Pages 1--56 from Independent Health

This brochure describes the benefits of Independent Health under our contract (CS 1933) 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, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and are
summarized on page 55. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible,
and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Independent Health.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of 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. You may also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E
Street, NW Washington, DC 20415-3650.

Introduction/ Plain Language 4
4 Page 5 6
2002 Independent Health 5 Table of Contents
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive,
billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800/ 501-3439 and explain the situation.

If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300

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.

Inspector General Advisory 5
5 Page 6 7
2002 Independent Health 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

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

Who provides my healthcare?
The first and most important decision you must make is the selection of a primary care doctor. The decision is
important since it is through this doctor that all other health services, particularly those of specialists, are obtained. If
you live in Western New York you have access to more than 981 participating primary care doctors and 1,676
specialists; more than 19,500 participating pharmacies nationwide, as well as all of the area hospitals.

Your Rights
OPM requires all FEHB Plans to provide certain information to their FEHB members. 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. Independent
Health is a not-for-profit Health Maintenance Organization.

We are licensed under Article 44 of the New York State Insurance Law.
Independent Health celebrated its 20 th anniversary in 2000.
We have 'Excellent' accreditation from the National Committee for Quality Assurance (NCQA).
If you would like more information, contact the Western New York Marketing Department at (716) 631-5392
or (800) 453-1910.

Service Area
You must live or work in our service area to enroll with us. Our service area is where our providers practice. You
may enroll with us if you live in the following Western New York counties:

Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming counties
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, as described on page 31. 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. You do not have to
wait until Open Season to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2002 Independent Health 7 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change now shown here is a
clarification that does not change benefits.

Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)

Changes to this Plan
Your share of the non-Postal premium will increase by 23.2% for Self Only or 22.4% for Self and Family.
Your hospital emergency room copay has increased from $35.00 to $50.00. (Section 5 (d)).
Your prescription drug copays have increased and are now $5.00 for Tier 1, $15.00 for Tier 2, and $30.00 for Tier 3. (Section 5 (f)).

You now pay 50% for infertility treatment. We no longer cover drugs and medication to treat infertility. We will not cover services for an infertility diagnosis as a result of a current or previous sterilization procedure( s) and/ or
procedure( s) for reversal of a sterilization. We do not pay for costs associated with the collection and donation of
sperm (e. g. sperm washing).

You have a $1,000 annual allowance for durable medical equipment per member per calendar year. (Section 5 (a)).

We have increased the amount that you pay for prosthetic and orthopedic devices from nothing to 50%. (Section 5( a)).
You pay $10.00 for each home health visit. (Section 5 (a)).
You are entitled to an annual eye refraction. (Section 5 (a)).
We now cover certain intestinal transplants. (Section 5( b)).
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a)).

We no longer limit total blood cholesterol tests to certain age groups. (Section 5 (a)). 7
7 Page 8 9
2002 Independent Health 8 Section 2
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 our Member
Services Department at (716) 631-8701 or (800) 501-3439, press 1.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to NCQA standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our web site at
www. independenthealth. com.

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

What you must do It depends on the type of care you need. First, you and each family to get covered care 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. Our provider directory lists primary care
doctors with their locations and phone numbers. We update directories
on a regular basis. We send a directory to you when you enroll. You
may also request one by calling our Western New York Marketing
Department at (716) 631-5392 or (800) 453-1910. You can also find out
if your doctor participates with us by calling one of the numbers listed above.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return vistis
unless your primary care physician give syou a referral. However, a
woman may see her OB/ GYN of record directly, with no need to be
referred from her primary care doctor. 8
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2002 Independent Health 9 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will work with us to develop a treatment plan that allows you to see
your specialist for a certain number of visits without additional
referrals. Your primary care physician 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 (716) 631-5392. 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. 9
9 Page 10 11
2002 Independent Health 10 Section 3
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our 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-authorization.
Independent Health is committed to working with your doctor to ensure
you receive the best possible medical care in the most appropriate
medical setting. Because some medical conditions can be treated in a
variety of ways, Independent Health's Medical Director has developed a
list of procedures that need to be approved before they are performed.
Your doctor will work with Independent Health to receive this approval
before they are performed. There is nothing that you need to do.

