabetics. Commercial over the counter shoe inserts or orthotic devices are not covered. 6
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2001 Preferred Plus of Kansas Section 3 7
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment

confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at (316) 609-2390.

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 to get care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since
your primary care physician provides or arranges for most of your health care. A list of primary care providers can be reviewed in our provider
directory for Preferred Plus of Kansas. You must complete a physician
selection form or you may call Customer Services Department at (316) 609-2390, or (800) 660-8114.

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

· · Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a contracting OB/ Gyn for an annual well-women
exam once a year without a referral.
When services are needed for Mental Health and Substance Abuse
treatment, you will need to contact Mental Health Network at (800) 456-5641, to coordinate your care.

Here are other things you should know about specialty care: 7
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2001 Preferred Plus of Kansas Section 3 8
· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop
a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the

physician may have to get an authorization or approval beforehand).

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

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

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

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

·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

· · Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise 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 (316) 609-2390 or (800) 660-
8114. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
· You are discharged, not merely moved to an alternative care center; or
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. 8
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2001 Preferred Plus of Kansas Section 4 9
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.

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

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

We call this review and approval process, pre-certification. Your physician
must obtain pre-certification for the following services:
· cardiac catheterization; ·
developmental therapy;
· durable medical equipment; ·
home IV services;
· hospice; ·
inpatient hospitalizations;
· matrix therapy; ·
OB care;
· occupational therapy, under age 12;
· outpatient IV services; ·
out of the service area referrals;
· outpatient surgical procedures; ·
pain management programs;
· physical therapy, under age 12; ·
prosthetics;
· request for use of non-contracting provider;
· speech therapy, under age 12. ·
Mental conditions and substance abuse services – Contact Mental Health Network at (800) 456-5641.

It is the responsibility of the provider to receive precertification from us for the primary care physician authorized services. If the provider fails to pre-certify
the services, he/ she will be held responsible for the services. If you choose to seek any services without coordinating them with your primary
care physician, you will be responsible for the costs of the services.

Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
· · Copayments A copayment is a fixed amount of money you pay when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.
· · Deductible We do not have a deductible
· · Coinsurance We do not have coinsurance.
Your out-of-pocket maximum We do not have an out-of-pocket maximum. 9
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2001 Preferred Plus of Kansas Section 5 10
Section 5. Benefits --OVERVIEW
(See page 6 for how our benefits changed this year and page 47 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 (316) 609-2390 or (800) 660-8114 or at our website at www. phsystems. com.

(a) Medical services and supplies provided by physicians and other health care professionals .............................. 11-18
·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
·Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals .......................... 19-22
·Surgical procedures
·Reconstructive surgery
·Oral and maxillofacial surgery
·Organ/ tissue transplants ·Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ............................................................ 23-24
·Inpatient hospital
·Outpatient hospital or ambulatory surgical center
·Extended care benefits/ skilled nursing care
facility benefits
·Hospice care ·Ambulance

(d) Emergency services/ accidents ....................................................................................................................................... 25-26
·Medical emergency ·Ambulance

(e) Mental health and substance abuse benefits................................................................................................................ 27-28
(f) Prescription drug benefits ............................................................................................................................................... 29-31
(g) Dental benefits ........................................................................................................................................................................ 32
Summary of benefits...................................................................................................................................................................... 47 10
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2001 Preferred Plus of Kansas Section 5( a) 11
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

· Plan physicians must provide or arrange your care.
· We have no calendar year deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
· In physician's office

$10 per office visit

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

· Office medical consultations
· Second surgical opinion

$10 per office visit

At home Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap tests
· Pathology
· X-rays
· Non-routine Mammograms
· Cat Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG

Nothing if you receive these services during your office visit;
otherwise, $10 per visit. 11
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2001 Preferred Plus of Kansas Section 5( a) 12
Preventive care, adult You Pay
Routine screenings, such as:
· Blood lead level – One annually
· Total Blood Cholesterol – once every three years, ages 19 through 64
· Colorectal Cancer Screening, including
··Fecal occult blood test

