Pages 1--56 from SuperMed HMO

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

Enrollment code:
Self Only -5M1
Self and Family -5M2

Federal Employees Health Benefits Program
RI 73-656

2002
For changes
in benefits
see page

8.

This Plan has a commendable
accreditation from the NCQA. See
the 2002 Guide for more information
on accreditation. 1
1 Page 2 3
2002 SuperMed HMO 2 Table of Contents
Table of Cont ent s
Introduction .......................................................................................................................................................................... 4
Plain Language....................................................................................................................................................................... 4
Inspector General Advisory ................................................................................................................................................... 5
Section 1. Facts about this HMO plan.................................................................................................................................. 6
How we pay providers......................................................................................................................................... 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 .......................................................................................................................................... 9-10
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.............. 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals.......... 24
(c) Services provided by a hospital or other facility, and ambulance services......................................... 28
(d) Emergency services/ accidents .............................................................................................................. 31
(e) Mental health and substance abuse benefits.................................................................................... 33-34
(f) Prescription drug benefits ................................................................................................................ 35-36
(g) Special features...................................................................................................................................... 37
Flexible benefits option.................................................................................................................. 37
Heart Sense ..................................................................................................................................... 37
Baby Link ....................................................................................................................................... 37 2
2 Page 3 4
2002 SuperMed HMO 3 Table of Contents
Breathe Easy ................................................................................................................................... 37
Transplanting Health ...................................................................................................................... 37
(h) Dental benefits....................................................................................................................................... 38
Section 6. General exclusions --things we don't cover .................................................................................................... 39
Section 7. Filing a claim for covered services .................................................................................................................. 40
Section 8. The disputed claims process........................................................................................................................ 41-42
Section 9. Coordinating benefits with other coverage...................................................................................................... 43
When you have
Other health coverage ................................................................................................................................ 43
Original Medicare ................................................................................................................................ 43-47
TRICARE/ Workers'Compensation/ Medicaid.......................................................................................... ....... 47
Other Government agencies............................................................................................................................. 48
When others are responsible for injuries ......................................................................................................... 48
Section 10. Definitions of terms we use in this brochure ................................................................................................. 49
Section 11. FEHB facts...................................................................................................................................................... 50

Coverage information....................................................................................................................................... 50
No pre-existing condition limitation ....................................................................................................... 50
Where you get information about enrolling in the FEHB Program....................................................... 50
Types of coverage available for you and your family ............................................................................ 50
When benefits and premiums start .......................................................................................................... 51
Your medical and claims records are confidential ................................................................................. 51
When you retire....................................................................................................................................... 51
When you lose benefits .................................................................................................................................... 51
When FEHB coverage ends..................................................................................................................... 51
Spouse equity coverage .......................................................................................................................... 51
Temporary Continuation of Coverage (TCC)................................................................................... 51-52
Converting to individual coverage ......................................................................................................... 52
Getting a Certificate of Group Health Plan Coverage........................................................................... 52
Long term care insurance is coming in 2002 ..................................................................................................................... 53
Index ....................................................................................................................................................................... 54
Summary of benefits ........................................................................................................................................................... 55
Rates ......................................................................................................................................................... Back cover 3
3 Page 4 5
2002 SuperMed HMO 4 Introduction/Plain Language
Int roduct ion
Medical Mutual of Ohio, dba SuperMed HMO
2060 East Ninth Street
Cleveland, Ohio 44115-1355

This brochure describes the benefits of SuperMed HMO under our contract (CS 2015) 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
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible,
and understandable to the public. For instance,

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

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov . 4
4 Page 5 6
2002 SuperMed HMO 5 Introduction/Plain Language
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 522-2066
and explain the situation.
If we do not resolve the issue, call or write to:

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 SuperMed HMO 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.

Your Rights
SuperMed HMO is a mixed model prepayment plan that provides care through a network of doctors, using groups of
doctors, staff model arrangements, and IPA systems. Both primary care and specialist doctors are part of the network.
Different members of the same family may select different centers or doctors.