Procedures that Require Pre-Authorization Alcohol/ substance abuse services

Bipap S& ST for sleep apnea only
Blepharoplasty
Bone growth stimulator
Breast implant removal
Breast reconstruction
Breast Reduction Mammoplasty
Chiropractic Services
Continuous passive motion devices
Cosmetic procedures
Depo Provera, when used for endometriosis
Disectomy
Durable medical equipment, including equipment for diabetics
Esophagoscopy with or without dilitation or with biopsy
Home care services
Hospice benefits
Inpatient dental services
Inpatient hospitalizations
Intra-articular injections of hyalgan or synvisc
IDET (intradermal electrotherapy)
Lumbar laminectomy
Mental health services
New technology
Out-of-plan referrals
Oxygen
Physical, occupational and speech therapy services
Podiatry outpatient services
Psychological testing
Self-injectable drugs
Septorhinoplasty
Skilled nursing facility/ subacute facility admissions
Surgeries that require the use of an operating room
Synagis vaccine
Transplants
UGI Endoscopy with or without dilatation with or without biopsy
UPPP 10
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2002 Independent Health Section 4 11
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

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

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

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

Your catastrophic protection Out-of-pocket maximum We do not have an out-of-pocket maximum. 11
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2002 Independent Health Section 5 12
Section 5. Benefits -OVERVIEW
(See page 13 for how our benefits changed this year and page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact
our Member Services Department at (716) 631-8701 or (800) 501-3439, press 1, or visit our web site at
www. independenthealth. com.

(a) Medical services and supplies provided by physicians and other health care professionals ........................... 13-22
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

Speech therapy
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
Chiropractic
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................ 23-26
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services...................................................... 27-29
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance

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

(e) Mental health and substance abuse benefits ................................................................................................... 32, 33
(f) Prescription drug benefits................................................................................................................................ 34-35
(g) Special features............................................................................................................................................... 36, 37

Flexible Benefits Option
Telesource 24-hour Medical Help Line
Telesource Audio Health Library
Services for the deaf and hearing impaired

Case Management
Centers of excellence for transplants/ heart surgery/ etc.
Travel benefit/ services overseas

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

Summary of benefits.................................................................................................................................................... 55 12
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2002 Independent Health Section 5( a) 13
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

coverage, including with Medicare.

I M
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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
Office medical consultations
Second surgical opinion

$10 per office visit

At home $10 per office visit
During a hospital stay
In a skilled nursing facility
Nothing

Diagnostic and treatment services -continued on next page 13
13 Page 14 15
2002 Independent Health Section 5( a) 14
Diagnostic and treatment services (Continued) You pay
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

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

Non-routine Mammograms Nothing
Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test

$10 per office visit

-Sigmoidoscopy, screening – every five years starting at age 50
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

Preventive Care -Adult – continued on next page 14
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2002 Independent Health Section 5( a) 15
Preventive care, adult (Continued) You pay
Routine mammogram – covered for women age 35 and older,
as follows:

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

Nothing

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

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

Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit
Note: If the only reason for your
office visit is an Influenza or
Pneumococcal vaccine, you
pay nothing.

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care charges for routine examinations, immunizations and care
-Examinations done on the day of immunizations
Nothing

Examinations, for dependents up to age 22, such as:
-Eye chart exams to determine the need for vision correction
-Ear exams to determine the need for hearing correction

$10 per office visit for eye and ear
exams. 15
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2002 Independent Health Section 5( a) 16
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You 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

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug
benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization,
genetic counseling
All charges. 16
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2002 Independent Health Section 5( a) 17
Infertility services You pay
Services for the sole purpose of inducing pregnancy, including
procedures, diagnostic testing, laboratory testing, hospital/ facility
services and physician services.

Artificial insemination:
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Note: The number of allowable procedures is based on accepted medical
practices.

Note: We cover medically necessary services to treat correctable medical
conditions that have resulted in infertility with applicable office visit,
inpatient and outpatient facility copays depending on the type and
location of treatment or services. [See section 5( a), 5( b) and 5( c)].
Correctable medical conditions include: endometriosis, uterine fibroids,
adhesive disease, congenital septate uterus, recurrent spontaneous
abortions, and varicocele.

50% copay

Not covered:
Services for an infertility diagnosis as a result of current or previous sterilization procedure( s) and/ or procedure( s) for reversal

of sterilization.

Assisted reproductive technology (ART) procedures, such as:
-In vitro fertilization
-Embryo transfer
-Gamete intrafallopian transfer (GIFT)
-Zygote intrafallopian transfer (ZIFT)

Services and supplies related to excluded ART procedures
Costs associated with the collection and donation of sperm (e. g. sperm washing)

Cost of donor sperm or donor egg and all related services
Over-the-counter medications, devices or kits, such as ovulation kits
Drugs to treat Infertility

All charges

Allergy care
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 17
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2002 Independent Health Section 5( a) 18
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 26.

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

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: – We will only cover GHT when we pre-authorize the treatment.
Your prescribing physician will request prior authorization from us if
GHT is medically necessary for your treatment. We review most
prior authorization requests within 24 hours of receipt of all
necessary information.