$10 per office visit

··Sigmoidoscopy, screening – every five years starting at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $10 per office 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 office visit

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

· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age 65 and older, one every two consecutive calendar years

$10 per office visit

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, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit

Dietitian services for up to 4 visits per member, per calendar year when authorized by your primary care doctor $10 per office visit
Preventive care, children
· Childhood immunizations recommended by the American Academy
of Pediatrics
Nothing for children up to age 72
months, otherwise $10 per office 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 office visit 12
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2001 Preferred Plus of Kansas Section 5( a) 13
Maternity care You Pay
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care
· Prospective parents may receive authorization to select a primary care physician for their unborn child and we will cover one visit to

that physician prior to the birth of the child
Note: Here are some things to keep in mind:
· You do not need to precertify your normal delivery; see page xx for
other circumstances, such as extended stays for you or your baby.

· You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
· We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

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

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

Nothing

· We cover Lamaze childbirth classes from a participating hospital or OB/ GYN up to a maximum benefit of $30. 50% of the charges up to a maximum Plan benefit of $30. You
must submit proof of payment and
class completion to our Member Services Department.

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

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling, or elective abortions
All charges. 13
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2001 Preferred Plus of Kansas Section 5( a) 14
Infertility services You pay
Diagnosis and treatment of infertility, such as:
· Artificial insemination:
··intravaginal insemination (IVI)
··intracervical insemination (ICI)
··intrauterine insemination (IUI)
· Diagnostic services to establish the cause or reason for infertility, including:

Medical evaluation limited to sperm counts
Hysterosalpingography
Endometrial biopsy
Counseling
Surgical correction of physiological abnormalities causing infertility

$10 per office visit

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
· Fertility drugs and surrogate parenting

All charges.

Allergy care You pay
Testing and treatment

· Allergy injection
Nothing

· Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges 14
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2001 Preferred Plus of Kansas Section 5( a) 15
Treatment therapies
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under Organ/ Tissue Transplants on page xx.

· 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)-424-0345 or (316) 609-2359 for preauthorization. We will

ask you to submit information that establishes if the GHT is medically necessary. 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 do 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 office visit

Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
· 60 outpatient visits 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.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 sessions per

condition

$10 per office visit

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

All charges

Developmental therapy You pay
Developmental therapy includes physical, speech, and occupational therapy. Your primary care physician must pre-certify your care. We

will cover as follows:
· for children under age 6 up to a maximum benefit of $1,000 for
each therapy listed in this section per calendar year

Nothing up to our maximum payment of $1,000; all charges thereafter 15
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2001 Preferred Plus of Kansas Section 5( a) 16
Hearing services (testing, treatment, and supplies)
· First hearing aid and testing only when necessitated by accidental injury

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

$10 per office visit

Not covered:
· all other hearing testing ·
hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment, and supplies) You pay
· Lenses and Frames immediately following cataract surgery under the following payment schedule. We will pay for two (2) lenses at $41
for single lenses, $62 for bifocal, $76 for trifocal or seamless, $140
for lenticular, $30 for frames, and $80 for contacts in lieu of lenses and frames.

All charges above our allowance

· Eye exam to determine the need for vision correction for children through age 17 (see preventive care) $10 per office visit
Not covered:
· Eyeglasses or contact lenses. Eye examinations for persons over age 17

· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

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

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. 16
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2001 Preferred Plus of Kansas Section 5( a) 17
Orthopedic and prosthetic devices You pay
· Artificial limbs and eyes; stump hose
· 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.

· Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: We pay internal prosthetic devices as

hospital benefits; see Section 5 (c) for payment information. 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.

· One pair of orthopedic shoes per diabetic member, per calendar year
Note: We will cover one standard appliance device per lifetime, unless repair/ replacement is medically necessary as a result of normal usage or

changes in condition.

