Pages 1--53 from Vytra Health Plans

Enrollment codes for this Plan:
J61 Self Only J62 Self and Family

RI 73-294

For changes
in benefits
See page 8. 1
1 Page 2 3
2002 Vytra Health Plans 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………............................................................. 4
Plain Language………………………………………………………………............................................................ 4
Inspector General Advisory……………………………………………………………………………………………. 5
Section 1. Facts about this HMO plan..................................................................................................................... 6
How we pay providers ........................................................................................................................... 6
Who provides my health care? ............................................................................................................... 6
Your Rights........................................................................................................................................... 7
Service Area.......................................................................................................................................... 7
Section 2. How we change for 2002………………………………………............................................................... 8
Program-wide changes........................................................................................................................... 8
Changes to this Plan .............................................................................................................................. 8
Section 3. How you get care …………................................................................................................................... 9
Identification cards ................................................................................................................................ 9
Where you get covered care ................................................................................................................... 9
Plan providers.................................................................................................................................. 9
Plan facilities................................................................................................................................... 9
What you must do to get covered care .................................................................................................... 9
Primary care .................................................................................................................................... 9
Specialty care .................................................................................................................................. 9
Hospital care ................................................................................................................................. 10
Circumstances beyond our control........................................................................................................ 11
Services requiring our prior approval ................................................................................................... 11
Section 4. Your costs for covered services ............................................................................................................ 12
Copayments................................................................................................................................... 12
Deductible ..................................................................................................................................... 12
Coinsurance................................................................................................................................... 12
Your out of pocket maximum ……………………………………………………………………………. 12
Section 5. Benefits…………………………………………………………............................................................ 13
Overview............................................................................................................................................. 13
(a) Medical services and supplies provided by physicians and other health care professionals .......... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 21
(c) Services provided by a hospital or other facility, and ambulance services.................................... 25
(d) Emergency services/ accidents.................................................................................................... 27
(e) Mental health and substance abuse benefits ................................................................................ 29
(f) Prescription drug benefits .......................................................................................................... 31
(g) Special features ......................................................................................................................... 34
Flexible benefits option….…………………………………………………………………….. 34 2
2 Page 3 4
2002 Vytra Health Plans Table of Contents 3
(h) Dental benefits .......................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members .......................................................................... 36
Section 6. General exclusions --things we don't cover ......................................................................................... 37
Section 7. Filing a claim for covered services ....................................................................................................... 38
Section 8. The disputed claims process ................................................................................................................. 39
Section 9. Coordinating benefits with other coverage............................................................................................ 41

When you have…
Other health coverage.................................................................................................................. 41
Original Medicare ....................................................................................................................... 41
Medicare managed care plan ....................................................................................................... 43
TRICARE/ Workers' Compensation/ Medicaid.................................................................................... 43
Other Government agencies .............................................................................................................. 44
When others are responsible for injuries ............................................................................................ 44
Section 10. Definitions of terms we use in this brochure ....................................................................................... 45
Section 11. FEHB facts ........................................................................................................................................ 46

Coverage information .........................................................................................................................
No pre-existing condition limitation………………………………………………………………. 46
Where you get information about enrolling in the FEHB Program............................................... 46
Types of coverage available for you and your family .................................................................. 46
When benefits and premiums start .............................................................................................. 47
Your medical and claims records are confidential ....................................................................... 47
When you retire......................................................................................................................... 47
When you lose benefits .................................................................................................................... 47
When FEHB coverage ends........................................................................................................ 47
Spouse equity coverage ............................................................................................................. 47
Temporary Continuation of Coverage (TCC) ............................................................................. 47
Converting to individual coverage ............................................................................................. 48
Getting a Certificate of Group Health Plan Coverage ................................................................. 48
Long term care insurance is coming later in 2002……………………………………………………………………. 49
Index ........................................................................................................................................................ 50

Summary of benefits ............................................................................................................................................. 51
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2002 Vytra Health Plans 4 Introduction/ Plain Language
Introduction
Vytra Health Plans
395 North Service Road
Melville, NY 11747

This brochure describes the benefits of Vytra Health Plans under our contract (CS 2206) 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 is 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 changes are
summarized on page xx. 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 Vytra Health Plans.
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. 4
4 Page 5 6
2002 Vytra Health Plans 5 Advisory
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 631/ 694-6565 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. 5
5 Page 6 7
2002 Vytra Health Plans 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 health care?
Vytra Health Plans is an Individual Practice Association-HMO who provides care to plan members. That means we provide a broad
range of medical benefits including unlimited hospitalization. Medical benefits are provided for your premium with few, if any,
additional "out-of-pocket" expenses to you.

