Pages 1--60 from HealthPartners Primary Cinic Plan

2002 A Health Maintenance Organization

Serving: Minneapolis-St. Paul-St. Cloud; South Central Minnesota;
West Central Wisconsin

Enrollment in this Plan is limited. You must live or work in our Geographic service
area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
HQ1 Self Only
HQ2 Self and Family

Authorized for distribution by the:
United States
Office of Personnel Management
Retirement and Insurance Service
http:// www. opm. gov/ insure

RI 73-584

For changes in benefits
see page
8.

This plan has been awarded a "Commendable" accreditation for it's
HMO, point-of-service and Medicare products from the National
Committee for Quality Assurance (NCQA). This is granted to health
plans that deliver high quality care and service and whose systems
for consumer protection and quality improvement exceed NCQA's
rigorous requirements. See the 2002 Guide for more information on
NCQA. 1
1 Page 2 3
2002 HealthPartners Primary Clinic Plan 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 ................................................................................................................................................... 6
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........ 25
(c) Services provided by a hospital or other facility, and ambulance services...................................... 30
(d) Emergency services/ accidents .......................................................................................................... 33
(e) Mental health and substance abuse benefits..................................................................................... 35
(f) Prescription drug benefits................................................................................................................. 37 2
2 Page 3 4
2002 HealthPartners Primary Clinic Plan 3 Table of Contents
(g) Special features................................................................................................................................ 40
Careline nurse line
Babyline Service
Partners for Better Health Phone Line
Services for deaf and hearing impaired
(h) Dental benefits ................................................................................................................................. 41
(i) Non-FEHB benefits available to Plan members.............................................................................. 42
Section 6. General exclusions --things we don't cover.............................................................................................. 43
Section 7. Filing a claim for covered services............................................................................................................. 44
Section 8. The disputed claims process....................................................................................................................... 45
Section 9. Coordinating benefits with other coverage ................................................................................................ 47
When you have…

Other health coverage ........................................................................................................................ 47
Original Medicare .............................................................................................................................. 47
Medicare managed care plan.............................................................................................................. 49
TRICARE/ Workers' Compensation/ Medicaid .......................................................................................... 49
Other Government agencies ....................................................................................................................... 50
When others are responsible for injuries .................................................................................................... 50
Section 10. Definitions of terms we use in this brochure............................................................................................ 51
Section 11. FEHB facts ............................................................................................................................................... 52

Coverage information............................................................................................................................... 52
No pre-existing condition limitation ................................................................................................ 52
Where you get information about enrolling in the FEHB Program................................................. 52
Types of coverage available for you and your family...................................................................... 52
When benefits and premiums start ................................................................................................... 52
Your medical and claims records are confidential........................................................................... 53
When you retire ................................................................................................................................ 53
When you lose benefits ............................................................................................................................ 53

When FEHB coverage ends ............................................................................................................. 53
Spouse equity coverage.................................................................................................................... 53
Temporary Continuation of Coverage (TCC).................................................................................. 53
Converting to individual coverage ................................................................................................... 53
Getting a Certificate of Group Health Plan Coverage ..................................................................... 54
Long term care insurance is coming later in 2002…………………………………………...……………………….. 55
Department of Defense/ FEHB Demonstration Project ………………………………………………………………. 56
Index ………………………………………………………………………………………………………….. 58

Summary of benefits..................................................................................................................................................... 59
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2002 HealthPartners Primary Clinic Plan 4 Introduction/ Plain Language/ Advisory
Introduction
HealthPartners, Inc.
8100 34 th Avenue South
Minneapolis, Minnesota 55440

This brochure describes the benefits of HealthPartners Primary Clinic Plan under our contract (CS 2649) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of benefits.
No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are
summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
Terms 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 HealthPartners Primary Clinic Plan.

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 this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at
www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of Personnel
Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650. 4
4 Page 5 6
2002 HealthPartners Primary Clinic Plan 5 Introduction/ Plain Language/ 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 952/ 883-5000 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 HealthPartners Primary Clinic Plan 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?
We are a mixed model prepayment plan which allows members to receive health services from individual doctors who practice out of
their own offices and through 600 medical clinics and 137 contracting hospitals throughout the Twin Cities and surrounding areas.
Our medical providers include more than 2,000 primary care doctors and over 2,600 community specialists to whom patients are
referred. Members may choose any medical center in the plan network to receive primary care services. Each covered person in a
family may select a different medical center.

Your Rights
OPM requires all FEHB Plans to provide certain information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.

HealthPartners, Inc. is a Minnesota nonprofit corporation under Articles of Incorporation dated December 28, 1983, and is operated
under the Minnesota Nonprofit Corporation Act, Minnesota Statues Chapter 317A. HealthPartners was formed through the affiliation
of Group Health, Inc. and MedCenters Health Plan in 1992. Group Health, Inc. (a 501( c) (3) corporation) has been in existence as a
nonprofit corporation since 1957. MedCenters Health Plan was founded in 1972, and is no longer in existence.

HealthPartners is Minnesota's only consumer-guided health plan. Our Board of Directors is composed of consumer-elected members.
HealthPartners is a licensed HMO in the State of Minnesota. Group Health, Inc. is a federally qualified HMO, and received that
qualification in 1974.

Information on the following topics is available by calling HealthPartners Member Services:
Plan preauthorization and utilization review procedures Use of clinic protocols, practice guidelines and utilization review standards

Special disease management programs and programs for persons with disabilities Prescription drug formulary and procedures for considering requests of patient-specific waivers
Qualifications of reviewers at the initial decision and reconsideration under the FEHB disputed claims process Member Services representatives are available from 7: 30 a. m. until 6: 00 p. m., Monday through Friday.