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

Medical Mutual of Ohio is the oldest health insurance company in Ohio. SuperMed HMO has been in existence since January 1, 1992.
SuperMed HMO has over 28,000 participating physicians. Medical Mutual of Ohio has been awarded three-year Commendable accreditation status SuperMed HMO by the
National Committee for Quality Assurance (NCQA), a leading independent evaluator of health plans.
If you want more information about us, call 800/ 522-2066, or write to SuperMed HMO, P. O. Box 6018, Cleveland,
Ohio 44101, Attn: HMO Member Services. You may also contact us by fax at 216/ 694-2910 or visit our website at
http:// www. mmoh. com . 6
6 Page 7 8
2002 SuperMed HMO 7 Section 1
Service Area
To enroll in this plan, you must live in or work in our service area. This is where our providers practice.
Our service area is:
The Ohio counties of Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Huron, Lake, Lorain,
Medina, Portage, Richland, Stark, Summit, Tuscarawas and Wayne.

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
dependants live out of the are (for example, if your child goes to college in a another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8 9
2002 SuperMed HMO 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 removed the requirement that services must be needed to restore functional speech from the speech therapy benefit

Changes to this Plan
Your share of the non-Postal premium will increase by 93.1 % for Self Only or 136.3 % for Self and Family.
There will be a $10 copayment for all office visits. Currently, the office visit copayment only applies to primary care physician office visits.

The Plan will provide one eye refraction including lens prescription, every year for a $10 copayment. Currently, the Planprovide one eye refraction including lens prescription, every two years, and does not charge a copayment
for this service.
The prescription copayment will change from $5 per prescription or refill to $10 per prescription or refill for generic drugs or $20 per prescription unit or refill for brand-name drugs. If the member requests a name brand

drug when a Federally-approved generic drug is available, and the member's physician has not specified Dispense
as Written for the name brand drug, the member will pay the difference in cost between the name brand drug and
the generic, as well as the generic copayment.

The Plan will implement a mail order prescription program that will allow members to receive a 90-day supply of drugs for two times the applicable prescription copayment.

The Plan will provide rehabilitative therapy for the greater of 20 visits or up to two months per condition. Currently, the Plan provides rehabilitative therapy for up to two months per condition.
We now cover certain intestinal transplants (Section 5( b)) 8
8 Page 9 10
2002 SuperMed HMO 9 Section 3
Sect ion 3. How you get care
Identification cards We will send you an identification (ID) card. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or obtain a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
800/ 522-2066.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
Both primary care and specialist doctors are part of the network.
Different members of the same family may select different centers or
doctors.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. (www. mmoh. com)

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

What you must do to get covered care The first and most important decision each member must make is the
selection of a primary care doctor. The decision is important since it is
through this doctor that all other health services, particularly those of
specialists, are obtained. It is the responsibility of your primary care
doctor to obtain any necessary authorizations from the Plan before
referring you to a specialist or making arrangements for hospitalization.
Services of other providers are covered only when there has been a
referral by a member's primary care doctor.

Primary care Your primary care physician can be a physician, or group of physicians, trained in family or general practice, internal medicine, pediatrics or
osteopathic medicine who has a contractual obligation with SuperMed
HMO to provide the primary care services listed in this brochure. Your
primary care physician will provide most of your health care, or give you
a referral to see a specialist.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a Plan Obstetrician/ Gynecologist or vision
provider without a referral. For mental conditions and substance abuse
call SuperMed Behavioral Health Care Management Department at
800/ 258-3186.

Here are other things you should know about specialty care: 9
9 Page 10 11
2002 SuperMed HMO 10 Section 3
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 800/ 522-2066. 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 ar e dischar ged, not mer ely m oved to an alter native car e center ; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefit of the hospitalized
person; we cover your other non-hospital care.

Circum st ances beyond our cont rol Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. 10
10 Page 11 12
2002 SuperMed HMO 11 Section 3
In that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your physician
must obtain approval before sending you to a hospital, referring you to a
specialist, or recommending follow-up care. 11
11 Page 12 13
2002 SuperMed HMO 12 Section 4
Sect ion 4. Your cost s f or 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: You pay a copayment of $10 per office visit.
Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.