$10 per office visit 18
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2002 Independent Health Section 5( a) 19
Physical and occupational therapies You pay
Up to two consecutive months per condition for the services of each of the following:

-Qualified physical therapists;
-Occupational therapists.
Note: We only cover therapy to restore bodily function when there
has been a total or partial loss of bodily function due to illness or
injury.

$15 per outpatient visit
Nothing per visit during covered
inpatient admission

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 36 sessions $10 per office visit
Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
Up to two consecutive months per condition for the services of a licensed Plan speech therapist $15 per office visit
Nothing per visit during covered
inpatient admission

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children up to age 22 to determine the need for hearing correction. (see Preventive care, children)
$10 per office visit

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

All charges. 19
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2002 Independent Health Section 5( a) 20
Vision services (testing, treatment, and supplies) You pay
Annual eye refraction exam $10 per office visit

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye glasses or contact lenses. Note: Discounts are available through Independent Health's optical discount program. Please see

Section 5( i) for Non-FEHB benefits available to Plan members.

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. 20
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2002 Independent Health Section 5( a) 21
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.

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

50% copayment per device.

Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy. Nothing
Not covered:
hearing aids
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices
wigs or hair prosthesis
prosthetic replacements provided less than 3 years after the last one we covered

All charges.

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

hospital beds;
wheelchairs;
crutches; and
walkers;

Note: You must receive pre-authorization from the Medical Director
before purchasing DME. When your physician prescribes this
equipment, the physician will contact us to receive approval.

50% copayment per device.
Note: You have an annual
maximum benefit of $1,000 for
DME.

insulin pumps
blood glucose monitors
$10 copay per item

Not covered:
Personal convenience items
Humidifiers, air conditioners Athletic or exercise equipment

Computer assisted communication devices

All charges. 21
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2002 Independent Health Section 5( a) 22
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.
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;

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.

All charges.

Chiropractic
The following services by a licensed Plan chiropractor

Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic care must be provided in connection with the
detection and correction by manual or mechanical means, of any
structural imbalance, distortion or subluxation in the human body.
You must receive a referral for chiropractic care from your Primary
Care Physician.

$10 per office visit

Alternative treatments
No Benefit. We do not cover service such as:
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

Diabetes self-management
Note: Please refer to Section 5( i) Non-FEHB benefits available to Plan
members for other classes such as Stop Smoking classes.

$10 per office visit 22
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2002 Independent Health Section 5( a) 23
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

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

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

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

surgical center, etc.).
YOUR PHYSICIAN MUST GET PRE-AUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the pre-authorization information shown in Section 3 to be sure

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

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure procedures
Biopsy procedure procedures
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.

$10 per office visit for outpatient
services and nothing for
inpatient services

Surgical procedures continued on next page.

Section 5( b) 23
23 Page 24 25
2002 Independent Health Section 5( a) 24
Surgical procedures (Continued) You pay
Voluntary sterilization
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
procedures received as an inpatient and office visit benefits for
procedures received as an outpatient.

$10 per office visit

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

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

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

$10 per visit for
outpatient services

Nothing for inpatient services

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.

$10 per visit for outpatient services
Nothing for inpatient services

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.

Section 5( b) 24
24 Page 25 26
2002 Independent Health Section 5( a) 25
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 office visit or
Nothing for inpatient services

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

All charges.

Section 5( b) 25
25 Page 26 27
2002 Independent Health Section 5( a) 26
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single – Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

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

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient. These benefits are subject to the
approval of the Medical Director.

$10 per office visit and
Nothing for inpatient services

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
Costs related to travel, food or lodging for the transplant recipient or donor

All charges.

Anesthesia
Professional services provided in –

Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing

Section 5( b) 26
26 Page 27 28
2002 Independent Health 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

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

We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
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).

YOUR PHYSICIAN MUST GET PRE-AUTHORIZATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services

require pre-authorization.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

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

Nothing

Inpatient hospital continued on next page. 27
27 Page 28 29
2002 Independent Health 28 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
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, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, 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.

$10 per visit

Not covered: blood and blood derivatives not replaced by the member All charges. 28
28 Page 29 30
2002 Independent Health 29 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): We provide a comprehensive range of
benefits for up to 45 days per calendar year when full-time skilled
nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved
by us.

All necessary services are covered, 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, maintenance care, respite care, or
convenience care
All charges.

Hospice care
We cover up to 210 days of Hospice services on an inpatient or
outpatient basis (including medically necessary supplies and drugs) for
a terminally ill member. Covered care is provided in the home or
hospice facility 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. As a part of hospice care, we cover
up to five (5) visits of bereavement counseling for covered family.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate, including ambulance services to a hospital, between hospitals and

between a hospital and a skilled nursing facility.
See 5( d) for emergency service

$25 per trip 29
29 Page 30 31
2002 Independent Health 30 Section 5( c)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

coverage, including with Medicare.