Furthermore, as an IPA-HMO, you receive care the way you're used to, through a private doctor's office. If your present doctor is a
Plan participant, you can stay with him/ her. This way, you can maintain or establish the doctor/ patient relationship you are familiar
with. Otherwise, you select a doctor from our list.

When you join Vytra Health Plans, we will ask you to select a primary care doctor. He/ she becomes your family doctor, arranging for
referrals to specialists. If hospitalization is necessary, your admission will occur at the hospital in which your doctor has admitting
privileges. Your primary care doctor becomes the manager of your care and, through him/ her, you have available all of the services we
provide. Adult female members also have the option of selecting a participating Ob/ Gyn.

The first and most important decision each member 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. Services of other providers
are covered only when there has been a referral by the member's primary care doctor with the following exceptions: a woman may see
her Plan gynecologist for her annual routine examination (this also includes a certified nurse/ midwife), and all members may see
participating Chiropractors, Podiatrists or Ophthalmologists without a referral from a primary care doctor. Member's seeking
treatment for Mental Conditions/ Substance Abuse must contact us at 1-800-528-3918 for a referral to a participating provider. We
will determine and authorize the appropriate number of visits. A referral from your PCP is not required.

The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists) with their
locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis
and are available at the time of enrollment or upon request by calling the Marketing Department at 631/ 694-6565. You can also find
out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider
who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients.
Important note: When you enroll in this Plan, services (except for emergency benefits) are provided through the Plan's delivery
system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

If you enroll, you will be asked to let the Plan know which primary care doctor( s) you've selected for each member of your family by
sending a selection form to the Plan. If you need help choosing a doctor, call the Plan. Members may change their selection by
notifying the Plan 30 days in advance. 6
6 Page 7 8
2002 Vytra Health Plans 7 Section 1
If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with
you to be seen by another participating doctor.

Your Rights
OPM requires that all FEHB Plans 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.

Vytra Health Plans meets all requirements of the New York State Insurance Department
We have been in existence since 1986
We are currently a not-for-profit organization

If you want more information about us, call 631/ 694-6565, or write to Vytra Health Plans, 395 North Service Road, Melville, NY
11747. You may also visit our website at www. vytra. com.

Service Area
To enroll with this plan, you must live in our Service Area. This is where our providers practice. Our service area includes Nassau,
Suffolk and Queens Counties on Long Island, New York.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to
change plans. Contact your employing or retirement office. 7
7 Page 8 9
2002 Vytra Health Plans 8 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 not shown here is a clarification that does not change
benefits.

Program-wide changes
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

Changes to this Plan
Your share of the non-Postal premium will increase by 28.4% for Self Only or 23.2% for Self and Family.
We clarified the Home health services benefit by removing yearly and lifetime visit limitations. (Section 5( a))
You pay $10 for a 90 day supply of maintenance drugs through our mail order prescription drug program. (Section 5( e))
We now cover certain intestinal transplants. (Section 5( b)) 8
8 Page 9 10
2002 Vytra Health Plans 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 631/ 694-6565.

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

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

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

What you must do to get It depends on the type of care you need. First, you and each family 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. To select a
primary care physician, you must complete the Primary Care Physician Selection form upon enrolling. These forms are included in our open enrollment packets or

you can obtain a form by contacting Vytra Health Plans.

Primary care Your primary care physician can be a family practitioner, internist, pediatrician or general practitioner. 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 tot he 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. Don't go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see
Obstetricians/ Gynecologists, Chiropractors, Podiatrists, Ophthalmologists and Mental Health/ Substance Abuse providers without a referral. Prior authorization is

required before you receive Mental Health/ Substance Abuse care. You must call us at 1-800-528-3918 to access this care before your first visit. 9
9 Page 10 11
2002 Vytra Health Plans 10 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 other providers
treating you and plan representatives to develop a treatment plan that allows you to
see your specialist for a certain number of visits without additional referrals. Your
primary care physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

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

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 631/ 694-6565. 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. 10
10 Page 11 12
2002 Vytra Health Plans 11 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 prior authorization. Your physician must obtain
prior authorization for the following services: such as inpatient hospitalization, surgical
procedures, care from specialists and mental health/ substance abuse care.

Your provider should supply us with appropriate medical documentation necessary for us
to make a determination.