Nothing

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

All charges.

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

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

All charges over the $1,000 yearly
benefit maximum.

Not covered:
· Motorized wheel chairs All charges. 17
17 Page 18 19
2001 Preferred Plus of Kansas Section 5( a) 18
Home health services
· Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide. Services include

oxygen therapy, intravenous therapy and medications.

$10 per visit

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

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

All charges.

Alternative treatments
Not covered:
· naturopathic services
· hypnotherapy ·
biofeedback
· music therapy
· guided imagery ·
therapeutic touch
· aroma therapy ·
acupressure
· reflexology ·
cranio-sacral therapy
· acupuncture

All charges.

Educational classes and programs
Coverage is limited to:
· Diabetes self-management

Outpatient self management training, and education for diabetics is covered
if treated in an approved program, and such treatment is rendered by a person certified by the National Certification Board of Diabetic Educators.

Nothing 18
18 Page 19 20
2001 Preferred Plus of Kansas 19 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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 and are payable only when we determine they are medically necessary.

· Plan physicians must provide or arrange your care.
· We have no calendar year deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

(i. e. hospital, surgical center, etc.).
· YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the pre-certification information shown in Section 3 to be sure which

services require pre-certification and identify which surgeries require pre-certification.

I M
P O
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T

Benefit Description You pay
Surgical procedures
Such as:
· 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 prostethic devices. See 5( a) – Orthopedic braces and prosthetic devices for device coverage information.
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing for hospital visits.

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

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit

Surgical procedures-Continued on next page. 19
19 Page 20 21
2001 Preferred Plus of Kansas 20 Section 5( b)
Surgical procedures (Continued) You pay
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 office visit

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

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

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

hours after the procedure.

See above.

Not covered:
· Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

· Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
· Reduction of fractures of the jaws or facial bones; ·
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

Oral and maxillofacial surgery – Continued on next page 20
20 Page 21 22
2001 Preferred Plus of Kansas 21 Section 5( b)
Oral and maxillofacial surgery (Continued) You Pay
Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

· Dental work related to TMJ

All charges.

Organ/ tissue transplants
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single –Double
· Pancreas
· 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

· National Transplant Program (NTP) -United Resource Network
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical trial at a Plan-designated center of excellence and if approved

by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We also cover transportation costs for the
member and a companion when the member resides more than 50 miles from the transplant site and if the transplant is performed outside our
service area. We define transportation costs as commercial
transportation for the member receiving the transplant, and a companion, to and from the site of the transplant. We also cover

reasonable and necessary lodging and meal costs of the member and
companion beginning 24 hours prior to the hospitalization and 48 hours after discharge. We cover transportation, lodging and meals up to $125

per day up to a maximum benefit of $2,000.

Nothing

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

· Implants of artificial organs
· Transplants not listed as covered

All charges 21
21 Page 22 23
2001 Preferred Plus of Kansas 22 Section 5( b)
Anesthesia You pay
Professional services provided in –

· Hospital (inpatient)
Nothing

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

$10 per visit 22
22 Page 23 24
2001 Preferred Plus of Kansas 23 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

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

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

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

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

· YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require pre-certification.

I M
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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

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

Nothing

Not covered:
· Custodial care ·
Non-covered facilities, such as nursing homes, extended care facilities, schools

· Personal comfort items, such as telephone, television, barber
services, guest meals and beds
· Private nursing care

All charges 23
23 Page 24 25
2001 Preferred Plus of Kansas 24 Section 5( c)
Outpatient hospital or ambulatory surgical center You Pay
· Operating, recovery, and other treatment rooms ·
Prescribed drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services
· Administration of blood, blood plasma, and other biologicals ·
Blood and blood plasma, if not donated or replaced
· Pre-surgical testing
· Dressings, casts, and sterile tray services ·
Medical supplies, including oxygen
· Anesthetics and anesthesia service

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

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
We cover all necessary services with no dollar or day limit, including:

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

Nothing

Not covered: custodial care All charges
Hospice care
We cover supportive and palliative care for a terminally ill member in the home or hospice facility. Services include inpatient and outpatient

care, and family counseling; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or

less.