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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 reasonably
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.

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 doctor's office or
urgent care center visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services
Note: We waive the copay if the emergency results in an inpatient
admission to the hospital.

$50 per hospital
emergency room 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 plus the
difference, if any, between
the Plan's reimbursement and
the provider's billed charges.

Note: We require a $10
copay for each provider per
date of service.

Emergency care as an outpatient or inpatient at a hospital, including doctors' services. $50 per hospital emergency room visit.

Section 5( d) 30
30 Page 31 32
2002 Independent Health 31 Section 5( c)
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges.

Ambulance
Professional ambulance service when medically appropriate, including
ambulance services to a hospital, between hospitals and between a
hospital and a skilled nursing facility.

See 5( c) for non-emergency ambulance service.

$25 per trip

Section 5( d) 31
31 Page 32 33
2002 Independent Health 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.

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

coverage, including with Medicare.
YOU MUST GET PRE-AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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

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

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

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

Medication management

$10 per visit

Mental health and substance abuse benefits -Continued on next page 32
32 Page 33 34
2002 Independent Health 33 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing if you receive these
services during your office
visit; otherwise, $10 per
office visit

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, residential treatment, facility based intensive
outpatient treatment

Nothing

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

All charges.

Pre-authorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
We are committed to working with our providers to ensure that you receive
the best possible care in the most appropriate setting. Because some mental
health and substance abuse conditions can be treated in a variety of ways,
we require that Plan providers obtain pre-authorization from us.

You need a referral from your Plan doctor for visits to all participating
psychiatrists, psychologists, counselors, and social workers. Referrals
to non-participating providers require prior written authorization from
Independent Health's Medical Director.

Independent Health recognizes that you and your doctor may need
assistance in finding an appropriate provider. Your doctor may contact our
Utilization Management Department for assistance. You will receive a
copy of our provider directory when you join Independent Health. If you
need an additional copy, call our Member Services Department at (716)
631-8701 or (800) 501-3439.

Limitation We may limit your benefits if you do not obtain a treatment plan. 33
33 Page 34 35
2002Independent Health 34 Section 5( g)
Section 5 (f). Prescription drug benefits
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T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Some drugs require prior authorization. Your prescribing physician will request require prior authorization from us when the drug is medically necessary for
your treatment. We review most prior authorization requests within 24 hours of
receipt of all necessary information.

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.

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There are important features you should be aware of. These include:
Who can write your prescription. Plan Providers must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan pharmacy. In addition to the many local pharmacies that are available, our national pharmacy network provides access to more

than 19,500 pharmacies across the country.
To take advantage of our National Pharmacy Network, simply present your member ID card at a participating pharmacy. We use a formulary. We use a 3-Tier prescription drug formulary. It is a

list of drugs that we have approved to be dispensed through Plan pharmacies. Our formulary has
more than 800 different medications and covers all classes of drugs prescribed for a variety of
diseases. Tier 1 contains generic, select brands, and some over-the-counter drugs. Tier 2 contains
preferred brand name drugs. Tier 3 contains non-formulary drugs. To obtain a copy of the
formulary, contact Member Services at (716) 631-8701 or (800) 501-3439, press 1.

Our Pharmacy and Therapeutics Committee, which consists of local doctors and pharmacists, meets
quarterly to review the formulary. The committee's recommendations are forwarded to the
Independent Health Board after each meeting, and the board makes the final decision.

These are the dispensing limitations. You may obtain up to a thirty-day supply. Plan pharmacies fill prescriptions using FDA-approved generic equivalents if available. All other prescriptions are

filled using FDA-approved brand name pharmaceuticals. You pay a $5 copay for all Tier 1 drugs, a
$15 copay for Tier 2 drugs and a $30 copay for all non-formulary drugs.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to
the original brand name product. The U. S. Food and Drug Administration sets quality standards for
generic drugs to ensure that these drugs meet the same standards for safety, purity, strength and
effectiveness as brand-name drugs. Generic drugs are less expensive than brand name drugs, are the
most cost effective therapy available, and save you money.

When you have to file a claim. When you receive a bill for prescriptions filled at a non-plan pharmacy, please send a copy of the bill, with your member ID number, to: Independent Health P. O.