Failure to obtain prior authorization will result in no coverage for services and related
supplies. 11
11 Page 12 13
2002 Vytra Health Plans 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, 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 A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.

Example: There is a $50 deductible for dental preventative coverage only.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. Coinsurance doesn't begin until you meet your deductible.

Example: You will pay 20% of our allowance for dental preventative coverage after you
meet your $50 deductible.

Your out-of-pocket maximum We do not have an out of pocket maximum. 12
12 Page 13 14
2002 Vytra Health Plans 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 52 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 631/ 694-6565 or at our website at
www. vytra. com.

(a) Medical services and supplies provided by physicians and other health care professionals……………………... 14-20

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
Durable medical equipment (DME)
Home health services
Chiropractic
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals....................... 21-24
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services................................................... 25-26
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Hospice care
Ambulance

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

(e) Mental health and substance abuse benefits......................................................................................... 29-30
(f) Prescription drug benefits.......................................................................................................................... 31-33
(g) Special features.............................................................................................................................................. 34
Flexible benefits option…………………………...............................................……………………….. 34

24 Hour Nurse LineHealthwise Knowledgebase…………………………………………………………. 34
(h) Dental benefits............................................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members .............................................................................................. 36

Summary of benefits ............................................................................................................................................. 51 13
13 Page 14 15
2002 Vytra Health Plans 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other
health care professionals

I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an urgent care center
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment

Office medical consultations
Second surgical opinion

$10 per visit

At home $10 per visit
During a hospital stay Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Note: Assigned radiologist for radiology procedures and Labcorp for
laboratory services must be used.

Nothing 14
14 Page 15 16
2002 Vytra Health Plans 15 Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening – every five years starting at age 50

$10 per office visit

Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$10 per office visit

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

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

Nothing

Not covered: Other types of preventative care such as physical exams
or immunizations required for obtaining or continuing employment or
insurance, attending schools or camp, or travel.

All charges.

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

Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit

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

Well-child care charges for routine examinations, immunizations and care (through age 17)
Examinations, such as:
-Eye exams through age 17 to determine the need for vision
correction.

-Ear exams through age 17 to determine the need for hearing
correction

-Examinations done on the day of immunizations (through age 17)

Nothing

Well-child care charges for routine examinations, immunizations and care in excess of the New York State well-child care schedule or from
age 17 to age 22
$10 per office visit 15
15 Page 16 17
2002 Vytra Health Plans 16 Section 5( a)
Maternity care You Pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your baby.

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

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

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

Surgery benefits (Section 5b).

$10 for the first visit only

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera if supplied by your provider)

Intrauterine devices (IUDs)
Diaphrams
NOTE: We cover oral contraceptives under the prescription drug
benefit.

$10 per office visit in providers office
Nothing if inpatient

Not covered: reversal of voluntary surgical sterilization, genetic
counseling, voluntary abortions
All charges.

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

$10 per office visit

Infertility services continued on next page 16
16 Page 17 18
2002 Vytra Health Plans 17 Section 5( a)
Infertility services (continued) You Pay
Not covered:
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
Services and supplies related to excluded ART procedures
Fertility drugs
Cost of donor sperm
Cost of donor egg

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.

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 24.

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

Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment.
See Services requiring our prior approval in Section 3. Growth
hormone drugs are covered under the prescription drug benefit.

$10 per office visit

Physical and occupational therapies
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 due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided.

$10 per office visit

Physical therapy coverage continued on next page 17
17 Page 18 19
2002 Vytra Health Plans 18 Section 5( a)
Physical and occupational therapies (continued) You Pay
Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
Up to two consecutive months per condition for rehabilitative purpose with a speech therapist

Up to 20 visits per year for non-rehabilitative purposes with a speech therapist
$10 per office visit

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit
Not covered:
all other hearing testing

hearing aids, testing and examinations for them

All charges

Vision services (testing, treatment, and supplies)
Limited to:
Eye exams for well child care (see Preventive care, children)
Nothing

Not covered: all other vision services such as
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

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

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

$10 per office visit

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

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. 18
18 Page 19 20
2002 Vytra Health Plans 19 Section 5( a)
Orthopedic and prosthetic devices You Pay
Standard artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5 (c) for payment information. See
5( b) for coverage of the surgery to insert the device.

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

$10 per office visit

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

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;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Call us at 631/ 694-6565 as soon as your Plan physician
prescribes this equipment.