If you want more information about us, call 952/ 883-5000 or 1-800-883-2177 or write to HealthPartners, P. O. Box 1309, Minneapolis,
MN 55440-1309. You may also contact us by fax at 952/ 883-5666 or visit our website at www. healthpartners. com. 6
6 Page 7 8
2002 HealthPartners Primary Clinic Plan 7 Section 1
Service Area
To enroll in this Plan, you must live or work in our Service Area. This is where our providers practice. Our service area is:
The following counties in Minnesota: Anoka, Benton, Carver, Chisago, Dakota, Dodge, Goodhue, Hennepin, Houston, Isanti,
LeSueur, McLeod, Meeker, Morrison, Ramsey, Rice, Scott, Sherburne, Stearns, Steele, Washington, Winona, and Wright.

The following partial counties in Minnesota: Olmsted, Fillmore, Wabasha, and Mille Lacs **
The following counties in Wisconsin: Buffalo, Pepin, Pierce, Polk and St. Croix
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 benefits. 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.

** Includes the following zip codes:
Olmsted Fillmore Wabasha Mille Lacs
County County County County
55901 55922 55041 55371
55902 55923 55932 56313
55903 55939 55945 56330
55904 55949 55956 56353
55905 55954 55957 55363
55906 55962 55964
55920 55986 55968
55929 55978
55934 55981
55960 55991
55976 7
7 Page 8 9
2002 HealthPartners Primary Clinic Plan 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 the address for sending disputed claims to OPM. (Section 8)

Changes to this Plan
Your share of the non-Postal premium will increase by 16.1% for Self Only or 14.5% for Self and Family.
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

We now cover certain intestinal transplants (Section 5( b))
We increased our coverage of tobacco cessation product to include 180-day limit.
We increased the office visit copay from $10 to $15 per visit.
We now require a $15 copay per visit for allergy testing and treatment. You pay nothing for allergy injections and serum.
We now use a formulary for the prescription drug benefit. The copays increased from $8 per prescription unit or refill to $10 for formulary and $20 for non-formulary prescription units or refills. The copay for mail order drugs increased from $16 for up to a
90-day supply to $20 for mail order formulary and $40 for mail order non-formulary drugs for up to a 90-day supply.
We increased the emergency room copay from $40 per visit to $50 per visit for emergency care you receive within our service area.

We decreased the benefit for oral contraceptives from one copay for 3 cycles of drugs, to one copay per cycle.
We clarified that we cover wigs required due to hair loss caused by alopetia areata with 20 percent coinsurance and a maximum Plan payment of $350 per calendar year. 8
8 Page 9 10
2002 HealthPartners Primary Clinic Plan 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 952/ 883-5000 or 1-800-883-2177
(hearing impaired individuals should call 952/ 883-5127).

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards. We are a mixed model prepayment plan which
allows members to receive health services from individual doctors who practice out of
their own offices and through 600 medical clinics and 137 contracting hospitals
throughout the Twin Cities and surrounding areas. Our medical providers include more
than 2,000 primary care doctors and over 2,600 community specialist to whom patients
are referred. Members may choose any medical center in the plan network to receive
primary care services. Each covered person in a family may select a different medical
center.

We list Plan providers in the provider directory, which we update periodically.

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.

What you must do It depends on the type of care you need. First, you and each family member must choose to get covered care a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. To choose a primary care physician,
call your clinic. Each covered person in a family may select a different medical center as
their primary care clinic.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, a woman may see a plan
gynecologist associated with her clinic for her annual wellness exam without a referral. 9
9 Page 10 11
2002 HealthPartners Primary Clinic Plan 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 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 952/ 883-5000 or 1-800-883-2177 (hearing impaired
individuals should call 952/ 883-5127). If you are new to the FEHB Program, we will
arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 10
10 Page 11 12
2002 HealthPartners Primary Clinic Plan 11 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.

Services requiring our Your primary care physician has authority to refer you for most services. For certain prior approval 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 Plan physician must
obtain prior authorization for services, such as:

reconstructive surgery promising therapies/ new technologies
transplants medically necessary dental care, such as orthagnathic surgery
durable medical equipment and prosthetics home health care
skilled nursing care hospice care
habilitative therapy
There may be additional services for which we require prior authorization. Your Plan
physician is responsible for obtaining prior authorization. 11
11 Page 12 13
2002 HealthPartners Primary Clinic Plan 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 $15 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. Expenses you incur for any other services do
not apply to this deductible.

We have a separate deductible for accidental injury dental benefits. Expenses you incur for any other services do not apply to this deductible.

Note: If you change plans during open season, you do not have to start a new deductible
under your old plan between January 1 and the effective date of your new plan.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 20% of our allowance for infertility services and durable
medical equipment.

Your catastrophic protection After your copayments and/ or coinsurance total $3,000 per person or $5,000 per family out-of-pocket maximum for enrollment in any calendar year, you do not have to pay any more for covered services.
deductibles, coinsurance, Be sure to keep accurate records of your copayments and/ or coinsurance since you are
and copayments responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 HealthPartners Primary Clinic Plan 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 59 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 952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127) or at our website at www. healthpartners. com.

(a) Medical services and supplies provided by physicians and other health care professionals....................................... 14-24
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

Speech therapy Hearing services (testing, treatment, and
supplies)
Vision services (testing, treatment, and supplies)

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ........................ 25-29
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ....................................................... 30-32

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

(d) Emergency services/ accidents .............................................................................................................................. 33-34
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ........................................................................................................ 35-36

(f) Prescription drug benefits ..................................................................................................................................... 37-39
(g) Special features............................................................................................................................................................ 40

CareLine Nurse Line BabyLine Service Partners for Better Health Phone Line Services for deaf and hearing impaired

(h) Dental benefits ....................................................................................................................................................... 41-42
(i) Non-FEHB benefits available to Plan members........................................................................................................ 42

Summary of benefits ........................................................................................................................................................... 59 13
13 Page 14 15
2002 HealthPartners Primary Clinic Plan 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
Office medical consultations
Second surgical opinion

$15 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Nothing

Not covered: genetic counseling and studies not required for diagnosis and treatment. All charges
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 14
14 Page 15 16
2002 HealthPartners Primary Clinic Plan 15 Section 5( a)
Preventive care, adult You pay
Routine health exams, periodic health assessments, and cancer 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
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older

Routine pap test
Testing and treatment of sexually transmitted diseases and testing for HIV and HIV related conditions provided by a Plan or non-Plan

provider
Routine hearing and eye exams

Nothing

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
Adult immunizations
Note: The above frequency guidelines are minimum benefits offered under the Plan. These services may be provided more frequently if they

are medically necessary.