Box 1642 Buffalo, NY 14231-1642 Attn: Member Services 34
34 Page 35 36
2002Independent Health 35 Section 5( g)
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:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as
Not Covered
Growth hormones
Oral contraceptives and contraceptive devices, including contraceptive diaphragms

Nutritional supplements medically necessary for the treatment of phenylketonuria (PKU) and other related disorders
Self-administered injectable drugs, with pre-authorization
Intravenous fluids and medication for home use, implantable drugs, and some injectable drugs, such as Depro Provera, are covered under

Medical and Surgical Benefits.
Sexual dysfunction drugs have dispensing limitations. Contact us for details.

Unless otherwise indicated,
$5 per 30-day supply of a Tier 1 drug

or
$15 per 30-day supply of a Tier 2 drug

or
$30 per 30-day supply of a Tier 3 drug

Note: If there is no Tier 1
equivalent available, you will still
have to pay the Tier 2 copay.

Insulin $8 per 30-day supply
Diabetic supplies such as test strips for glucose monitors and visual reading and urine testing strips, syringes, lancets and cartridges for
the legally blind
$8 copay or 20% per item,
whichever is less, for up to a 30-
day supply

Disposable needles and syringes needed to inject covered prescribed medication

Implanted time-release medications, such as Norplant
20% copay

Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Drugs available without a prescription except for some over-the-counter products as listed on our formulary.

Medical supplies such as dressings and antiseptics

All charges. 35
35 Page 36 37
2002Independent Health 36 Section 5( g)
Section 5 (g). Special Features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly

alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

TeleSource 24-Hour Medical Help Line Independent Health's TeleSource 24-Hour Medical Help Line is ideal for those times when you can't reach your doctor right away and you
have concerns and questions about an illness or you need to reach a
utilization management case manager. Our registered nurses are on call
to assist you 24 hours a day, 7 days a week, and can even coordinate a
trip to the hospital in case of an emergency. Call 1-800-501-3439,
press 2 to get the help you need when you need it most.

TeleSource Audio Health Library The TeleSource Audio Health Library features more than 1,500 pre-recorded health-related messages. Learn how to stay healthy, get
parenting tips, or just find out about your Independent Health benefits.
To try this member benefit, call 1-800-501-3439, press 3 anytime, 24
hours a day, 7 days a week. Press 1, then enter a four-digit code, such
as one of the following examples:

4994 Quit Smoking
4452 Ear infection in children
4293 Chest pain and angina
4398 What is diabetes?
4192 Causes of back pain
6406 Breast Cancer
For more instructions, press 1, then dial 1000. Make sure you have a
pen handy to jot down any notes. For a complete directory of topics
and codes, please visit our web site at www. independenthealth. com.
Please note that Independent Health's TeleSource should not be used
for diagnosis, or as a substitute for a physician.

Services for deaf and hearing impaired Members may contact Independent Health through a TDD machine at (716) 631-4840. 36
36 Page 37 38
2002Independent Health 37 Section 5( g)
Section 5 (g). Special Features
Case Management Independent Health has case management programs for geriatric, pediatric, mental health, chemical dependency, pre-natal, chronic
diseases and catastrophic cases. Physicians are the main source for
identifying high-risk members. The most suitable cases are members
that have or are anticipated to have complex care needs, and/ or long-term
care needs.

If you think you and/ or one of your dependents may benefit from one
of our case management programs, call your doctor. Together you can
decide on the appropriate treatment plan, and if you are referred to case
management, one of our case managers will contact you to obtain
additional information.

Centers of excellence for transplants/ heart
surgery/ etc

With pre-authorization, you have access to the following Centers
of Excellence:

Bone Marrow – Roswell Park Cancer Institute
Heart – Kaleida Health (Buffalo), Children's Hospital of Pittsburgh,
University of Wisconsin, Cleveland Clinic Foundation

Heart/ Lung – University of Wisconsin, Cleveland Clinic Foundation
Lung – University of Wisconsin, Cleveland Clinic Foundation
Kidney – Kaleida Health (Buffalo), University of Wisconsin,
Cleveland Clinic Foundation

Liver – Children's Hospital of Pittsburgh, University of Wisconsin,
Cleveland Clinic Foundation

Kidney/ Pancreas – Kaleida Health (Buffalo), University of Wisconsin
Neonatal Critical Care – Kaleida Health (Buffalo)
Contact us for details.

Travel benefit/ services overseas Independent Health members have worldwide coverage for emergency care services. This does not include travel-related expenses. Contact us
for details. 37
37 Page 38 39
2002 Independent Health 38 Section 5( h)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

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

coverage, including with Medicare.

I M
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Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly
(within 12 months) repair (but not replace) sound natural teeth. The
need for these services must result from an accidental injury.