Nothing

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

$10 per office visit

Home health services continued on next page 19
19 Page 20 21
2002 Vytra Health Plans 20 Section 5( a)
Home health services (continued) You Pay
Not covered:
nursing care requested by, or for the convenience of, the patient or the patient's family;

home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative..

All charges.

Chiropractic
Manipulation of the spine and extremities $10 per office visit

Not covered:
Treatment to maintain current condition
Chiropractic equipment
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

All charges.

Alternative treatments
Not covered:
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback

All charges.

Educational classes and programs
Coverage is limited to:
Diabetes self-management
Tobacco cessation
Note: Federal Drug Administration drugs approved for the treatment of
tobacco cessation are covered under the prescription drug benefit

$10 per office visit

Lamaze at designated facilities
Note: Contact us at 631/ 694-6565 for additional information.
Prices vary 20
20 Page 21 22
2002 Vytra Health Plans 21 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health
care professionals

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

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

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

center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which

services require precertification and identify which surgeries require precertification.

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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 procedures Biopsy 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 and prosthetic devices for device coverage information.

$10 per office visit in providers office;
nothing for hospital visit

Surgical procedures continued on next page. 21
21 Page 22 23
2002 Vytra Health Plans 22 Section 5( b)
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
a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit if in providers office;
Nothing if admitted into the hospital

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

All charges.

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

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

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

$10 per office visit

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 office visit
.

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

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

All charges 22
22 Page 23 24
2002 Vytra Health Plans 23 Section 5( b)
Oral and maxillofacial surgery You Pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate 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

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. 23
23 Page 24 25
2002 Vytra Health Plans 24 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic 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.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor
when we cover the recipient. Approval of the medical director is
required.

Nothing

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

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia You pay
Professional services provided in –

Hospital (inpatient)
Nothing

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

Nothing 24
24 Page 25 26
2002 Vytra Health Plans 25 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.

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
Sections 5( a) or (b).

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services

require prior 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

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 and schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care that is not medically necessary

All charges. 25
25 Page 26 27
2002 Vytra Health Plans 26 Section 5( c)
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

$10 per office visit

Not covered: Services related to dental care All charges
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): Limited to 45 days per calendar year.
Admission must be within 3 days from an inpatient hospital stay
Nothing

Not covered: custodial care All charges
Hospice care
Limited to 210 days per lifetime Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 26
26 Page 27 28
2002 Vytra Health Plans 27 Section 5( d)
Section 5 (d). Emergency services/ accidents
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.

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan
member so they can notify the Plan.

If you are hospitalized in non-plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.

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

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

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

If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any
ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by
Plan providers. 27
27 Page 28 29
2002 Vytra Health Plans 28 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care as an outpatient or inpatient at a hospital, including doctors' services or at an urgent care center $25 copay; waived if admitted

Emergency care at a doctor's office $10 per office visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $25 copay

Not covered:
Elective care or non-emergency care
Emergency care at a doctor's office
Emergency care at an urgent care center

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

All charges.

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing 28
28 Page 29 30
2002 Vytra Health Plans 29 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.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

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

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

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

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

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

Medication management
Note: Medications prescribed are covered under the prescription drug
benefit Section 5( f).

$10 per office visit

Mental health and substance abuse benefits -Continued on next page 29
29 Page 30 31
2002 Vytra Health Plans 30 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests $10 Per Visit

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

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.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
Services must be authorized before you receive treatment. You must call Value
Options at 1-800-528-3918 to obtain authorization for your first visit. Your
providers are responsible for obtaining authorization for additional visits. For a
listing of providers, please see our medical directory or consult our web site at
www. vytra. com. You can call Vytra Health Plans at 631/ 694-6565 to obtain a
listing of participating providers.

Limitation We may limit your benefits if you do not obtain a treatment plan. 30
30 Page 31 32
2002 Vytra Health Plans 31 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

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

I M
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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or licensed dentist must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy or maintenance drugs may be filled through our mail order program with Express Pharmacy Services. (A maintenance drug is a drug for

which you receive a prescription for a 90 day supply or more at one time.) To fill a prescription through our
mail order program for maintenance drugs, complete the order form (included in your Vytra Health Plans
enrollment packet), enclose your prescription and a check, money order, or credit card number. For more
information about our mail order program, please call us at 631/ 694-6565 or Express Pharmacy Services at
800/ 222-3383. For a two month's prescription drug copay you will receive a three month's supply of
maintenance drugs. NOTE: Some self injectibles must be obtained through mail order, see These are the
depensing limitations below for additional information.