Your out-of-pocket maximum Your out-of-pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits. 12
12 Page 13 14
2002 SuperMed HMO 13 Section 5
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 56 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. To obtain claims forms, claims filing advice, or more information about our benefits,
contact us at 800/ 522-2066 or at our website at www. mmoh. com.
(a) Medical services and supplies provided by physicians and other health care professionals. 14-23

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Rehabilitative therapies
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 ........................... 24-27
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .......................................................... 28-30

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

Hospice care
Ambulance

(d) Emergency services/ accidents................................................................................................................................ 31-32
Medical emergency Ambulance

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

Flexible Benefits Option
Baby Link
Breathe Easy

Heart Sense
Transplanting Health

(h) Dental benefits ............................................................................................................................................................. 38
Summary of benefits ........................................................................................................................................................... 55 13
13 Page 14 15
2002 SuperMed HMO 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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion (in office)

$10 per of f ice visit

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

Nothing

Professional services of physicians
At home
Nothing

Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2002 SuperMed HMO 15 Section 5(a)
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

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

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening every five years starting at age 50

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

Prostate Specific Antigen (PSA test) one annually for men age 40 and
older

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

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

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

Influenza/ Pneumococcal vaccines, annually, age 65 and over
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges. 15
15 Page 16 17
2002 SuperMed HMO 16 Section 5(a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

Well-child care charges for routine examinations, immunizations and care (up to age 22)
Examinations, such as:
-Eye exams through age 17 to determine the need for vision correction.

-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations ( up to age 22) 16
16 Page 17 18
2002 SuperMed HMO 17 Section 5(a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to pre-certify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

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

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

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

Surgery benefits (Section 5b).

$10 per office visit; initial visit
only

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphrams
Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

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

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

$10 per office visit 17
17 Page 18 19
2002 SuperMed HMO 18 Section 5(a)
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

Fertility drugs
Cost of donor sperm
Cost of donor egg

All charges.

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 18
18 Page 19 20
2002 SuperMed HMO 19 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 27.

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

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

$10 per office visit 19
19 Page 20 21
2002 SuperMed HMO 20 Section 5(a)
Physical and occupational therapies You pay
Physical therapy, and occupational therapy --
For the greater of 20 visits or up to two months per condition, on an inpatient or outpatient basis, if significant improvement can be

expected within two months, for 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.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, provided at a Plan facility as

prescribed by your primary care doctor.

$10 per office visit
Nothing per visit during covered
inpatient admission.

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges.

Speech therapy
Speech Therapy --
For the greater of 20 visits or up to two months per condition
$10 per office visit
Nothing per visit during covered
inpatient admission.

Hearing services (testing, treatment, and supplies)

Hearing evaluations $10 per office visit

Not covered:
hearing aids, testing and examinations for them
All charges. 20
20 Page 21 22
2002 SuperMed HMO 21 Section 5(a)
Vision services (testing, treatment, and supplies) You pay
In addition to the medical and surgical benefits provided for diagnosis and
treatment of diseases of the eye, the Plan provides certain vision care
benefits from Plan providers:

One eye refraction, including lens prescription, every year.

$10 per office visit

Not covered:
Corrective lenses or frames
Eye exercises and orthoptics
Sunglasses

All charges.

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

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

$10 per office visit

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

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

treatment is by open cutting surgery)

All charges. 21
21 Page 22 23
2002 SuperMed HMO 22 Section 5(a)
Orthopedic and prosthetic devices You pay
Orthopedic devices, such as braces; foot orthotics
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

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

Nothing

Not covered:
arch supports
heel pads and heel cups
trusses, elastic stockings, support hose, and other supportive devices

All charges.

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

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

Note: Call us at 800/ 522-2066 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Nothing

Not covered:
Specially designed wheel chairs for use in sporting events
All charges. 22
22 Page 23 24
2002 SuperMed HMO 23 Section 5(a)
Home health services
Home health services of nurses and health aides, including intravenous fluids and medications, when prescribed by your Plan
doctor, who will periodically review the program from continuing
appropriateness and need.

Services include oxygen therapy, intravenous therapy and medications.

Nothing

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

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

All charges.

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

$10 per office visit

Not covered: All charges.
Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for: anesthesia, pain relief $10 per office visit

Not covered:
Naturopathic services Hypnotherapy

Biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

Smoking Cessation drugs and medication, including nicotine patches
Diabetes self-management

$10 per office visit 23
23 Page 24 25
2002 SuperMed HMO 24 Section 5(b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Any costs associated with the facility charge (i. e.

hospital, surgical center, etc.) are covered in Section 5 (c).
Your physician must get precertification of some surgical procedures. Please refer to the precertification information shown in Section 3 to be sure which

services require precertification and identify which surgeries require precertification.

