Pages 1--48 from Foundation Health

Serving: South Florida (Miami-Dade, Broward and Palm Beach Counties)
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 5 for requirements.

Enrollment codes for this Plan:
5E1 Self Only 5E2 Self and Family

For changes
in benefits
see page 6.

A Health Maintenance Organization

RI 73-683 1
1 Page 2 3
2002 Foundation Health -Florida 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………..................................................................................................... 4
Plain Language.............................................................................................................................................................................................................. 4
Inspector General Advisory ........................................................................................................................................................................................ 4
Section 1. Facts about this HMO plan...................................................................................................................................................................... 5
How we pay providers ............................................................................................................................................................................. 5
Who provides my health care.................................................................................................................................................................. 5
Your Rights................................................................................................................................................................................................ 5
Service Area............................................................................................................................................................................................... 5
Section 2. How we change for 2002 ........................................................................................................................................................................ 6
Program-wide changes ............................................................................................................................................................................ 6
Changes to this Plan ................................................................................................................................................................................. 6
Section 3. How you get care ..................................................................................................................................................................................... 7
Identification cards................................................................................................................................................................................... 7
Where you get covered care.................................................................................................................................................................... 7
Plan providers................................................................................................................................................................................... 7
Plan facilities .................................................................................................................................................................................... 7
What you must do to get covered care .................................................................................................................................................. 7
Primary care...................................................................................................................................................................................... 7
Specialty care.................................................................................................................................................................................... 7
Hospital care ..................................................................................................................................................................................... 8
Circumstances beyond our control........................................................................................................................................................ 8
Services requiring our prior approval.................................................................................................................................................... 9
Section 4. Your costs for covered services ........................................................................................................................................................... 10
Copayments .................................................................................................................................................................................... 10
Coinsurance.................................................................................................................................................................................... 10
Your out-of-pocket maximum............................................................................................................................................................... 10
Section 5. Benefits..................................................................................................................................................................................................... 11
Overview.................................................................................................................................................................................................. 11
(a) Medical services and supplies provided by physicians and other health care professionals ......................................... 12
(b) Surgical and anesthesia services provided by physicians and other health care professionals ..................................... 20
(c) Services provided by a hospital or other facility, and ambulance services....................................................................... 23
(d) Emergency services/ accidents .................................................................................................................................................. 25
(e) Mental health and substance abuse benefits .......................................................................................................................... 27
(f) Prescription drug benefits.......................................................................................................................................................... 28
(g) Special features ........................................................................................................................................................................... 30 2
2 Page 3 4
2002 Foundation Health -Florida 3 Table of Contents
Flexible benefits option
High risk pregnancies
Centers of excellence for transplants

HIV/ AIDS
Congestive heart failure (CHF)
(h) Dental benefits............................................................................................................................................................................. 31
(i) Non-FEHB benefits available to Plan members .................................................................................................................... 32
Section 6. General exclusions --things we don't cover...................................................................................................................................... 33
Section 7. Filing a claim for covered services ...................................................................................................................................................... 34
Section 8. The disputed claims process................................................................................................................................................................. 35
Section 9. Coordinating benefits with other coverage ....................................................................................................................................... 37
When you have…
Other health coverage................................................................................................................................................................... 37
Original Medicare .......................................................................................................................................................................... 37
Medicare managed care plan ...................................................................................................................................................... 39
TRICARE/ Workers' Compensation/ Medicaid ................................................................................................................................. 40
Other Government agencies.................................................................................................................................................................. 40
When others are responsible for injuries ............................................................................................................................................ 40
Section 10. Definitions of terms we use in this brochure .................................................................................................................................... 41
Section 11. FEHB facts ............................................................................................................................................................................................. 42
Coverage information........................................................................................................................................................................... 42
No pre-existing condition limitation ...................................................................................................................................... 42
Where you get information about enrolling in the FEHB Program.................................................................................. 42
Types of coverage available for you and your family ......................................................................................................... 42
When benefits and premiums start ......................................................................................................................................... 43
Your medical and claims records are confidential............................................................................................................... 43
When you retire......................................................................................................................................................................... 43
When you lose benefits ....................................................................................................................................................................... 43

When FEHB coverage ends .................................................................................................................................................... 43
Spouse equity coverage........................................................................................................................................................... 43
Temporary Continuation of Coverage (TCC)...................................................................................................................... 43
Converting to individual coverage ........................................................................................................................................ 44
Getting a Certificate of Group Health Plan Coverage........................................................................................................ 44
Long term care insurance is coming later in 2002................................................................................................................................................. 45
Index ................................................................................................................................................................................................................ 46
Summary of benefits .................................................................................................................................................................................................. 47
Rates.............................................................................................................................................................................................................. Back cover 3
3 Page 4 5
2002 Foundation Health -Florida 4 Introduction/ Plain Language/ Advisory
Introduction
Foundation Health, a Florida Health Plan, Inc. 1340 Concord Terrace
Sunrise, Florida 33323
This brochure describes the benefits of Foundation Health, a Florida Health Plan, Inc. under our contract (CS 2715) 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 6. 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 Foundation Health.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street NW, Washington DC 20415-3650.