We use a formulary. A formulary is a preferred listing of medications that Vytra uses. If a plan provider prescribes you a medication that is not on our formulary, your prescription will be filled. We will reeducate

the provider about our formulary and work with them to develop an appropriate treatment plan with
medications that are on our formulary.

These are the dispensing limitations. You can obtain up to a 34 day supply or 100 unit doses, whichever is greater, of a prescribed medication through a retail pharmacy. Prescriptions filled too soon after the last one

was filled will be denied. We follow FDA dispensing guidelines. This plan covers brand name and generic
medications at your $5 copay.

Self injectibles must be obtained through our mail order program except for diabetic supplies and growth
hormones. Our mail order vendor for self injectibles is American Prescription Providers, Inc. (APP).
Prescriptions for self injectibles should be mailed to APP, PO Box 9019, Famingdale, NY 11735-9019. For
questions regarding coverage for self injectibles, please call Vytra Health Plans at 631/ 694-6565 or APP at
800/ 227-1195.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in

strength and dosage to the original brand-name product. Generics cost your plan less than the equivalent
brand-name products. The U. S. Food and Drug Administration sets quality standards for generic drugs to
ensure that these drugs meet the same standards of quality and strength as brand-name drugs. Your
prescription will automatically be filled with a generic equivalent unless otherwise specified by your provider.

Prescription drug benefits begin on the next page. 31
31 Page 32 33
2002 Vytra Health Plans 32 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:
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
Vitamins All Federal Drug Administration approved medications for treatment

of tobacco cessation
Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Prior authorization below)
Contraceptive drugs and devices

Note: Prior authorization for Viagra is required for men under 40 years of
age. Limited to 6 pills per month for organic impotence. Sedatives and
hypnotics limited to three months.

$5 per 34 day supply at a retail pharmacy
$10 per 90 day maintenance supply through
our mail order program

Insulin Diabetic supplies
Note: Insulin and diabetic supplies are covered under your medical
benefits however, you can obtain these items at participating pharmacies.
Diabetic equipment is covered under your durable medical equipment
benefit see Section 5( a).

$10 per office visit

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

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

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call 631-694-6565 or visit our website
at www. vytra. com

Prescription drug benefits continued on next page 32
32 Page 33 34
2002 Vytra Health Plans 33 Section 5( f)
Covered medications and supplies (continued) You Pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Vitamins, nutrients and food supplements that can be purchased without a prescription

Nonprescription medicines available over the counter

All Charges 33
33 Page 34 35
2002 Vytra Health Plans 34 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 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.

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-622-6252 and talk with a registered nurse who will discuss treatment options and
answer your health questions.

Healthwise Knowledgebase For members who have access to the internet, Vytra offers a link to the Healthwise Knowledgebase. The Healthwise Knowledgebase is a credible source of current
health and medical information, written in

language that is easy to understand. Members of certain Vytra plans can search the
knowledgebase for information about various health conditions, medical tests and
procedures, and drug therapies. Since topics in the database are updated regularly by
a team of physicians, nurses, medical writers and researchers, you can be secure in
knowing that information is reliable and up-to-date. 34
34 Page 35 36
2002 Vytra Health Plans 35 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.
The calendar year deductible is: $50 the deductible applies to all benefits in this Section. We added "( No deductible)" to show when the calendar year deductible does not apply

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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Accidental injury benefit

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for
these services must result from an accidental injury and care must be received within 12 months from the date of the
accident. You pay nothing. Prior authorization required.

Dental Benefits
Upon your enrollment with our plan we encourage you to complete our dental application. You can contact us at 631/ 694-6565
or Healthplex (our dental carrier) at 516/ 794-3000 for more information.

Services You pay
Dental prophylaxis or cleaning (not more than 1 in a 6 consecutive month period)

Fluoride treatment (limited to 1 service in a 12 consecutive month period)
Oral Hygiene instruction
Sealants
Clinical oral examination (not more than 1 exam in a 6 consecutive month period)

Bitewing x-rays (limited to 1 service in a 6 consecutive month period)
Full mouth or panorex x-rays (limited to 1 service in a 36 consecutive month period)
Other dental x-rays as necessary
Note: This benefit is for preventive services only and
you may seek care from non-network dentists if you
choose the reimbursement option on the dental
application. Benefit limited to a maximum of $500 per
person per year.

20% coinsurance of our allowance after meeting a $50
deductible.