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics.

Child health supervision services, including well-child care charges for routine examinations, immunizations and care (through age 22).
Routine hearing and eye exams.

Nothing 15
15 Page 16 17
2002 HealthPartners Primary Clinic Plan 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Postnatal care

Nothing

Delivery
Note: Here are some things to keep in mind:

You do not need to prior authorize your normal delivery; see below 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)

Not covered: Routine sonograms to determine fetal age, size or sex. All charges
Family planning
A broad range of voluntary family planning services, such as:
Family planning services by a Plan or non-Plan provider

Nothing

Voluntary sterilization $15perofficevisit Nothingforinpatient oroutpatienthospital
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
NOTE: We cover oral contraceptives and diaphragms under the prescription drug benefit.

20% of charges

Not covered: reversal of voluntary surgical sterilization or genetic counseling, All charges 16
16 Page 17 18
2002 HealthPartners Primary Clinic Plan 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. We cover the

diagnosis of infertility services provided by a Plan or non-Plan provider.

20% of charges

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm or ova
Cost of storage of donor sperm, ova or embryo
Treatment of infertility after reversal of sterilization
Artificial insemination for surrogate pregnancy

All charges

Allergy care
Testing and treatment $15 per office visit

Allergy injection and serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges 17
17 Page 18 19
2002 HealthPartners Primary Clinic Plan 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 28.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy

$15 per office visit
Nothing for inpatient or outpatient hospital

Blood and blood plasma (unless replaced) and blood derivatives for the treatment of blood disorders Nothing
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Note: – We will only cover GHT when your Plan physician prior authorizes the treatment. If we determine GHT is not medically
necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

20% of charges

Not covered: Growth hormones which are not for growth hormone deficiency or chronic renal insufficiency. All charges 18
18 Page 19 20
2002 HealthPartners Primary Clinic Plan 19 Section 5( a)
Physical and occupational therapies You pay
Two months per condition for the services of each of the following:
qualified physical therapists and
occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or

injury. You must achieve significant functional improvement, within a predictable period of time (generally within a period of two
months), toward your maximum potential ability to perform functional daily living activities.

Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the successful initiation of
normal speech and motor development.
Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward

achieving functional goals and your maximum potential ability, within a predictable period of time. We will supplement and
coordinate such services with similar benefits made available by other agencies, including the public school system. Our Plan Medical
Director will determine whether measurable progress has been made based on objective documentation.

$15 per office visit
Nothing for inpatient or outpatient hospital

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for Phase I. Phase II is provided
if we determine it is medically necessary. Phase III is not covered.

$15 per office visit
Nothing for inpatient or outpatient hospital

Not covered:
exercise programs
All charges 19
19 Page 20 21
2002 HealthPartners Primary Clinic Plan 20 Section 5( a)
Speech therapy You pay
Speech therapy for congenital, developmental or medical conditions which have significantly limited the successful

initiation of normal speech development or for restoration of speech.

Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward
achieving functional goals and your maximum potential ability, within a predictable period of time. We will
supplement and coordinate such services with similar benefits made available by other agencies, including the public school
system. Our Plan Medical Director will determine whether measurable progress has been made based on objective
documentation.

$15 per office visit
Nothing for inpatient or outpatient hospital

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

Hearing testing (see Preventive care, adults and children)

Nothing

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

All charges 20
20 Page 21 22
2002 HealthPartners Primary Clinic Plan 21 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Diagnosis and treatment of illness and injury to the eye; and $15 per office visit

Initial evaluation, lenses and fitting for contact or eyeglass lenses if medically necessary for the post-surgical treatment of cataracts or for
the treatment of aphakia or keratoconous

$15 per office visit
All charges for lens replacement beyond the initial pair.

Eye exam to determine the need for vision correction (see preventive care).
Annual eye refractions
Note: See Preventive care, children for eye exams for children.

Nothing

Not covered:
Eyeglasses or contact lenses and, except as described above
Eye exercises
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.
$15 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 21
21 Page 22 23
2002 HealthPartners Primary Clinic Plan 22 Section 5( a)
Orthopedic and prosthetic devices You pay
We cover the following:
Orthopedic devices, such as braces and foot orthotics;
Prosthetic devices, such as artificial limbs and eyes;
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; and
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Orthopedic and corrective shoes when approved by Plan based on our criteria

20% of charges

Wigs required due to hair loss caused by alopetia areata up to a maximum Plan payment of $350 per calendar year. 20% of charges, and all charges beyond the $350 calendar year
limit
Not covered:
over-the-counter foot orthotics replacement or repair of any covered items if they are damaged or

destroyed by member misuse, abuse or carelessness; lost; or stolen.
duplicate or similar items. items which are primarily educational in nature or for vocation,

comfort, convenience or recreation.

All charges 22
22 Page 23 24
2002 HealthPartners Primary Clinic Plan 23 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

20% of charges

Not covered:
replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen.

duplicate or similar items. items which are primarily educational in nature or for vocation,
comfort, convenience or recreation.
household equipment, such as exercise cycles, air purifiers, water purifiers, air conditioners, non-allergenic pillows, mattresses or

water beds.
household fixtures, such as escalators or elevators, ramps, swimming pools or saunas.

modifications to the home, such as wiring, plumbing or charges to install equipment.
vehicle, car or van modifications, such as hand brakes, hydraulic lifts and car carriers.
Rental of medically necessary durable medical equipment while member's equipment is being repaired, beyond one month rental

All charges

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

health aide, as shown below:
Physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services. $15 per visit

TPN/ intravenous therapy, skilled nursing services, prenatal and postnatal services, child health services, and phototherapy. Nothing
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 23
23 Page 24 25
2002 HealthPartners Primary Clinic Plan 24 Section 5( a)
Chiropractic You pay
Chiropractic services for rehabilitative care, provided to diagnose and treat acute neuromusculo-skeletal conditions, limited to:

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

they are performed in conjunction with other treatment by a chiropractor, are part of a prescribed treatment plan and are not billed
separately

$15 per office visit

Not covered:
Naturopathic services Hypnotherapy
All charges

Alternative treatments
We cover the following services:
Acupuncture – by a certified Plan acupuncturist for:
anesthesia pain management

chemical dependency headaches
nausea
Biofeedback for:
incontinence headaches

musculo-skeletal spasms which do not respond to other treatments
mental/ nervous disorders neurological retraining

$15 per office visit

Not covered:
naturopathic services

hypnotherapy

All charges

Educational classes and programs
We cover education for preventive services and smoking cessation. Nothing

We cover education for the management of chronic health problems (such as diabetes) $15 per office visit/ session 24
24 Page 25 26
2002 HealthPartners Primary Clinic Plan 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

Medicare.
The services described in this section are for the charges billed by a physician or other health care professional for your surgical care. The amount that you pay for these services depends on where the

services are provided and follow the benefits described in Section 5 (a) and (c), unless otherwise specified below.

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure
which services require prior authorization and identify which surgeries require prior authorization

I M
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T

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
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and Prosthetic devices for device coverage information. (See note
below)

$15 per office visit
Nothing for inpatient or outpatient hospital

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 for insertion of the pacemaker.

$15 per office visit
Nothing for inpatient or outpatient hospital

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care. All charges 25
25 Page 26 27
2002 HealthPartners Primary Clinic Plan 26 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

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

* Note: port wine stains do not have to result in a functional defect to be covered.

$15 per office visit
Nothing for inpatient or outpatient hospital

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

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

Nothing

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, unless determined medically necessary by the Plan Medical Director

All charges 26
26 Page 27 28
2002 HealthPartners Primary Clinic Plan 27 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 (limited to dependent

children to age 18);
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, including non-dental treatment of
temporomandibular joint dysfunction (TMJ).

$15 per office visit Nothing for inpatient or outpatient hospital

Orthognathic surgery for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non-surgical
treatment alone and a demonstrable functional impairment exists.

25% of charges

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

(such as the periodontal membrane, gingiva, and alveolar bone)
Orthodontic services (pre or post operative) associated with orthognathic surgery.

All charge 27
27 Page 28 29
2002 HealthPartners Primary Clinic Plan 28 Section 5( b)
Organ/ tissue transplants You pay
Transplant services are covered at our designated centers of excellence for transplants and are limited to:

Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas for diabetes
Liver, for bilary atresia ion children, primary bilary cirrhosis, post acute viral infection (including hepatitus A, hepatitus B anitgen e

negative and hepatitus C) causing acute atrophy or post necrotic cirrhosis, primary sclerosing cholangitis and alcoholic cirrhosis

Lung: Single – Double, for primary pulmonary hypertension, Eisenmenger's syndrome, end stage pulmonary fibrosis, alpha 1
antitrypsin disease, cystic fibrosis and emphysema
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; Hodgkin's lymphoma; non-Hodgkin's lymphoma; Burkitt's lymphoma; neuroblastoma;

breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Allogenic (donor) bone marrow transplants or peripheral stem cell support associated with high dose chemotherapy for acute
myelogenous leukemia; acute lymphotytic leukemia; chronic myelogenouis leukemia; severe combined immunodeficiency
disease; Wiscott-Aldrich syndrome; and aplastic anemia
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.

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 28
28 Page 29 30
2002 HealthPartners Primary Clinic Plan 29 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient) Nothing

Professional services provided in –
Ambulatory surgical center
Nothing

Professional services provided in --
Hospital outpatient department Skilled nursing facility

Office

$15pervisit 29
29 Page 30 31
2002 HealthPartners Primary Clinic Plan 30 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

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

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care Any costs

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

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T

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

meals and special diets.
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 and blood plasma (unless replaced) and blood derivatives 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
NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

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

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

Private nursing care

All charges 30
30 Page 31 32
2002 HealthPartners Primary Clinic Plan 31 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 (unless replaced) and blood derivatives Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We

do not cover the dental procedures.

Nothing

Extended care benefits/ skilled nursing care facility benefits
We cover a comprehensive range of benefits for up to 180 days per period of confinement when full-time skilled nursing care is necessary
and confinement in a skilled nursing facility is medically appropriate as determined by your Plan physician and prior authorized by this Plan.
All necessary services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, services and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your

Plan doctor.
Period of confinement means (1) continuous stay in a hospital or skilled nursing facility, or (2) a series of two or more stays in a hospital or

skilled nursing facility for the same condition in which the end of each inpatient stay is separated from the beginning of the next one by less
than 90 days. Same condition means illness or injury related to a former illness or injury that is (1) within the same ascertainable
diagnosis, or (2) within the scope of complications, or related conditions.

Nothing

Not covered: custodial care All charges 31
31 Page 32 33
2002 HealthPartners Primary Clinic Plan 32 Section 5( c)
Hospice care You pay
We cover supportive and palliative care in your home or a hospice facility if you are terminally ill. We cover the following services:

Outpatient care, family counseling and continuous care*. Nothing
Inpatient care. Nothing
Respite care*.
* Note: Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30 days.

20% of charges

Not covered: independent nursing, homemaker services All charges
Ambulance
Ambulance and medical transportation for medical emergencies described in section 5( d). 20% of charges

Prior authorized transfers between network hospitals for treatment if initiated by a Plan physician. Nothing 32
32 Page 33 34
2002 HealthPartners Primary Clinic Plan 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

I M
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T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or

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

What to do in case of emergency:
Emergencies within our service area: If you need emergency care, call your clinic, or call the CareLine sm nurse after hours at 612/ 339-3663 (hearing impaired individuals should call 952/ 883-5474).
The service nurse or Plan physician will recommend how, when and where to obtain the appropriate treatment. In extreme emergencies, if you are unable to contact your primary care doctor or clinic or the
CareLine sm nurse, contact the local emergency system (e. g., 911 telephone system) or go to the nearest hospital emergency room.