$10 per office visit

Dental benefits
We cover treatment that is Medically Necessary due to congenital
disease or anomaly such as cleft lip/ cleft palate.
$10 per office visit

Not covered: Dental services not shown as covered. 38
38 Page 39 40
2002 Independent Health Section 5( i) 39
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or
out-of-pocket maximums.

Fitness Programs Independent Health covers a number of wellness programs through our Feeling Fit program. These include: Stop
Smoking classes, Nutritional Consulting, Parenting Classes, and Stress Management workshops to name just a few.
Please contact Independent Health's Feeling Fit Department Line at 1-800-501-3439, press 4 in Western New York
for more information on these expanded benefits as well as our new member discount program. The discount program
includes savings on vision, dental services, entertainment, sporting goods and more.

Independent Health's vision discount program
Benefit You pay
The following plastic lenses are available:
Single Vision
Bifocal
Trifocal
Lenticular, and
Progressive

Conventional Contact Lenses
Frames

No discount for disposable contact lenses

$35 Copayment
$55 Copayment
$90 Copayment
$90 Copayment
$100 Copayment

85% of retail price
50% of retail price up to $130 and 80% of the balance over $130

Stop Smoking Program
Benefit You pay
Smoking Cessation Programs $10 copay (reimbursed upon presentation of certificate of completion of
program.)
Smoking Cessation Classes A discounted rate through our Feeling Fit Discount Program
Smoking Cessation Drug Therapy –
Nicotine Replacement Therapy.
The full price of the nicotine replacement product. Upon completion of a
Smoking Cessation program or Feeling Fit discount program. The
member submits the receipt and the certificate of completion or other
written evidence to Independent Health. The member is reimbursed for
up to a 3-month supply of the nicotine replacement product up to the
maximum reimbursement, which is 95% of the average wholesale price
of the drug.
Note: The Member is eligible to receive reimbursement for one participating program per calendar year.
Independent Health's Medicare+ Choice Plan: Encompass 65

Independent Health's Encompass 65 is a comprehensive, flexible health plan for Medicare beneficiaries in Western
New York. To be eligible for Independent Health's Encompass 65 coverage, you must be entitled to Medicare Part A
and enrolled in Medicare Part B. You must live in Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara,
Orleans, or Wyoming county in New York State and not be out of the service area for more than 90 consecutive days.

If you are interested in enrolling, contact your retirement system for information on canceling your FEHB enrollment
and joining Independent Health's Encompass 65 . You may also choose to enroll in Independent Health's Encompass
65 and retain your enrollment in Independent Health's FEHB plan. For more information on plan benefits,
copayments, and premiums, contact Independent Health's Marketing Department at 716-631-9452 or
1-800-453-1910, Monday through Friday, 8 a. m. until 5 p. m.

For more information, be sure to visit our web site at www. independenthealth. com. 39
39 Page 40 41
2002 Independent Health Section 6 40
Section 6. General exclusions -things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition and we agree.

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

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

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

rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 40
40 Page 41 42
2002 Independent Health 41 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment
or coinsurance.

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

Medical, Hospital and 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 (716) 631-8701 or (800) 501-3439, press 1.
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 of the 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: Independent Health
P. O. Box 1642
Buffalo, NY 14231-1642
Attn: Member Services

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative
operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 41
41 Page 42 43
2002 Independent Health 42 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies -including a request for pre-authorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Independent Health – Benefit Administration Department, P. O. Box 2090,
Buffalo, New York 14231; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C. 20415-3630. 42
42 Page 43 44
2002 Independent Health 43 Section 8
The Disputed Claims Process (contintued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

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

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must provide a copy of your specific written consent with the
review request.

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

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior
approval. 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 our
Benefits Admnistration Department at (716) 635-3951, Member Services at (800) 501-3934, press 1 or send
a fax to (716) 635-3504, attention: Review Specialist and we will expedite our review; or

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

You can call OPM's Health Benefits Contracts Division 3 at (202) 606-0755 between 8 a. m. and 5 p. m. eastern time. 43
43 Page 44 45
2002 Independent Health 44 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under
another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."

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

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

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

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered

employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January
1, 1983 or since automatically qualifies.) Otherwise, if you are age 65
or older, you may be able to buy it. Contact 1-800-MEDICARE for
more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social

Security check or your retirement check.
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 (Original Medicare) is available everywhere (Part A or B) in the United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits
now. You may go to any doctor, specialist, or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare, like
prescription drugs. 44
44 Page 45 46
2002 Independent Health 45 Section 9
When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your primary care
physician. We do not waive copayments or coinsurance when you are
enrolled in Medicare.