Not covered: Restorative services and other dental
services not shown as covered
All charges. 35
35 Page 36 37
2002 Vytra Health Plans 36 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about
them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

The services listed below can only be provided by participating dentists and if you selected the comprehensive option on your dental application. Dental applications are included in your enrollment packets or you can call Vytra Health Plans at
631/ 694-6565 or Healthplex (our dental carrier) at 631/ 794-3000 to obtain a dental enrollment form. You must select Vytra Health Plans as you medical carrier to have access to the benefits listed below.

Diagnostic & Preventive Services You Pay
Oral Exam (limit 2 x per year)……………………..... No Charge
Full Mouth X-rays (1 x in 36 months)…………..…... No Charge
Cleaning of Teeth
(prophylaxis & polishing, 1x in 6 months) …….….... No Charge
Bitewing Series……………….…………………...… No Charge
Single Films (periapical or bitewing) …….….……… No Charge
Fluoride Treatment ( 1 x in 12 months) …………….. No Charge
Specialty Consultation…………………………..…… No Charge
Clinical Oral Cancer Exam……………………......… No Charge
Emergency Treatment……………………………...... No Charge
Occlusal Film……………………………………..…. No Charge
Bitewings (two films)……………………………..… No Charge
Panoramic Film……………………………….……... No Charge
Prophylaxis – child…………………………...……… No Charge

Restorative
Silver Amalgam, One Surface…………………..…… 25.00
Silver Amalgam, Two Surfaces………………...…… $40.00
Silver Amalgam, Three Surfaces or More……...…… $55.00
Composite Filling, One Surface…………….…..……$ 40.00
Composite Filling, Two Surfaces…………….………$ 50.00
Composite Filling, Three Surfaces………...…………$ 60.00

Oral Surgery
Routine Extraction, First Tooth………………………$ 35.00
Surgical Extraction………………………...…………$ 65.00
Soft Tissue Impaction……………………………...…$ 100.00
Partial Bony Impaction…………………………….…$ 155.00
Full Bony Impaction……………………………….…$ 220.00
Alveolectomy, Per Quad…………………….….....… $50.00

Root Canal Therapy You Pay
Pulpotomy………………………………….….…….$ 70.00
Pulp Capping, Indirect………………………….…...$ 10.00
Pulp Capping, Direct…………………………….….$ 25.00
Root Canal Therapy, One Canal…………….………$ 250.00
Root Canal Therapy, Two Canals………………….. $290.00
Root Canal Therapy, Three Canals or more………...$ 360.00
Apicoectomy with retrograde…………………….....$ 225.00

Periodontics
Scaling of Teeth Per Quad…………………………..$ 65.00
Subgingival Curettage Per Quad………………….…$ 65.00
Gingivectomy, Per Quad…………………………....$ 90.00
Mucogingival Surgery, Per Quad……………………$ 360.00
Osseous Surgery, Per Quad………………………....$ 360.00

Prosthetics -Fixed, Removable
Acrylic w/ Metal Crown……………….………….…$ 300.00
Porcelain Crown…………………..………………....$ 350.00
Porcelain w/ Metal Crown……………………………$ 450.00
Stainless Steel Crown……………………….…….…$ 110.00
Cast Post……………………………………….……$ 150.00
Recementation, Per Crown……………..……………$ 70.00
Acrylic w/ Metal Crown or Pontic……………….…. $325.00
Porcelain w/ Metal Crown or Pontic…………………$ 450.00
Recementation, Bridge……………………………….$ 75.00
Full Upper or Lower Denture, Inc. Adjustment……. $525.00
Partial Upper or Lower Denture, Cast Chrome……..$ 35.00-$ 75.00
Base Denture Adjustment

Orthodontic
Maximum case fee -24 months……………………..$ 2,000.00

Not covered………………. Services not listed as covered above 36
36 Page 37 38
2002 Vytra Health Plans 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 37
37 Page 38 39
2002 Vytra Health Plans 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, and deductible.

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

Medical, 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 631/ 694-6565.

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: Vytra Health Plans
395 North Service Road
Melville, NY 11747

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely

filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 38
38 Page 39 40
2002 Vytra Health Plans 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 395 North Service Road, Melville, NY 11747; 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 medical 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.

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. 39
39 Page 40 41
2002 Vytra Health Plans 40 Section 8
The Disputed Claim process (continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include 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 us at 631/ 694-6565 and
we will expedite our review; or

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

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 40
40 Page 41 42
2002 Vytra Health Plans 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary
plan pays, we will pay what is left of our allowance, up to our regular benefit. 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
managed care plan is the term used to describe the various health plan choices available to Medicare
beneficiaries. The information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) (Part A or Part B) available everywhere 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.