Nothing

Not covered: Independent nursing, and homemaker services All charges
Ambulance
· Ambulance service when medically appropriate Nothing 24
24 Page 25 26
2001 Preferred Plus of Kansas 25 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.

· We have no deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
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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:
Emergencies within our service area: If you are in an emergency situation, please call your primary care
doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency

room personnel that you are a Plan member so they can notify us. You or a family member should notify us
within 48 hours. It is your responsibility to ensure that we have been timely notified. We can be reached by phone at (316) 609-2390, or (800) 660-8114.

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

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition. To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by

Plan providers.
Emergencies outside the service area: Benefits are available for any medically necessary health service that
is immediately required because of injury or unforeseen illness. If you need to be hospitalized, we must be
notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us within that time. If a Plan doctor believes care can be better provided in a Plan hospital,

you will be transferred when medically feasible with any ambulance charges covered in full. 25
25 Page 26 27
2001 Preferred Plus of Kansas 26 Section 5( d)
Benefit Description You pay
Emergency within our service area

· Emergency care at a doctor's office
· Emergency care at an urgent care center
$10 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 All charges.
Emergency outside our service area

· Emergency care at a doctor's office
· Emergency care at an urgent care center
$10 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 ·
Emergency care provided outside the service area if the need for
care could have been foreseen before leaving the service area
· Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

Ambulance
Ambulance service when medically appropriate including, air ambulance

See 5( c) for non-emergency service.
Nothing 26
26 Page 27 28
2001 Preferred Plus of Kansas 27 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

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

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

Here are some important things to keep in mind about these benefits:
· All benefits are subject to the definitions, limitations, and exclusions in this brochure.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
· YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

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 Mental Health Network, Inc.

approves.

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

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

· Medication management

$10 per office visit

· Diagnostic tests $10 per visit
· Services provided by a hospital or other facility
· Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Mental health and substance abuse benefits -Continued on next page 27
27 Page 28 29
2001 Preferred Plus of Kansas 28 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Not covered: Services not approved in advance by Mental Health Network, Inc.

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.

Pre-authorization
To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

All services for mental conditions/ substance abuse benefits must be coordinated by Mental Health Network, Inc. prior to receiving services. Please contact Mental Health Network, Inc. at 1-800-456-5641.

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

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

If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional provider. During the transitional period, you may continue to see your

treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our notice to you of the change in coverage and will end 90 days after you

receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.

Limitation We may limit your benefits if you do not follow your treatment plan. 28
28 Page 29 30
2001 Preferred Plus of Kansas 29 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
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T
A
N
T

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

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

I
M
P
O
R
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.

· These are the dispensing limitations.
Participating Retail Pharmacy: Covered prescriptions are limited to a 34 day supply or 100 unit
dose, whichever is less. Covered prescriptions for erectile dysfunction are limited to an eight (8) unit dose per 34 day supply. Oral Contraceptives may be dispensed in a three month supply,

however, a co-payment is required for each months supply. If we authorize an exception to the dispensing limitation, each supply given will be subject to a co-payment.

Participating Mail Order or Internet Pharmacy (PlanetRx. com): Covered prescriptions are
limited to a 90 day supply, except as follows:

· Covered narcotic prescriptions, except Ritalin, are limited to a 34 day supply or a 100 dose of tablets or capsules, whichever is less.

· Covered prescriptions for erectile dysfunction are limited to a twenty-four (24) unit dose per 90 day supply.
· When you have to file a claim. The pharmacy will file the claim for you. If you have a situation
where the pharmacy is unable to file the claim for your prescription, contact our Member Service Department at (316) 609-2390 or (800) 660-8114, and ask them to send you a prescription

reimbursement form.