(Primary payer chart begins on next page.) 45
45 Page 46 47
2002 Independent Health 46 Section 9
The following chart illustrates whether the Original Medicare Plan 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 …

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

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a) the position is excluded from FEHB
b) or, the position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

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

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

(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,

(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,

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

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

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

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee … 46
46 Page 47 48
2002 Independent Health 47 Section 9
Claims process when you have the Original Medicare Plan – You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
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 (716) 631-8701 or (800) 501-3439
or visit our website at www. independenthealth. com

We do not waive any costs when you have Medicare.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --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 provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are
available to you:

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

This Plan and another plan's Medicare managed care plan: You
may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments, coinsurance, or
deductibles. If you enroll in a Medicare managed care plan, tell us. We
will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with
Medicare.

Suspended FEHB coverage to enroll in 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 managed care plan's service area. 47
47 Page 48 49
2002 Independent Health 48 Section 9
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.

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 illness 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 care. You must use our providers.

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

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 48
48 Page 49 50
2002 Independent Health 49 Section 10
Section 10. Definitions of terms we use in this brochure
Allowable Expense The necessary, reasonable, and customary item of expense for covered health care.

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.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Copayment A copayment is a fixed amount of money you pay to the provider when you receive covered services. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care which does not require the continuing attention of a trained medical person. Examples of custodial care are activities of daily
living, such as bathing, dressing, feeding and toileting. Custodial care is
not covered under this contract.

Medical, surgical or other treatments, procedures, techniques, and drug or
pharmacological therapies that have not yet been proven to be safe and
efficacious treatment. We do not cover procedures that are ineffective or
are in a stage of being tested or researched with questions( s) as to safety
and efficacy.

Medical Director This person is a licensed physician that we have designated to exercise general supervision over medical care.

Medical necessity Medical necessity is the term we use for health services that are required to preserve and maintain your health as determined by acceptable
standards of medical practice. Independent Health's Medical Director has
the right to determine whether any health care rendered to you meets
medical necessity criteria.

Referral Written authorization for specialty care services from a participating physician or Independent Health's Medical Director.

Us/ We Us and we refer to Independent Health
You You refers to the enrollee and each covered family member.

Experimental or
investigational services 49
49 Page 50 51
2002 Independent Health 50 Section 11
Section 11. FEHB facts
No pre-existing We will not refuse to cover the treatment of a condition that you had condition 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 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 for you and your family Self Only coverage is for you alone. Self and Family coverage is for
you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

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

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 50
50 Page 51 52
2002 Independent Health 51 Section 11
When benefits and premiums start The benefits in this brochure are effective on January 1. If you joined
this Plan during Open Season, your coverage begin on the first day of
your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any other
time during the year, your employing office will tell you the effective
date of coverage.

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.

Temporary Continuation of coverage 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, if
you lose your job, if you are a covered dependent child and you turn 22
or you marry, etc. 51
51 Page 52 53
2002 Independent Health 52 Section 11
You may not elect TCC if you are fired from your Federal job due to or
gross misconduct.

Enrolling in TCC. 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.
It explains what you have to do to enroll.

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 it 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 Group Health Plan Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPPA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group 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.

For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPPA" frequently asked questions. These highlight HIPPA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPPA, and have information about Federal and State
agencies you can contact for more information. 52
52 Page 53 54
2002 Independent Health 53
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective
in October 2002. As part of its educational effort, OPM asks you to consider these questions:

What is long term care (LTC) insurance?
It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or injury, or an age-related disease such as Alzheimer's.

LTC insurance can provide broad, flexible benefits for care in a nursing home, in an assisted living facility, in your home, adult day care, hospice care, and more. LTC insurance can supplement care provided by family
members, reducing the burden you place on them.
I'm healthy. I won't need long term care. Or, will I?
76% of Americans believe they will never need long term care, but the facts are that about half of them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need

chronic care due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but you should have a plan just in case. LTC insurance may be vital to your financial and retirement planning.

Is long term care expensive?
Yes. A year in a nursing home can exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a year, that's before inflation!

LTC can easily exhaust your savings but LTC insurance can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of your FEHB brochure. Custodial care, assisted living, or continuing home health care for activities of daily living are not covered. Limited stays in skilled

nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care after a hospitalization with a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but restricts covered services and where they can be received. LTC insurance can provide choices of care and preserve your independence.

When will I get more information?
Employees will get more information from their agencies during the late summer/ early fall of 2002.
Retirees will receive information at home.

How can I find out more about the program NOW? A toll-free telephone number will begin in mid-2002. You can learn more about the program now at
www. opm. gov/ insure/ ltc.

Many FEHB enrollees think their health plan and/ or Medicare covers long-term care. Unfortunately, they are WRONG! How are YOU planning to pay for the future custodial or chronic care you may need? Consider buying long term care insurance.