Emergencies outside our service are: You must notify us within two days of admittance to an out-of-network hospital, or as soon as reasonably possible under the circumstances. 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. 33
33 Page 34 35
2002 HealthPartners Primary Clinic Plan 34 Section 5( d)
Emergency within our service area You pay
Emergency care and urgent care at a doctor's office $15 per office visit

Emergency care and urgent care as an outpatient at a hospital, including doctors' services
Note: copay waived if admitted to the hospital for the same condition within 24 hours.

$50 per office visit

Not covered: Elective care or non-emergency care All charges
Emergency outside our service area

Emergency care and urgent care at a doctor's office Emergency care and urgent care at an urgent care center

Emergency care and urgent care as an outpatient at a hospital, including doctors' services

20% of the first $2,500 of charges per calendar year

Emergency admission to an out of area hospital, including doctors' services 20% of the first $2,500 of charges per calendar year
Not covered:
Elective care or non-emergency care
Emergency or urgently needed care provided outside the service area if the need for care could have been foreseen before leaving

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

All charges

Ambulance
Ambulance and medical transportation for medical emergencies described in Section 5( d).

Note: air ambulance is covered if medically necessary.

20% of charges 34
34 Page 35 36
2002 HealthPartners Primary Clinic Plan 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

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 descriptions below.

I M
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T

Benefit Description You pay
All diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services,
drugs, and supplies described elsewhere in this brochure.
Note: In-network 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 by providers such
as psychiatrists, psychologists, or clinical social workers

Medication management

$15 per office visit

Group therapy $7.50 per office visit
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as:
Residential treatment
Partial hospitalization or full-day hospitalization for mental
health services

Nothing 35
35 Page 36 37
2002 HealthPartners Primary Clinic Plan 36 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM

will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Prior authorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
You do not need a referral from your primary care Physician to obtain mental or substance abuse services. You must use a mental or
substance abuse provider that is in our Plan network and associated with your clinic. We list the mental and substance abuse providers

associated with your clinic's care system in our provider directory. If you have questions or need a provider directory, call HealthPartners
Member Services Department at 952/ 883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127).

Limitation We may limit your benefits if you do not obtain a treatment plan. 36
36 Page 37 38
2002 HealthPartners Primary Clinic Plan 37 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

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

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

I M
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T
There are important features you should be aware of. These include:
Who can write your prescription. A plan or referral physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy or by mail.
We use a formulary. However, we cover non-formulary drugs prescribed by a Plan doctor. 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.

These are the dispensing limitations. Unless otherwise specified in this section, you may receive up to a 30-day supply per prescription. No more than a 90-day supply will be covered and dispensed
at a time. A generic equivalent will be dispensed if available, unless your physician specifically requires a name brand. If a copayment is required, you must pay one copayment for each 30-day
supply, or portion thereof, or for each manufacturer's pre-packaged dispensing unit (but not less than what your doctor recommends is a 30-day supply), except as follows:

For insulin a copay will apply per vial or box of insulin cartridges.
For contraceptive barrier devices, a copayment will apply per device.
For Mail order drugs, see benefit described below.
If you request a refill too soon after the last one was filled, it may not be filled at that time. It may require up to 14 days to get mail order prescriptions filled, so this service is best for maintenance

drugs, not for drugs you need immediately or for drugs you are taking on a short-term basis. Federal or state regulations may prevent us from filling certain prescriptions through our mail order service,
such as laws which prohibit us from sending narcotic drugs across state lines.
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 may have to pay the difference in cost between the name brand drug and the generic.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original name brand product. Generic drugs cost you and your plan less
money than a name brand drug.
When you have to file a claim. You do not need to file a claim for drugs obtained at a network pharmacy or through our mail order service. You would need to file a claim for prescription drugs

covered as part of an out-of-area emergency, if you did not get them at a network pharmacy. See section 7 for instructions on filing a claim.

Prescription drug benefits begin on the next page. 37
37 Page 38 39
2002 HealthPartners Primary Clinic Plan 38 Section 5( f)
Covered medications and supplies You pay
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase
Insulin, with a copay applied per vial Diabetic testing supplies (see glucose monitors under Durable
Medical Equipment)
Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Limited Benefits below) Oral contraceptive drugs and contraceptive barrier devices; a single
copay charge will apply for 1 cycle of oral contraceptive drugs or for each barrier device

Tobacco cessation products, as determined by this Plan, limited to a 180-day supply per calendar year. No more than a 30-day supply
will be covered and dispensed at a time.

$10 copay for formulary drugs $20 copay for non-formulary drugs

Mail order benefits
You may also get outpatient prescription drugs which can be self-administered through HealthPartners mail order service. For

information on how to obtain drugs through HealthPartners mail order service, please call our Member Services Department at 1-800/ 883-2177
(hearing impaired individuals should call 952/ 883-5127). This benefit does not apply to drugs listed under Limited Benefits below.

$20 copay for formulary drugs $40 copay for non-formulary drugs 38
38 Page 39 40
2002 HealthPartners Primary Clinic Plan 39 Section 5( f)
Limited benefits
Injectable or implantable contraceptive drugs or devices (such as, Depo Provera, Norplant, IUDs)

Growth hormones
Injectable drugs for the treatment of infertility
Special dietary treatment for phenylketonuria (PKU)
Drugs to treatment of sexual dysfunction are limited to six doses per month.

20% of charges

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them, except as specified

Nonprescription medicines
Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance

All Charges 39
39 Page 40 41
2002 HealthPartners Primary Clinic Plan 40 Section 5( g)
Section 5 (g). Special features
Feature Description

CareLine sm nurse line When you call the CareLine after regular clinic hours, you reach a skilled nurse who is specially trained to assess medical conditions of all kinds. Call 612/ 339-3663 or 1-800-551-0859 and talk with a
registered nurse who will discuss treatment options and answer your health questions.