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 1-800/ 441-5501 and explain the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/ 418-3300 or write to:

The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400

Washington, DC 20415. Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take administrative action against you. 4
4 Page 5 6
2002 Foundation Health -Florida 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services.

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

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.

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

Who provides my health care
Foundation Health is an individual practice prepayment (IPP) plan that contracts with doctors to provide services for you out of their own offices.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.
Foundation Health, a Florida Health Plan, Inc., is a for-profit entity and has been operational since 1984. Foundation Health is NCQA accredited and is licensed by the Department of Insurance and Agency for Health Care Administration to conduct business in the State

of Florida.
If you want more information about us, call 800/ 441-5501, or write to Attn: Customer Service Department, Foundation Health, a Florida Health Plan, Inc., 1340 Concord Terrace, Sunrise, FL 33323. You may also contact us by fax at 954/ 846-8873 or visit our
website at www. fhfl. com.

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: South Florida – Miami-Dade, Broward and Palm Beach Counties (Code 5E).

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. Reciprocity arrangements do not exist in any other Foundation Health Plan
networks. 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. 5
5 Page 6 7
2002 Foundation Health -Florida 6 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM.
Changes to this Plan
Your share of the non-Postal premium will increase by 6.8% for Self Only and for Self and Family.

We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

We now cover certain intestinal transplants. (Section 5( b))
We changed the benefit for hospital admissions from no copay to a $200 copay per person once per calendar year. (Section 5( c))
We changed the benefit for outpatient surgery from no copay to a $50 copay per visit. (Section 5( c))
We changed the benefit for home health care from no copay for physicians visits to a $10 copay per visit; no copay for visits by nurses and health aides. (Section 5( a))

We added 40% coinsurance of reasonable and customary charges for second opinions provided by non-Plan physicians.
We changed the emergency room copay from $25 per visit to $50 per visit. (Section 5( c))
The Plan will no longer offer Dental coverage under Non-FEHB benefits. (Section 5( h) & 5( i))
The Plan has extended the benefit for treatment of chronic and disabling conditions when a specialist terminates from the network from 90 days to 6 months. If the member is pregnant she may continue with the specialist until the end of postpartum care.

(Section 3)
We changed the prescription drug copayments to $7 (generic) / $14 (generic formulary when no generic is available) / $34 (non-formulary). (Section 5( f))

We expanded the benefit for smoking cessation to cover drugs for one program per person with a $100 maximum per lifetime. (Section 5( a)). The office visit copay is $10. 6
6 Page 7 8
2002 Foundation Health -Florida 7 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800/ 441-5501. You may also
verify eligibility by visiting our website at www. fhfl. com and/ or our Interactive Voice Response System (IVR) by calling 800/ 977-6870.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

Plan facilities Plan facilit ies 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.
It depends on the type of care you need. First, you and each family member must choose
a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. Using our provider directory to select

your Primary Care Physician (PCP) you then complete and submit the HMO Provider
Choice card physician information provided in your enrollment packet.

Primary care Your primary care physician can be a family practitioner, internist , general practitioner,
or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your

primary care physician gives you a referral. However, you may see the following
specialists without a referral: Chiropractor 12 times per calendar year; Dermatologist 5 times per calendar year; Podiatrist 12 times per calendar year; OB/ GYN once per

calendar year for a Well Woman Exam;. You may also access Optometrists for routine
vision care and unlimited visits for medical conditions of the eyes.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that

What you must do
to get covered care 7
7 Page 8 9
2002 Foundation Health -Florida 8 Section 3
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 6 months after the specialists contract termination date. 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 6 months.
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 800-441-5501. If you are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care. 8
8 Page 9 10
2002 Foundation Health -Florida 9 Section 3
Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally

accepted medical practice.

We call this review and approval process precertification. Your physician must obtain precertification for the following services:

This is not an exhaustive list
Inpatient/ Outpatient Surgery Home Health
Durable Medical Equipment (DME)
Total OB Care MRIs / Pet Scans

Lithotripsy
Transplant Evaluation Referrals Oral Surgeon / Dental

Physical, Occupational And Speech
Therapy

Hospice Hyperbaric Therapy
Nuclear Medicine -Thallium/ Muga
Non-Participating Provider Referrals Dialysis

Injectable Medicine
Genetic Testing Plastic Surgery

Skilled Nursing Facilities (SNF)/ Nursing Home
Growth Hormone Evaluation

Your primary care physician (PCP) has authority to refer you for most services.
However your PCP must contact Foundation Health Department for Authorization at 800/ 242-7174 for certain medical services (see above list) for approval before the service

is performed. Requests will be denied if the services are deemed not medically
necessary, experimental and/ or not covered. All precertifications are conditioned upon the member being actively enrolled at the time the services are requested and/ or

performed. Medical services receiving precertification are subject to the Plan's
copayments.