I M
P O
R T
A N
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 --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over
Insertion of internal prostethic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

$10 per office visit;
Nothing for hospital visits

Surgical procedures continued on next page. 24
24 Page 25 26
2002 SuperMed HMO 25 Section 5(b)
Surgical procedures (Continued) You pay
Voluntary sterilization Treatment of burns

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

$10 per office visit
Nothing for hospital visits

Not covered:
Reversal of voluntary sterilization Surgery primarily for cosmetic purposes

Routine treatment of conditions of the foot; see Foot care.

All charges.

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

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

$10 per office visit
Nothing for hospital visits 25
25 Page 26 27
2002 SuperMed HMO 26 Section 5(b)
Reconstructive surgery (Continued) You pay
All stages of breast reconstruction surgery following a mastectomy, such as:

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

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

$10 per office visit
Nothing for hospital visits

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

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

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit

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

(such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges. 26
26 Page 27 28
2002 SuperMed HMO 27 Section 5(b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic bone marrow transplants

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

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

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

stomach, and pancreas
National Transplant Program (NTP) Ohio Department of Health and Ohio Organ Transplant Consortium

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

Anesthesia You pay
Professional services provided in

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

Nothing 27
27 Page 28 29
2002 SuperMed HMO 28 Section 5(c )
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

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

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

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

I M
P O
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A N
T

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

Meals and special diets.

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

Nothing

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed private nursing care

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

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care Non-covered facilities, such as schools

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

All charges. 28
28 Page 29 30
2002 SuperMed HMO 29 Section 5(c )
Out pat ie nt hospit al or am bulat or y surgical c ent er
Operating, recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing 29
29 Page 30 31
2002 SuperMed HMO 30 Section 5(c )
Ext ended care benefit s/ skilled nursing care f acilit y benef it s You pay
Extended care benefit:
The Plan provides a comprehensive range of benefits for up to 100 days
per calendar year when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan. All necessary
services are covered, including:

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

doctor.

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care
Personal comfort items, such as telephone and television

All charges

Hospice care
Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient
care, and family counseling, and durable medical equipment; these
services are provided under the direction of a Plan doctor who certifies
that the patient is in the terminal stages of illness, with a life expectancy
of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 30
30 Page 31 32
2002 SuperMed HMO 31 Section 5(d )
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

Her e ar e some impor tant things to keep in mind about these benef its:
Please r emember that all benef its ar e subject to the def initions, limitations, and exclusions in this br ochur e.

Be sur e to r ead Section 4, Your costs f or cover ed ser vices, f or valuable inf or mation about how cost shar ing wor ks. Also r ead Section 9 about coor dinating benef its with other
cover age, including with Medicar e.

I M
P O
R T
A N
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:
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you
are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or
go to the nearest hospital emergency room.

Emergencies within our service area:
Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You
or a family member should notify the Plan within 48 hours, unless it was not reasonably possible to do so.
It is your responsibility to ensure that the Plan has been timely notified.

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

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

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

The Plan pays reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers.

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

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

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers. 31
31 Page 32 33
2002 SuperMed HMO 32 Section 5(d )
The Plan pays reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center Nothing
Emergency care as an outpatient at a hospital, including doctors' services.

Note: If the emergency results in admission to a hospital, the emergency
care copay is waived.

$50 copay per visit

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

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center Nothing

Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

Note: If the emergency results in admission to a hospital, the emergency
care copay is waived.

$50 copay per visit

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance when ordered or authorized by a Plan doctor
See 5( c) for non-emergency service.

Nothing 32
32 Page 33 34
2002 SuperMed HMO 33 Section 5(e )
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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A N
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 description below.

I M
P O
R T
A N
T

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

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

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

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

Medication management

$10 per visit

Mental health and substance abuse benefits -Continued on next page 33
33 Page 34 35
2002 SuperMed HMO 34 Section 5(e )
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing

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

Nothing

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
This may be arranged by calling the SuperMed Behavioral Health Care
Management Department at 800/ 258-3186. It is not necessary to obtain a
referral from your primary care doctor. 34
34 Page 35 36
2002 SuperMed HMO 35 Section 5(f)
Section 5 (f). Prescription drug benefits
I M
P O
R
T A

N T

Here are some import ant t hings t o keep in mind about t hese benef it s:
We cover pr escr ibed dr ugs and medications, as descr ibed in the char t beginning on the next page.