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 Plan PCP, or precertified as required.

We will not waive any of our copayments.
(Primary payer chart begins on next page.) 41
41 Page 42 43
2002 Vytra Health Plans 42 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 …

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

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

b) 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, and
a) Are an annuitant, or
b) Are an active employee, or

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee …

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. If your Plan
physician participates in Vytra Health Plans and Medicare is the primary payor, you must submit your claim to Medicare first. Then
submit the Medicare explanation of benefits and the claim to Vytra. 42
42 Page 43 44
2002 Vytra Health Plans 43 Section 9
Claims process when you have the Original Medicare Plan – You probably will never have 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 631/ 694-6565 or contact us at our web
site at www. vytra. 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 the 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 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, 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 and enroll in a

Medicare managed care plan. 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.

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

covered under the FEHB Program. We cannot require you to enroll in Medicare.

TRICARE TRICARE is the health care program for members, 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 43
43 Page 44 45
2002 Vytra Health Plans 44 Section 9
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 medical or hospital for injuries care for injuries or illness caused by another person, you must reimburse us for any
expenses we paid. However, we will cover the cost of treatment that exceeds the amount
you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures. 44
44 Page 45 46
2002 Vytra Health Plans 45 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care that does not require skilled nursing.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 11.

Experimental or Vytra Health Plans maintains advisory committees (The Technology
investigational Review Committee and the Pharmacy and Therapeutics Committee) to review and determine medical necessity of new technology and pharmaceuticals. These committees

are comprised of independent physicians, pharmacists and other professionals.

Group health coverage Group health coverage is coverage that is obtained through an employer, association, etc. and not on an individual basis.
Medical necessity A determination has been made in accordance with well-established professional medical starndards that are consistent and essential for diagnosis and treatment of you condition,
disease, ailment or injury, the most appropriate supply or level of service which can be
provided safely, provided for the diagnosis or the direct care treatment of your condition,
disease, ailment or injury and when applied to hospitalization, means further that you
require acute care as an inpatient due to th enature of the services rendered or your
condition and the you cannot receive safe or adequate care as an outpatient.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways.
We determine our allowance as follows: base Plan allowance on the reasonable and
customary charge

Us/ We Us and we refer to Vytra Health Plans
You You refers to the enrollee and each covered family member. 45
45 Page 46 47
2002 Vytra Health Plans 46 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

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

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

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

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

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

If you or one of your family members is enrolled in one FEHB plan, that person
may not be enrolled in or covered as a family member by another FEHB plan. 46
46 Page 47 48
2002 Vytra Health Plans 47 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan
premiums start during Open Season, your coverage begins 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.

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 marry, etc, etc.

You may not elect TCC if you are fired from your Federal job due to 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 47
47 Page 48 49
2002 Vytra Health Plans 48 Section 11
of Coverage and Former Spouse Enrollees, from your employing or retirement
office or from www. opm. gov/ insure.

Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Group Health Plan Coverage Group 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 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/ unsure/ health); refer to the "TCC and HIPAA" frequency asked
question. These highlight HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed
access to individual health coverage under HIPAA, and have information about
Federal and State agencies you can contact for more information. 48
48 Page 49 50
2002 Vytra Health Plans 49 Long Term Care
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in
October 2002. As a part 9of it's educational effort, OPM ask 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 nursing home care, care in an assisted living facility, care 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?

Welcome to the club!
76% of American's 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 everyone should have a plan just in case. Many people no consider long term care insurance to be

vital to their financial and retirement planning.

Is long term care expensive? Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And that's before inflation!
Long term care can easily exhaust your savings. Long term care insurance can protect your savings.

But won't my FEHB plan, Medicare or
Medicaid cover my long term care? Not FEHB. Look at the "Not covered" blocks in section 5( a) and 5( c) of your FEHB brochure. Health plans don't cover custodial care or stay in an
assisted living facility or a continuing need for a home health aide to help
you get in and out of bed and with other activities of daily living. Limited
stays in skilled nursing facilities can be covered in some circumstances,
Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65 or older

or fully disabled. It also has a 100-day limit.
Medicaid covers long term care for those who meet their state's poverty guidelines, but has restrictions on covered services and where they can be

received. Long term care insurance can provide choices of care and
preserve your independence.