BabyLine sm Service If you're an expecting or new parent and have questions after regular clinic hours, our BabyLine service is just for you. BabyLine is staffed by obstetric nurses who can help with questions relating to pregnancy,
new baby care, nursing and postpartum concerns. Call 612/ 333-BABY (333-2229) or 1-800-845-9297.

Partners for Better Health Phone Line The HealthPartners Partners for Better Health Phone Line is a special service designed to help you improve your health, prevent disease and lead a healthier lifestyle.
When you call 952/ 883-7800 weekdays between 8 a. m. and 6 p. m., you will speak directly with a health educator or registered dietitian
who will help you develop a personalized action plan to make healthier choices in you daily routine. You can also register for health education
classes, learn about member discounts for many health and safety products, plus much more.

Services for deaf and hearing impaired If you are deaf or hearing impaired, we have phone lines which you may call for the following services:
Member Services: 952/ 883-5127
CareLine sm Service: 952/ 883-5474
Baby Line sm Service: 952/ 883-5127
Partners for Better Health: 952/ 883-7498 40
40 Page 41 42
2002 HealthPartners Primary Clinic Plan 41 Section 5( h)
Section 5 (h). Dental benefits
I M
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T

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

Plan dentists must provide or arrange your care.
There is a $50 calendar year deductible for emergency accidental dental services provided by non-Plan dentists.

We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not
cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Dental benefits You pay
We cover preventive and diagnostic dental services shown below for all members when provided by Plan dentists. Benefit limits are noted
where they apply.
Routine dental examinations (per Plan dentist's recommendation); Teeth cleaning, prophylaxis or periodontal maintenance recall

(limited to twice per calendar year);
Topical application of fluoride (per Plan dentist's recommendation);

Oral hygiene instruction (per Plan dentist's recommendation); Bitewing x-rays (limited to once per calendar year); and
Full mouth (panoramic) x-rays (limited to once every three calendar years).

Nothing

Not covered: other dental services not shown as covered. All charges
Accidental injury benefit
We cover restorative services and supplies provided by Plan dentists necessary to promptly repair or replace sound natural teeth, including
the cost and installation of necessary prescription dental prosthetic items or devices. The need for these services must directly result from an
accidental injury, not including injury from biting or chewing, and the treatment or repair must be initiated within twelve months of the date of
injury.

Nothing

Emergency dental services for accidental injury, as described above, are covered when they are provided by non-Plan dentists if the services
require immediate treatment.
$50 calendar year deductible, then 20% of the charges, up to a
maximum benefit of $300 per calendar year, and any charges
thereafter.
Not covered:
any dental services rendered in connection with previously missing teeth or for teeth not injured in the accident.

other dental services not shown as covered.

All charges 41
41 Page 42 43
2002 HealthPartners Primary Clinic Plan 42 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.

Medicare prepaid plan enrollment – This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare without payment of an FEHB premium. As indicated on page 49, certain annuitants and former spouses who
are covered by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB. Contact your retirement system for information on changing your FEHB enrollment. Call us at 952/ 883-5600
for information on the Medicare prepaid plan and the cost of enrollment.

Expanded Provider Network Option
An Expanded Provider Network (EPN) option is available to you as a member of this HealthPartners medical plan. The EPN option offers a network of allied health care professionals in addition to the network available under your medical
plan. EPN health care professionals include audiologists, chiropractors, home health care providers, mental health providers, occupational therapists, optometrists, physical therapists, podiatrists and speech therapists.

The EPN option is offered as a rider, or "add-on," to your current medical plan. You have the opportunity to purchase the EPN rider within 31 days of enrolling in this Plan and annually at the beginning of each year.
The EPN option does not increase or change the benefits under this Plan. The coverage, limitations and exclusions are the same as this Plan with a per visit copayment for care received from an EPN provider. There is a monthly cost to you
for enrolling in the EPN option.
For a complete EPN Information Packet, including benefit summary, rates, provider listing and enrollment form, please call HealthPartners Member Services at 952-883-5000 or the toll-free number at 1-800-883-2177. If you have additional
questions about the EPN option after you receive your packet, please call Member Services.

Benefits on this page are not part of the FEHB Contract. 42
42 Page 43 44
2002 HealthPartners Primary Clinic Plan 43 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 unless determined medically necessary by the Plan Medical Director; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 43
43 Page 44 45
2002 HealthPartners Primary Clinic Plan 44 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

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

Medical, hospital and In most cases, providers and facilities file claims for you. Physicians drug benefits 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 952/ 883-5000 or 1-800-
883-2177 (hearing impaired individuals should call 952/ 883-5127).

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: HealthPartners claims
P. O. Box 1289
Minneapolis, MN 55440-1289

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. 44
44 Page 45 46
2002 HealthPartners Primary Clinic Plan 45 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: HealthPartners, Member Services, P. O. Box 1309, Minneapolis, MN 55440-
1309; and

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

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C. 20415-3610. 45
45 Page 46 47
2002 HealthPartners Primary Clinic Plan 46 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

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

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must 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 952/ 883-5000 or
1-800-883-2177 (hearing impaired individuals should call 952/ 883-5127) 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. 46
46 Page 47 48
2002 HealthPartners Primary Clinic Plan 47 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 order,
you may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement
check.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere 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. You must coordinate your care with
your Plan primary care physician, who will authorize your referrals to Plan specialists
and prior authorize services with the Plan, as specified under Section 3.

We will waive any of our copayments, coinsurance and deductibles.
(Primary payer chart begins on next page.) 47
47 Page 48 49
2002 HealthPartners Primary Clinic Plan 48 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
48
48 Page 49 50
2002 HealthPartners Primary Clinic Plan 49 Section 9
Claims process when you have the Original Medicare Plan – You probably will never
have to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When original Medicare is the primary payer, medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the
balance of covered cahrges. You will not need to do anything. To find out if you
need to do something about filing your claims, call us at 952/ 883-5000 or 1-800-883-
2177 (hearing impaired individuals should call 952/ 883-5127) or at our website at
www. healthpartners. com.