Prescription drug benefits begin on the next page. 29
29 Page 30 31
2001 Preferred Plus of Kansas 30 Section 5( f)
Benefit Description You pay
Covered medications and supplies
.

We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order program:

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

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

· Contraceptive drugs and devices
· Oral contraceptive drugs -up to a three-cycle supply may be obtained at one time with a copay charge applied to each cycle.

· Contraceptive devices, such as diaphragms and IUD's
Diabetic supplies, including syringes, diagnostic strips, alcohol swabs and lancets. Diagnostic strips will be subject to the name brand

copayment. All other diabetic supplies will be subject to the generic
copayment.
· Intravenous fluids and medication for home use, implantable drugs, such as Norplant and some injectable drugs, such as Depo Provera are

covered under Medical and Surgical Benefits.
· Drugs to treat sexual dysfunction are limited to an 8 unit dose per 34-day supply and a 24 unit dose per 90-day supply

$5 copay per generic prescription – retail.
$15 copay per brand name prescription – retail
$10 copay per mail-order
prescription.

When generic substitution is permissible (i. e., a generic drug is

available and the prescribing doctor does not require the use of
a brand name drug), but you
request the brand name drug, you pay the difference between the

generic and brand name drug as
well as the $15 copay

Note: If there is no generic equivalent available, you will still

have to pay the brand name copay.

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 brand name. If you receive a brand name drug when a Federally-approved generic drug is

available, and your physician has not specified Dispense as Written
for the brand name drug, you have to pay the difference in cost between the brand name drug and the generic as well as the

copayment.

· We have an open formulary. If your physician believes a brand name product is necessary or there is no generic available, your
physician may prescribe a brand name drug from a formulary list.
This list of brand name drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost.

· Medications requiring pre-authorization include: Adderal, Dexedrine and
Desoxyn; Oral Anabolic Steroids; Medications to treat acne for persons over the age of 30 including, but not limited to, Retin-A, Accutane, and Differin;

Hormone suppositories and powders; Anti-fungal medication including, but
not limited to, Lamisil or Sporanox; and Wellbutrin SR/ 150 mg.

Covered medications and supplies – Continued on next page 30
30 Page 31 32
2001 Preferred Plus of Kansas 31 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
· Drugs and supplies for cosmetic purposes
· Vitamins, nutrients and food supplements even if a physician prescribes or administers them

· Drugs available without a prescription or for which there is a
nonprescription equivalent available.

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

· Medical supplies such as dressings and antiseptic.
· Drugs to enhance athletic performance.
· Drugs to aid in smoking cessation, including nicotine patches.
· Fertility drugs.
· Appetite suppressants, except for treatment of morbid obesity.

All Charges 31
31 Page 32 33
2001 Preferred Plus of Kansas 32 Section 5( g)
Section 5 (g). Dental benefits
I M
P O
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A N
T

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

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

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

I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must
result from an accidental injury. Treatment must be initiated within 30
days of the date of injury.

$10 copay per office visit

Dental benefits
We cover the administration of general anesthetic and hospital inpatient
charges (not the dental procedure) we determine to be medically necessary for dental care for the following persons:

· Dependent children five years of age or under; or
· A member who is severely disabled; or
· A member who has a medical or behavioral condition which requires hospitalization or general anesthesia when dental care is
provided.

Nothing

We have no other dental benefits. 32
32 Page 33 34
2001 Preferred Plus of Kansas Section 6 33
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition.

We do not cover the following:
· Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

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

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

incest;
· Services, drugs, or supplies related to sex transformations; or
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 33
33 Page 34 35
2001 Preferred Plus of Kansas 34 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.

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, hospital, drug 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)-660-8114 or 316-( 609)-2390.