All benef its ar e subject to the def initions, limitations and exclusions in this br ochur e and ar e payable only when we deter mine they ar e medically necessar y.
We have no calendar year deductible.
Be sur e to r ead Section 4, Your costs for covered services, f or valuable inf or m ation about how cost shar ing wor ks. Also r ead Section 9 about coor dinating benef its with other

cover age, including with Medicar e.

I M
P O
R
T A

N T

There are important features you should be aware of. These include:
Who can write your prescription. A plan or referral physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy, except for out-of-area emergencies, or by mail for a maintenance medication.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. A formulary is a list of selected FDA approved, prescription medications
reviewed by an independent Pharmacy and Therapeutics Committee brought together by Merck-Medco
Managed Care, L. L. C. These drugs are made by many different pharmaceutical
manufacturers, including Merck & Co., Inc. We cover non-formulary drugs prescribed by a Plan
doctor.

We have an open formulary. If your physician believes a name brand product is necessary or there
is no generic available, you physician may prescribe a name brand drug from a formulary list. This
list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower
cost. To order a prescription drug brochure call 800/ 491-1961.

Mail Order Program. To receive mail order prescription drug benefits, you mail your prescription order and the prescription drug deductible amount which is specified above to a contracting mail

order pharmacy. No benefits are payable if your prescription order is sent to a pharmacy other than
a contracting mail order pharmacy. The contracting mail order pharmacy will fill your prescription
order and send you up to a 90-day supply of the mail order prescription drug which your physician
has prescribed. The contracting mail order pharmacy will dispense the medication and mail it to you
within 72 hours. If you fail to receive the mail order prescription drug within ten days after you
mailed in your prescription order, call the contracting mail order pharmacy directly to determine the
status of the prescription order.

These are the dispensing limitations. Prescription drugs obtained at a Plan pharmacy will be dispensed for up to a 30-day supply. You pay a $10 copay per prescription unit or refill for generic

drugs or for name brand drugs when a generic substitution is not permissible. When a generic
substitution is permissible (i. e., generic drug is available and the prescribing doctor does not require
the use of a name brand drug), but you request the name brand drug, you pay the price difference
between the generic and name brand drug, as well as a $20 copay per prescription unit or refill.

Prescription drugs obtained by using the mail order prescription drug program will be dispensed for
up to a 90-day supply. You pay a $20 copay for all generic drugs and a $40 copay for all name brand
drugs.

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name

drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.
When you have to file a claim. You should contact Merck-Medco at 800/ 417-1961 for prescription drug claim forms. You should submit all claims to Paid Prescriptions, P. O. Box 709, Lee Summit,

MO 64063. Normally, when you use plan pharmacies, you will not have to file claims.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 SuperMed HMO 36 Section 5(f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

Drugs for which a prescription is required by Federal Law
Insulin
Disposable needles and syringes for the administration of covered medications

Contraceptive drugs and devices
Smoking cessation drugs and medication, including nicotine patches
Growth Hormone

Limited benefits:
Sexual dysfunction drugs have dispensing limitations. Contact the Plan for details.

30-day supply at a Plan pharmacy
$10 copay per prescription or refill
for generic drugs

$20 copay per prescription or refill
for formulary name brand drugs

Up to a 90-day supply through the mail order program
$20 copay per prescription or refill
for generic drugs

$40 copay per prescription or refill
for formulary name brand drugs

Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available.

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
Vitamins and nutritional substances that can be purchased without a prescription.
Medical supplies such as dressings and antiseptics
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Diabetic supplies, including glucose test tablets and test tape, Benedict's solution, or equivalent, and acetone test tablets

All Charges 36
36 Page 37 38
2002 SuperMed HMO 37 Section 5(g)
Sect ion 5 ( g) . Special f eat ures
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

Congestive Heart Failure (Heart Sense) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-877-726-2715 and talk with a cardiac nurse disease manager who will set up a program of telephone and home visit( s) that
will help you learn more about your condition and how to manage
your symptoms.

Maternity Care (BabyLink) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-338-4114 and talk with a maternity care nurse who can answer your questions and provide necessary information and
additional resources that you may need concerning maternity care,
during and after pregnancy.

Respiratory/ Asthma Disease (Breathe Easy) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-224-6906 and talk with a disease specific case manager who will discuss treatment, monitor progress and individualize care.