We waive some costs when you have the Original Medicare Plan --When Original
Medicare is the primary payer we will waive any of our copayments, coinsurance and
deductibles.

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

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare
managed care plan and also remain enrolled in our FEHB plan. In this case, we do waive
any of our copayments, coinsurance, or deductibles for your FEHB coverage.

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

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

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under the Medicare Part A or Part B FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't
get premium free Part A, we will not ask you to enroll in it.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both TRICARE
and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you
have questions about TRICARE coverage. 49
49 Page 50 51
2002 HealthPartners Primary Clinic Plan 50 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they
must provide; or

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

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

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for 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.
This Plan will be entitled to immediately collect the present value of subrogation rights
from any recovery payments you receive, whether or not you have been fully
compensated for your losses and damages. Unless we agree,, you may not deduct
attorneys' fees and expenses, which you incur in the recovery of monies from a third
party, from the subrogation/ reimbursement amounts.

If you need more information, contact us for our subrogation procedures. 50
50 Page 51 52
2002 HealthPartners Primary Clinic Plan 51 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 12.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
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 12.

Experimental or This Plan determines if a treatment or procedure is investigational services experimental/ investigative or unproven if it is:

Not approved by the U. S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use; or
If reliable evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing Phase I, II, or III Clinical Trials; or
If reliable evidence shows that the drug, device or medical treatment or procedure is under study to determine its maximum tolerated dose, its toxicity, its safety, and its
efficacy as compared with the standard means of treatment or diagnosis.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our
allowance as follows:
For covered services delivered by Plan providers, or Plan referral providers, our
allowance is the provider's discounted charge for a given medical/ surgical service,
procedure or item, which Plan providers have agreed to accept as payment in full.

For covered services delivered by non-Plan providers, our allowance is the provider's
charge for a given medical/ surgical service, procedure or item, according to the fair and
reasonable charge amount.

The Fair and Reasonable Charge is the maximum amount we allow when we calculate
the payment for charges incurred for covered services provided by non-Plan providers. It
is consistent with what other providers in the same community charge for a given service
or item, as defined by the Health Insurance Association of America (HIAA) schedule.

Us/ We Us and we refer to HealthPartners Primary Clinic Plan
You You refers to the enrollee and each covered family member. 51
51 Page 52 53
2002 HealthPartners Primary Clinic Plan 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation 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 can answer about enrolling in the 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 you, your spouse, for you and your family and your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for. Under certain
circumstances, you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

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

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

If you or one of your family members is enrolled in one FEHB plan, that person may not
be enrolled in or covered as a family member by another FEHB plan.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan during premiums start 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 January 1. If you joined at
any other time during the year, your employing office will tell you the effective date of
coverage. 52
52 Page 53 54
2002 HealthPartners Primary Clinic Plan 53 Section 11
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and

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

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

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

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

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

Temporary Continuation If you leave Federal service, or if you lose coverage because you no longer qualify as a of Coverage (TCC) 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.

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 of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB individual policy if: individual coverage Your coverage under TCC or the spouse equity law ends. (If 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. 53
53 Page 54 55
2002 HealthPartners Primary Clinic Plan 54 Section 11
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) is a Federal Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHBProgram, we will give
you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with
us. You can use this certificate when getting health insurance or other health care coverage. Your new
plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions
based on the information in the certificate, as long as you enroll within 63 days of losing coverage
under this Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from those
plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health): refer to the "TCC and HIPAA: frequently 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. 54
54 Page 55 56
2002 HealthPartners Primary Clinic Plan 55 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover all 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? 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 part of its educational effort, OPM asks you to consider these questions:

What is long term care (LTC) insurance?
It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended
illness or injury, or an age-related disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your
home, adult day care, hospice care, and more. LTC can supplement care provided by family members, reducing the burden
you place on them.

I'm healthy. I won't need long term care. Or, will I?
76% of Americans believe they will never need long term care, but the facts are that about half of them will. And it's not just
the old folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but you should have a plan just in case. LTC insurance may be vital to your
financial and retirement planning.

Is long term care expensive?
Yes, a year in a nursing home can exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a year, that's
before inflation!
TLC can easily exhaust your savings but LTC insurance can protect it.

But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Custodial care, assisted
living, or continuing home health care for activities of daily living are not covered. Limited stays in skilled nursing facilities
can be covered in some circumstances.
Medicare only covers skilled nursing home care after a hospitalization with a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but restricts covered services and where they can be
received. LTC insurance can provide choices of care and preserve your independence.

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

How can I find out more about the program NOW?
A toll-free telephone number will begin in mid-2002. You can learn more about the program now at
www. opm. gov/ insure/ ltc. 55
55 Page 56 57
2002 HealthPartners Primary Clinic Plan 56 DoD/ FEHB Demonstration Project
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to enroll in the FEHB Program. The
demonstration will last for three years and began with the 1999 open season for the year 2000.
Open season enrollments will be effective January 1, 2002. DoD and OPM have set up some
special procedures to implement the Demonstration Project, noted below. Otherwise, the
provisions described in this brochure apply.

Who is eligible DoD determines who is eligible to enroll in the FEHB Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for Medicare;
You are a dependent of an active or retired uniformed service member and are eligible for Medicare;

You are a qualified former spouse of an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.

If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits
Program, you are not eligible to enroll under the DoD/ FEHBP Demonstration Project.

The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA
When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2001 open season, November 12, 2001, through December 10, 2001. Your coverage will begin January 1, 2002.
DoD has set-up an Information Processing Center (IPC) in Iowa to provide you with information
about how to enroll. IPC staff will verify your eligibility and provide you with FEHB Program
information, plan brochures, enrollment instructions and forms. The toll-free phone number for
the IPC is 1-877/ DOD-FEHB (1-877/ 363-3342).

You may select coverage for yourself (Self Only) or for you and your family (Self and Family)
during open season. Your coverage will begin January 1, 2002. If you become eligible for the
DoD/ FEHB Demonstration Project outside of open season, contact the IPC to find out how to
enroll and when your coverage will begin.