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: Preferred Health Systems, 8535 E. 21 st
North, Wichita, Kansas 67206

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. 34
34 Page 35 36
2001 Preferred Plus of Kansas 35 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 8535 E. 21 st Street North, Wichita, Kansas 67206; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III,
P. O. Box 436, Washington, D. C. 20044-0436.

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. 35
35 Page 36 37
2001 Preferred Plus of Kansas 36 Section 8
The Disputed Claims Process (Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must provide a copy of your specific written consent with the

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

5 5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

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

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was

before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-
(800)-424-0345 or (316)-609-2359; and we will expedite our review; or

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

·· You can call OPM's Health Benefits Contracts Division III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 36
36 Page 37 38
2001 Preferred Plus of Kansas 37 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. We will not waive any of our copayments. Your care must continue to be authorized

by your primary care physician, or precertified as required.

(Primary payer chart begins on next page.) 37
37 Page 38 39
2001 Preferred Plus of Kansas 38 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) Areanactiveemployee withtheFederalgovernment (includingwhenyouor afamilymemberare eligibleforMedicaresolely becauseofadisability), ü

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

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

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

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

ü
(for other
services)

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined

that you are unable to return to duty,

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

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

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

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

3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, ü
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or………………………………………………… ………. ü
b) Are an active employee… ………………………………… ………………………..……. ü 38
38 Page 39 40
2001 Preferred Plus of Kansas 39 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 (316) 609-2390 or 1-( 800)-660-
8114 or locate us at www. phsystems. com.

· · 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.

This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care

plan's network and/ or service area (if you use our Plan providers), but we
will not waive any of our copayments.

Suspended FEHB coverage and a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage 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. 39
39 Page 40 41
2001 Preferred Plus of Kansas 40 Section 9
· · 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.

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 for injuries When you receive money to compensate you for medical or hospital care
for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement. 40
40 Page 41 42
2001 Preferred Plus of Kansas 41 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.

Covered services Care we provide benefits for, as described in this brochure.
Experimental or If a service has not been approved by the Federal Drug Administration investigational services (FDA) or is labeled experimental or investigational on the protocol the
Plan considers the service experimental or investigational.
Medical necessity Means a service or item (intervention) that is delivered or undertaken primarily to prevent, diagnose, treat or palliate a disease, illness or injury,
genetic or congenital defect, pregnancy, or psychological condition that lies outside the range of normal, age appropriate human variation.
Interventions must be:
· Effective for the patient's medical condition and indications, which is determined by scientific evidence consisting primarily of

controlled clinical trails that demonstrate the effect of the intervention on health outcomes. If clinical trails have not been
conducted, effectiveness is evaluated on the basis of professional
standards of care or expert opinion.
· Expected to produce the intended results and have expected outcomes that outweigh potential harmful effects.

· Measurable by positive changes in the patient's health status as determined by length or quality of life.
· Appropriate for the patient's medical condition and indications. The
expected outcome relative to cost must represent an economically efficient use of resources.

· Performed in the proper setting, at the proper time, in the proper
amounts, and by the proper provider of care relative to the patient's condition.

· Recommended by the PCP and treating physician and determined by the Health Plan medical director to meet the above criteria.

Us/ We Us and we refer to Preferred Plus of Kansas
You You refers to the enrollee and each covered family member. 41
41 Page 42 43
2001 Preferred Plus of Kansas 42 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.

The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective

on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your spouse until you marry.

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

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan. 42
42 Page 43 44
2001 Preferred Plus of Kansas 43 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

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

· Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;

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

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

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

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

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

· · Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the

Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices.