Section 11 53
53 Page 54 55
2002 Independent Health 54 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental Injury 19 Allergy tests 17
Alternative treatment 22 Allogenetic (donor) bone
Marrow transplant 26 Ambulance 29
Anesthesia 26 Autologous bone marrow
transplant 26
Biopsies 23 Birthing centers 16
Blood and blood plasma 28 Breast cancer screening 15

Casts 23 Catastrophic protection 11
Changes for 2001 7 Chemotherapy 18
Childbirth 16 Chiropractic 22
Cholesterol tests 14 Claims 42
Coinsurance 14 Colorectal cancer screening 14
Congenital anomalies 23 Contraceptive devices and drugs 35
Coordination of benefits 44 Covered charges 11
Covered providers 8
Crutches 21

Deductible 11 Definitions 49
Dental care 38 Diagnostic services 13
Disputed claims review 42 Donor expenses (transplants) 26
Dressings 28 Durable medical equipment
(DME) 21
Educational classes and programs 22 Effective date of enrollment 51
Emergency 30 Experimental or investigational 40
Eyeglasses 20
Family planning 16 Fecal occult blood test 14
Feeling Fit 39

General Exclusions 40
Hearing services 19 Home health services 22
Hospice care 29 Home nursing care 22
Hospital 9, 27
Immunizations 15 Infertility 17
Inhospital physician care 13 Inpatient Hospital Benefits 27
Insulin 35
Laboratory and pathological services 14

Machine diagnostic tests 14 Magnetic Resonance Imagings
(MRIs) 14 Mammograms 15
Maternity Benefits 16 Medicaid 48
Medically necessary 40, 49 Medicare 44
Mental Conditions/ Substance Abuse Benefits 32

Newborn care 11 Non-FEHB Benefits 39
Nurse Licensed Practical Nurse 22
Nurse Anesthetist 28 Registered Nurse 22
Nursery charges 16
Obstetrical care 16 Occupational therapy 19
Office visits 13 Oral and maxillofacial surgery 25
Orthopedic devices 21 Ostomy and catheter supplies 21
Out-of-pocket expenses 11 Outpatient facility care 11
Oxygen 10, 22

Pap test 14 Physical examination 6
Physical therapy 19 Physician 11, 30
Pre-admission testing 28 Precertification 10
Preventive care, adult 14 Preventive care, children 15
Prescription drugs 34 Preventive services 14
Prior approval 10 Prostate cancer screening 14
Prosthetic devices 21 Psychologist 32
Psychotherapy 32
Radiation therapy 18 Rehabilitation therapies 19
Renal dialysis 18 Room and board 27

Second surgical opinion 13 Skilled nursing facility care 29
Smoking cessation 39 Speech therapy 19
Splints 28 Sterilization procedures 16
Subrogation 48 Substance abuse 32
Surgery 23 Anesthesia 26
Oral 25 Outpatient 28
Reconstructive 24 Syringes 35

Telesource 36 Temporary continuation of
coverage 51 Transplants 26
Treatment therapies 18
Vision services 20
Well child care 15 Wheelchairs 21
Workers' compensation 48
X-rays 14 54
54 Page 55 56
2002 Independent Health 55
Summary of benefits for the Independent Health -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 primary care; $10 specialist 13

Services provided by a hospital:
Inpatient............................................................................................
Outpatient .........................................................................................
Nothing
$10 per visit

27
28
Emergency benefits:
In-area..............................................................................................

Out-of-area ......................................................................................

$10 per visit to doctor's office or
urgent care center; $50 hospital
emergency room copay per visit

$10 plus difference (if any) in
Plan's payment for doctor's and
urgent care center visits; $50
hospital emergency room copay
per visit

30
31

Mental health and substance abuse treatment ....................................... Regular cost sharing. 32
Prescription drugs .................................................................................
Up to a 30 day supply
$5 for Tier 1 drugs, $15 for Tier 2
drugs, or $30 for Tier 3 drugs per
prescription unit or refill

34

Dental Care .......................................................................................
For accidental injury to sound natural teeth
For congenital disease or anomaly

$10 per office visit 38

Vision Care .......................................................................................
Annual Eye refractions
$10 per office visit 20

Special features: Telesource Medical Help Line and Audio Health Library, Transplant Centers of
Excellence, World-wide Travel Benefits
36

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

Stated copays and coinsurance of
covered benefits 11 55
55 Page 56
2002 Independent Health 56
2002 Rate Information for
Independent Health

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; 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 who are not career postal employees. 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 QA1 $70.47 $23.49 $152.69 $50.89 $83.39 $10.57
Self and Family QA2 $196.46 $65.48 $425.66 $141.88 $232.47 $29.47 56

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