If you become eligible for the DoD/ FEHB Demonstration Project outside of open season, contact
the IPC to find out how to enroll and when your coverage will begin.

DoD has a web site devoted to the Demonstration Project. You can view information such as their
Marketing/ Beneficiary Education Plan, Frequently Asked Questions, demonstration area locations
and zip code lists at www. tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2002 Guide to Federal Employees Health Benefits Plans
Participating in the DoD/ FEHB Demonstration Project," on the OPM web site at www. opm. gov. 56
56 Page 57 58
2002 HealthPartners Primary Clinic Plan 57 DoD/ FEHB Demonstration Project
TCC eligibility See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the only individual eligible for TCC is one who ceases to be
eligible as a "member of family" under your self and family enrollment. This occurs when a child
turns 22, for example, or if you divorce and your spouse does not qualify to enroll as an
unremarried former spouse under title 10, United States Code. For these individuals, TCC begins
the day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC enrollment
terminates after 36 months or the end of the Demonstration Project, whichever occurs first. You,
your child, or another person must notify the IPC when a family member loses eligibility for
coverage under the DoD/ FEHB Demonstration Project.

TCC is not available if you move out of a DoD/ FEHB Demonstration Project area, you cancel
your coverage, or your coverage is terminated for any reason. TCC is not available when the
demonstration project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project. 57
57 Page 58 59
2002 HealthPartners Primary Clinic Plan 58 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 41 Allergy tests 17
Alternative treatment 24 Allogenetic (donor) bone marrow
transplant 28 Ambulance 32,34
Anesthesia 29, 31 Autologous bone marrow transplant 28
Biopsies 25 Birthing centers 30
Blood and blood plasma 18 Breast cancer screening 15
Casts 25, 31 Catastrophic protection 12
Changes for 2002 8 Chemotherapy 18
Childbirth 16, 30 Chiropractic 24
Cholesterol tests 15 Circumcision 16
Claims 44 Coinsurance 12
Colorectal cancer screening 15 Congenital anomalies 25
Contraceptive devices and drugs 16, 38 Coordination of benefits 47
Covered charges 12 Covered providers 9
Crutches 23 Deductible 12
Definitions 51 Dental care 41
Diagnostic services 14, 35 Disputed claims review 45
Donor expenses (transplants) 28 Dressings 30
Durable medical equipment (DME) 23 Educational classes and programs 24
Effective date of enrollment 4 Emergency 33-34
Experimental or investigational 43 Eyeglasses 21
Family planning 16 Fecal occult blood test 15

General Exclusions 43 Hearing services 23
Home health services 23 Hospice care 32
Home nursing care 23 Hospital 10
Immunizations 15 Infertility 17
Inhospital physician care 30 Inpatient Hospital Benefits 30
Insulin 23 Laboratory and pathological
services 14 Machine diagnostic tests 14
Magnetic Resonance Imagings (MRIs) 14
Mail Order Prescription Drugs 38 Mammograms 14
Maternity Benefits 16 Medicaid 50
Medically necessary 43 Medicare 47
Members 5 Mental Conditions/ Substance
Abuse Benefits 35 Neurological testing 14
Newborn care 16 Non-FEHB Benefits 42
Nurse Licensed Practical Nurse 23
Nurse Anesthetist 29 Nurse Midwife 16
Nurse Practitioner 14 Psychiatric Nurse 35
Registered Nurse 23 Nursery charges 16
Obstetrical care 16 Occupational therapy 19
Ocular injury 21 Office visits 14
Oral and maxillofacial surgery 27 Orthopedic devices 22
Ostomy and catheter supplies 23 Out-of-pocket expenses 31

Outpatient facility care 31 Oxygen 23, 31
Pap test 14 Physical examination 15
Physical therapy 23 Physician 14
Point of service (POS) 9 Pre-admission testing 31
Precertification 11 Preventive care, adult 15
Preventive care, children 15 Prescription drugs 37
Preventive services 15 Prior approval 11
Prostate cancer screening 15 Prosthetic devices 22
Psychologist 35 Psychotherapy 35
Radiation therapy 18 Renal dialysis 18, 23, 47
Room and board 30 Second surgical opinion 14
Skilled nursing facility care 14, 31 Smoking cessation 24
Speech therapy 20 Splints 23
Sterilization procedures 16 Subrogation 50
Substance abuse 35 Surgery 25
Anesthesia 29 Oral 27
Outpatient 31 Reconstructive 26
Syringes 38 Temporary continuation of
coverage 53 Transplants 28
Vision services 21 Well child care 15
Wheelchairs 23 Workers' compensation 50
X-rays 14 58
58 Page 59 60
2002 HealthPartners Primary Clinic Plan 59
Summary of benefits for the HealthPartners Primary Clinic Plan -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. $15 per office visit primary care; $15 per office visit specialist 14

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

Nothing.
Nothing.

25
25

Emergency benefits:
In-area ..............................................................................................

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

$50 Emergency Room visit
$15 Urgent Care Center visit

20% of the first $2,500;
nothing thereafter

34
34

Mental health and substance abuse treatment...................................... Regular cost sharing 35
Prescription drugs.................................................................................. $10 copay for formulary
$20 copay for non formulary
per prescription unit or refill
(mail order benefit is two copays
per 90-day supply)

37

Dental Care........................................................................................ Nothing for preventive care. 41
Vision Care........................................................................................ Nothing 21
Special features: CareLine SM nurse line,
BabyLine SM Service, Partners
for Better Health Phone Line,
Services for deaf and hearing
impaired.

40

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

$3,000 /Self Only or $5,000
/Family per calendar year 12 59
59 Page 60
2002 HealthPartners Primary Clinic Plan 60
2002 Rate Information for HealthPartners Primary Clinic Plan
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 .

Minneapolis St. Paul St. Cloud South Central Minnesota West Central Wisconsin
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share Share Share

Self Only HQ1 $97.86 $68.10 $212.03 $147.55 $115.52 $50.44
Self and Family HQ2 $223.41 $174.90 $484.06 $378.95 $263.75 $134.56 60

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