When will I get more information on Employees will get more information from their agencies during the how to apply for this new insurance LTC open enrollment period in the last summer/ early fall of 2002
coverage Retirees will receive information at home.
How can I find out more about the Our toll-free teleservice center will begin in mid-2002. In the
Program NOW? Meantime you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc 49
49 Page 50 51
2002 Vytra Health Plans 50 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 35 Allergy tests 17
Alternative treatment 20 Allogenetic (donor) bone marrow
transplants 24 Ambulance 26
Anesthesia 24 Autologous bone marrow transplant 24
Biopsies 21 Blood and blood plasma 25
Casts 26 Changes for 2002 8
Chemotherapy 17 Childbirth 16
Chiropractic 20
Cholesterol tests 15
Claims 38 Coinsurance 45

Colorectal cancer screening 15 Congenital anomalies 21
Contraceptive devices and drugs 16 Coordination of benefits 41
Covered providers 9
Crutches 19
Deductible 45 Definitions 45

Dental care 35 Diagnostic services 14
Disputed claims review 39 Donor expenses (transplants) 24
Dressings 25 Durable medical equipment (DME) 19
Educational classes and programs 20 Effective date of enrollment 47
Emergency 27 Experimental or investigational 37
Eyeglasses 18 Family planning 16

Fecal occult blood test 15 General Exclusions 37
Hearing services 18 Home health services 19
Hospice care 26 Hospital 10
Immunizations 15 Infertility 16
In hospital physician care 25 Inpatient Hospital Benefits 25
Insulin 32 Laboratory and pathological
services 14 Machine diagnostic tests 14
Magnetic Resonance Imagings (MRIs) 14
Mammograms 15 Maternity Benefits 16
Medicaid 43 Medically necessary 37
Medicare 41 Mental Conditions/ Substance
Abuse Benefits 29 Newborn care 16
Non-FEHB Benefits 36 Nurse
Licensed Practical Nurse 19 Nurse Anesthetist 25
Registered Nurse 19 Nursery charges 16
Obstetrical care 16 Occupational therapy 17
Office visits 12 Oral and maxillofacial surgery 23
Orthopedic devices 19 Out-of-pocket expenses 13
Outpatient facility care 26 Oxygen 26
Pap test 15

Physical examination 15 Physical therapy 17
Physician 6 Pre-admission testing 26
Precertification 11 Preventive care, adult 15
Preventive care, children 15 Prescription drugs 31
Preventive services 15 Prior approval 11
Prostate cancer screening 15 Prosthetic devices 19
Psychologist 29 Psychotherapy 29
Radiation therapy 17 Renal dialysis 17
Room and board 25 Second surgical opinion 14
Skilled nursing facility care 26 Speech therapy 18
Splints 26 Sterilization procedures 16
Subrogation 44 Substance abuse 29
Surgery 21 Anesthesia 24
Oral 23 Outpatient 26
Reconstructive 22 Syringes 32
Temporary continuation of coverage 47
Transplants 24 Treatment therapies 17
Vision services 18 Well child care 15
Wheelchairs 19 Workers' compensation 43
X-rays 14 50
50 Page 51 52
Summary of benefits for Vytra Health Plans -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.
Below, an asterisk (*) means the item is subject to the $50 calendar year deductible for dental only.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 14

Services provided by a hospital:
Inpatient ........................................................................................
Outpatient .....................................................................................
Nothing
$10 per visit
25
26

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

$25 per emergency room or
urgent care visit

$25 per emergency room visit

28
28
Mental health and substance abuse treatment ................................... Regular cost sharing. 29
Prescription drugs............................................................................. $5 copay 31
Dental Care* ................................................................................
Accidental Injury
Preventative
Nothing
20% coinsurance after $50
deductible met

35

Vision Care ................................................................................... No benefit.
Special features: 24 hour nurse line, Healthwise Knowledgebase, Constellation Club 34
Protection against catastrophic costs
(your out-of-pocket maximum) ......................................................

Your out-of-pocket expenses for
benefits covered under this Plan
are limited to the stated
copayments which are required for
a few benefits.

12 51
51 Page 52 53
2002 Rate Information for
Vytra Health Plans

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

Nassau, Suffolk and Queens Counties, Long Island, New York

Self Only J61 $97.86 $50.50 $212.03 $109.42 $115.52 $32.84
Self and Family J61 $ 223.41 $ 165.32 $ 484.06 $ 358.19 $263.75 $124.98

2002 Vytra Health Plans 52 Rates 52
52 Page 53
53

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