Transplants (Transplanting
Health)

For any of your health concerns, 24 hours a day, 7 days a week, you
may call 1-800-922-1154 Ext. 734 or 813 and talk with a case manager
who will discuss treatment, answer questions and provide necessary
information. 37
37 Page 38 39
2002 SuperMed HMO 38 Section 5(h)
Sect ion 5 ( h) . Dental benef it s
I M
P O
R T
A N
T

Here are some import ant t hings t o keep in mind about t hese benef it s:
Please r emember that all benef its ar e subject to the def initions, limitations, and exclusions in this br ochur e and ar e payable only when we deter mine they ar e medically necessar y.

We cover hospitalization f or dental pr ocedur es only when a nondental physical impair m ent exists which m akes hospitalization necessar y to saf eguar d the health of the patient; we do
not cover the dental pr ocedur e unless it is descr ibed below.
Be sur e to r ead Section 4, Your costs f or cover ed ser vices, f or valuable inf or mation about how cost shar ing wor ks. Also r ead Section 9 about coor dinating benef its with other

cover age, including with Medicar e.

I M
P O
R T
A N
T
Accidental injury benefit You Pay

Restorative services and supplies necessary to promptly repair (but not
replace) sound natural teeth. The need for these services must result
from an accidental injury. These services must be initiated within 90
days from the date of the accident. We do not cover services necessary
because of injury as a result of chewing or biting.

Nothing.

Dental benefits
We have no other dental benefits. 38
38 Page 39 40
2002 SuperMed HMO 39 Section 6
Sect ion 6. General exclusions --t hings 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 or condition.

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

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

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

incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 39
39 Page 40 41
2002 SuperMed HMO 40 Section 7
Sect ion 7. Filing a claim f or covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 800/ 522-2066.

When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and

Receipts, if you paid for your services.
Submit your claims to: SuperMed HMO, P. O. Box 6018, Cleveland, Ohio 44101, Attn: HMO Member Services. You may also
contact us by fax at 216/ 694-2910, or visit our website
http:// www. mmoh. com .

Prescription drugs Submit your claims to: Paid Prescriptions, P. O. Box 709, Lee Summit, MO 64063.

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. 40
40 Page 41 42
2002 SuperMed HMO 41 Section 8
Sect ion 8. The disput ed claim s 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: SuperMed HMO, P. O. Box 6018, Cleveland, Ohio 44101; 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 arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your medical provider for more information. If we ask your provider, we will send you a copy of our request go to step 3.

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1990 E Street,
NW, Washington, D. C. 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim. 41
41 Page 42 43
2002 SuperMed HMO 42 Section 8
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
800/ 522-2066 and we will expedite our review; or

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

-You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 42
42 Page 43 44
2002 SuperMed HMO 43 Section 9
Sect ion 9. Coordinat ing benef it s wit h ot her coverage
When you have ot her healt h 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.

If we pay second, we will determine our allowance. After the first plan
pays, we will pay either what is left of our allowance or our regular
benefit, whichever is less. We will not pay more than our allowance. If
we are the secondary payer, we may be entitled to receive payment from
your primary plan.

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

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

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

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

retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare + Choice is the term used to describe the various health plan choices available to
Medicare beneficiaries. The information in the next few pages shows how we coordinate
benefits with Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in (Part A or Part B) 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 this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. Your Plan
PCP must continue to authorize your care. 43
43 Page 44 45
2002 SuperMed HMO 44 Section 9
We will waive some copayments. (see page 46)
(Primary payer chart begins on next page.) 44
44 Page 45 46
2002 SuperMed HMO 45 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.

P rimary 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 anactive employee withtheFederal government( includingwhenyouor a familymember areeligible for Medicare solelybecause ofa disability),

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

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

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

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

(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

(except for claims
related to Workers'
Compensation.)

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD,

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

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 45
45 Page 46 47
2002 SuperMed HMO 46 Section 9
Claims process when you have the Origianl Medicare Plan --You probably will never have to file a claim form when you have both our Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something
about filing your claims, call us at 800/ 522-2066, or visit
our website http:// www. mmoh. com.

We waive some costs when you have the Original Medicare Plan --When Original Medicare is the primary payer, we will waive some out-of-
pocket costs, as follows:
Our office visit copays

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 .

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. 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. 46
46 Page 47 48
2002 SuperMed HMO 47 Section 9
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.