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

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

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or

retirement office or from www. opm. gov/ insure. 43
43 Page 44 45
2001 Preferred Plus of Kansas 44 Section 11
· · Converting to You may convert to a non-FEHB individual policy if: individual coverage ··
Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot convert;

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

·· You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days after you receive this notice. However, if you are a family member who

is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

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

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

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

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

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

· Call the provider and ask for an explanation. There may be an error. ·
If the provider does not resolve the matter, call us at (316)-609-2390
or 1-( 800)-660-8114 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. 44
44 Page 45 46
2001 Preferred Plus of Kansas 45 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury 32
Allergy tests 14 Alternative treatment 18

Ambulance 26 Anesthesia 22
Autologous bone marrow transplant 21
Biopsies 19
Blood and blood plasma 23 Breast cancer screening 12

Casts 19 Changes for 2001 6
Chemotherapy 15 Childbirth 13
Cholesterol tests 12 Claims 34
Colorectal cancer screening 12 Congenital anomalies 19
Contraceptive devices and drugs 13,29 Coordination of benefits 37
Covered providers 7
Crutches 17 Definitions 41

Dental care 32 Developmental therapy 15

Diagnostic services 11 Disputed claims review 35
Donor expenses (transplants ) 21 Dressings 24
Durable medical equipment (DME) 17
Educational classes and programs 18 Effective date of enrollment 43
Emergency 25 Experimental or
investigational 33 Eyeglasses 16
Family planning 13

Fecal occult blood test 12 General Exclusions 33
Hearing services 16 Home health services 18
Hospice care 24 Home nursing care 18
Hospital 23 Immunizations 12
Infertility 14 Inhospital physician care 23
Inpatient Hospital Benefits 23 Insulin 30
Laboratory and pathological
services 11 Machine diagnostic tests 11

Magnetic Resonance Imagings (MRIs) 11
Mail Order Prescription Drugs 29 Mammograms 12
Maternity Benefits 13 Medicaid 40
Medicare 37 Mental Conditions/ Substance
Abuse Benefits 27 Neurological testing 11
Newborn care 13 Nursery charges 13
Obstetrical care 13
Occupational therapy 15 Office visits 11

Oral and maxillofacial surgery 20 Orthopedic devices 17
Out-of-pocket expenses 9 Outpatient facility care 24
Oxygen 17 Pap test 12
Physical examination 12 Physical therapy 15
Physician 7

Pre-admission testing 11 Precertification 9
Preventive care, adult 12 Preventive care, children 12
Prescription drugs 29 Preventive services 12
Prior approval 9 Prostate cancer screening 12
Prosthetic devices 17 Psychotherapy 27
Radiation therapy 15
Rehabilitation therapies 15 Renal dialysis 15

Room and board 23 Second surgical opinion 11
Skilled nursing facility care 24 Smoking cessation 31
Speech therapy 15 Sterilization procedures 13
Substance abuse 27 Surgery 19
· Anesthesia 22 · Oral 20
· Outpatient 24 · Reconstructive 20
Syringes 30 Temporary continuation of
coverage 43 Transplants 21
Treatment therapies 15 Vision services 16
Well child care 12
Wheelchairs 17 Workers' compensation 40

X-rays 11 45
45 Page 46 47
2001 Preferred Plus of Kansas 46 Notes
NOTES: 46
46 Page 47 48
2001 Preferred Plus of Kansas 47 Summary
Summary of benefits for the Preferred Plus of Kansas -2001
· Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

· We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
· Diagnostic and treatment services provided in the office ................... Office visit copay: $10 primary care; $10 specialist 11

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

· Outpatient....................................................................................................

Nothing 23
24
Emergency benefits:
· In-area .........................................................................................................
· Out-of-area .................................................................................................

$50 per visit

$50 per visit

26
26
Mental health and substance abuse treatment............................................ Regular cost sharing 27
Prescription drugs........................................................................................... $5 generic copay; $15 name brand copay; $10 mail-order copay 29

Dental Care................................................................................................... Accidental injury benefit; $10 copay per visit 32
Vision Care................................................................................................... No benefit. 16 47
47 Page 48
2001 Rate Information for
Preferred Plus of Kansas

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 VA1 $85.28 $28.43 $184.78 $61.59 $100.92 $12.79
Self and Family VA2 $195.82 $106.63 $424.28 $231.03 $231.17 $71.28 48

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