TRICARE TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first. 47
47 Page 48 49
2002 SuperMed HMO 48 Section 9
When other Governm ent 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 care for injuries for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 48
48 Page 49 50
2002 SuperMed HMO 49 Section 11
Sect ion 10. Def init ions of t erm s we use in t his 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.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Treatment or services that are mainly to help the patient with daily living activities

Experimental or A drug, device or medical treatment or procedure is experimental or investigational services investigational:
If the drug or device does not have required Food and Drug Administration (FDA) approval.
If reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I, II, III clinical trials or is
under study to determine maximum tolerated does, toxicity, safety,
efficacy, or efficacy as compared with the standard means of treatment or
diagnosis.

Group Health Coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies.

Medical necessity A service, supply or Prescription Drug that is required to diagnose or treat a Condition and which SuperMed HMO determines is:
appropriate with regard to the standards of good medical practice; not primarily for your convenience or the convenience of a Provider; and
the most appropriate supply or level of service which can be safely provided to you.

When applied to the care of an Inpatient, this means that your medical
symptoms or condition requires that the services cannot be safely or
adequately provided to you as an Outpatient. When applied to
Prescription Drugs, this means the Prescription Drug is cost effective
compared to alternative Prescription Drugs, which will produce
comparable effective clinical results.

Plan Allowance The amount a Contracting Institutional Provider or a Participating Professional Provider has agreed with SuperMed HMO to accept as
payment in full for Covered Services.

Us/ We Us and we refer to SuperMed HMO.
You You refers to the enrollee and each covered family member. 49
49 Page 50 51
2002 SuperMed HMO 50 Section 11
Sect ion 11. FEHB fact s
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

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

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

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

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

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

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 50
50 Page 51 52
2002 SuperMed HMO 51 Section 11
When benefits and The benef its in this br ochur e ar e ef f ective on Januar y 1. I f you joined this Plan prem iums st art during Open Season, your coverage beginson the first day of your first
pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.

Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

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

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

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

OPM, when r eviewing a disputed claim or defending litigation about a claim.
When you retire When you r etir e, you can usually stay in the FE HB Pr ogr am. Gener ally, you must have been enr olled in the FEHB Pr ogr am f or the last f ive year s of your
Feder al ser vice. I f you do not meet this r equir em ent, you may be eligible f or
other f or ms of cover age, such as Tempor ar y Continuation of Cover age ( TCC) .

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

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

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

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

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

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 51
51 Page 52 53
2002 SuperMed HMO 52 Section 11
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 ar e not eligible f or cover age under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no
longer eligible for coverage.

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

Getting a Certificate of You may be entitled to continued coverage through the Health Insurance Group Healt h Plan Coverage Portability and Accountability Act of 1996 (HIPAA). This Federal law
offers limited Federal protections for health coverage availability and
continuity to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You
can use this certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the
information in the certificate, as long as you enroll within 63 days of
losing coverage under this Plan. If you have been enrolled with us for
less than 12 months, but were previously enrolled in other FEHB plans,
you may also request a certificate from those plans.

Get OPM pamphlet RI 79-27, Temporary Continuation of Coverage
(TCC) under the FEHB Program. It highlights 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 it has information about Federal and State agencies you can
contact for more information. 52
52 Page 53 54
2002 SuperMed HMO 53 Section 11
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need? You should consider buying long-term care insurance.

The Office of Personnel Management (OPM) will sponsor a high-quality long-term care
insurance program effective in October 2002. As part of its educational effort, OPM asks you to
consider these questions:

What is long term care It's insurance to help pay for long term care services you may need
(LTC) insurance? 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.
I'm healthy. I won't need Welcome to the club!
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 everyone should have a plan just in case.

But won't my FEHB plan, Not FEHB. Look at the not covered" blocks in sections 5( a) and
Medicare or Medicaid 5( c) of your FEHB brochure. Health plans don't cover custodial cover my long term care? care or a stay in an assisted living facility or a continuing need for a

home health aide to help you get in and out of bed and with other
activities of daily living. Limited stays in skilled nursing facilities can be covered in some circumstances.

Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty guidelines, but has restrictions on covered services and where

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

When will I get more Employees will get more information from their agencies during the
information on how to LTC open enrollment period in the late summer/ early fall of 2002. apply for this new
Retirees will receive information at home.
insurance coverage

How can I find out more Our toll-free teleservice center will begin in mid-2002. In the
about the program NOW? meantime, you can learn more about the program on our web site at www. opm. gov/ insure/ ltc . 53
53 Page 54 55
2002 SuperMed HMO 54 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 31 Allergy tests 18
Allogenic (donor) bone marrow
transplant 27
Alternative treatment 23
Ambulance 30,32
Anesthesia 27
Autologous bone marrow
transplant 27
Biopsies 24 Blood and blood plasma 15,28

Breast cancer screening 15
Casts 29
Changes for 2001 8
Chemotherapy 19
Childbirth 17
Chiropractic 23
Cholesterol tests 15
Claims 40
Colorectal cancer screening 15
Congenital anomalies 24
Contr aceptive devices and dr ugs 17
Coordination of benefits 43
Covered charges 9
Covered providers 9
Crutches 22 Definitions 49

Dental care 38
Diagnostic services 14,34
Disputed claims review 41
Donor expenses (transplants) 27
Dressings 22,28
Durable medical equipment
(DME) 22
Educational classes and pr ogr ams 23 Effective date of enrollment 51

Emergency 31

Exper imental or investigational 49
Eyeglasses 21
Family planning 17
General Exclusions 39
Hearing services 20 Home health services 23

Hospice care 30
Home nursing care 23
Hospital 10,28
Immunizations 15,16 Infertility 17

Inhospital physician care 24
Inpatient Hospital Benefits 28
Insulin 36
Laboratory and pathological services 15

Machine diagnostic tests 15 Magnetic Resonance Imagings
(MRIs) 15
Mammograms 15
Maternity Benefits 17
Medicaid 47
Medically necessary 49
Medicare 43
Members 50
Mental Conditions/ Substance
Abuse Benefits 33
Newborn care 17 Nurse Midwife 17

Occupational therapy 20 Office visits 14
Or al and ma xil lof aci al surge ry 26 Orthopedic devices 22
Out-of-pocket expenses 12 Outpatient facility care 29
Oxygen 29 Pap test 15

Physical examination 15 Physical therapy 20
Physician 9 Precertification 34
Preventive care, adult 15 Pr eve nti ve ca re, children 16
Prescription drugs 35 Preventive services 15,16
Prostate cancer screening 15 Prosthetic devices 22
Psychologist 33 Radiation therapy 19
Renal dialysis 19 Room and board 28
Skilled nursing facility care 30 Smoking cessation 23,36
Speech therapy 20 Sterilization procedures 17
Subrogation 48 Substance abuse 34
Surgery 24
Anesthesia 27 Oral 26

Outpatient 24 Reconstructive 25
Syringes 36 Temporary continuation of
coverage 51 Transplants 27
Vision services 21 Well child care 16
Wheelchairs 22 Workers' compensation 47
X-rays 15 54
54 Page 55 56
2002 SuperMed HMO 55 Summary
Summary of benefits for the SuperMed HMO 2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.

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

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

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

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

Nothing
Nothing for outpatient hospital or
ambulatory surgical center

28
29
Emergency benefits:
In-area ..................................................................................................
Out-of-area...........................................................................................

$50 per hospital emergency room
visit, nothing per urgent care
center visit for services that are
covered benefits of this Plan. If
the emergency results in
admission to a hospital, the
emergency care copay is waived.

31-
32

32

Mental health and substance abuse treatment......................................... Regular cost sharing 33-
34

Prescription drugs...................................................................................... $10 copay for generic drugs
$20 copay for name brand drugs
$20 copay for generic drugs mail
order
$40 copay for name brand drugs
mail order

35-
36

Dental Care............................................................................................ Accidental injury benefit; you
pay nothing. 38

Vision Care............................................................................................ Every two years, one refraction;
$10 copay per office visit 21

Special features: Disease Management Programs; Heart Sense, Baby Link, Breathe Easy, Transplant
Health
37

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

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

12 55
55 Page 56
562002 SuperMed HMO 56 Rates
2002 Rate Information for
SuperMed HMO

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization who are not career postal employees. Refer to the applicable
FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

Self Only 5M1 $97.86 $47.07 $212.03 $101.99 $115.52 $29.41
Self and Family 5M2 $223.41 $147.31 $484.06 $319.17 $263.75 $106.97 56

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