If a member receives services that require precertification without approval, those
services could be denied. If the services are denied based on medical necessity or rendered without approval the member may file a grievance. 9
9 Page 10 11
2002 Foundation Health -Florida 10 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay $200 once per calendar year.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services and durable medical equipment.

After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However,
copayments/ coinsurance for the following services do not count toward your out-of-pocket maximum and you must continue to pay copayments/ coinsurance for these
services:

Routine Vision Care
Prescription Drugs
Infertility Treatment

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

Your catastrophic protection out-of-pocket maximum for
coinsurance and copayments 10
10 Page 11 12
2002 Foundation Health -Florida 11 Section 5
Section 5. Benefits --OVERVIEW
(See page 6 for how our benefits changed this year and page 47 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 800-441-5501 or at our website at www. fhfl. com.

(a) Medical services and supplies provided by physicians and other health care professionals ........................................................... 12-19
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................................................... 20-22

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

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

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

(e) Mental health and substance abuse benefits .................................................................................................................................................. 27
(f) Prescription drug benefits............................................................................................................................................................................ 28-29
(g) Special features .................................................................................................................................................................................................. 30
Flexible benefits option

High risk pregnancies
Centers of excellence for transplants
HIV/ AIDS
Congestive Heart Failure (CHF)
(h) Dental benefits (No benefit).............................................................................................................................................................................. 31
(i) Non-FEHB benefits available to Plan members ........................................................................................................................................... 32
Summary of benefits .................................................................................................................................................................................................. 47 11
11 Page 12 13
2002 Foundation Health -Florida 12 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

Medicare.

I M
P O
R T
A N
T

Benefit Description You pay

Diagnostic and treatment services
Professional services of physicians
In physician's office

$10 per office visit

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

Nothing

Second surgical opinion Nothing if performed by a Plan physician or 40% of usual and customary charges if
performed by a non Plan physician

At home $10 per office visit
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 12
12 Page 13 14
2002 Foundation Health -Florida 13 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol – once every three years

Colorectal Cancer Screening, including

-Fecal occult blood test
-Sigmoidoscopy, screening – every five years starting at age 50

$10 per office visit

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

$10 per office visit

Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 49, one every two years
At age 50 and older, one mammogram every year.

In addition to routine screening, mammograms are covered when prescribed by your doctor as medically necessary to diagnose or treat

your illness.

Nothing

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

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing

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

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)

$10 per office visit 13
13 Page 14 15
2002 Foundation Health -Florida 14 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:
Your doctor must get precertification for your delivery; see page 9 for other circumstances, such as extended stays for you or your baby.

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

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

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

Surgery benefits (Section 5b).

$10 per office visit

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 $200

Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

NOTE: We cover oral contraceptives under the prescription drug
benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI) -intracervical insemination (ICI)

-intrauterine insemination (IUI)

50% of covered charges

Infertility services --continued on next page 14
14 Page 15 16
2002 Foundation Health -Florida 15 Section 5( a)
Infertility services (continued) You pay
Not covered:
Fertility drugs
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization -embryo transfer, gamete GIFT and zygote ZIFT

-Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
$15 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges.

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 22
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: – We will only cover GHT when we preauthorize the treatment. Call you primary care physician to coordinate you care. We will ask

him/ her to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date

the information is submitted. If prior authorization is not given or if we
determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior

approval in Section 3.

$10 per office visit 15
15 Page 16 17
2002 Foundation Health -Florida 16 Section 5( a)
Physical and occupational therapies You pay
60 visits per condition for the services of each of the following:
-qualified physical therapists and -occupational therapists.

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

Inpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 100
sessions.
Outpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction.

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

$10 per office visit

Not covered:
long-term rehabilitative therapy
pulmonary rehabilitation
exercise programs

All charges.

Speech therapy
Habilitative and Rehabilitative Services
60 visits per condition
$10 per office visit. Nothing per visit during covered inpatient admission.

Not covered:
All services not deemed medically necessary
All charges.

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

Hearing testing for children through age 18 (see Preventive care, children)

$10 per office visit

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

All charges.

Vision services (testing, treatment, and supplies)
Annual eye refractions, including written lens prescription
Note: See Preventive care, children for eye exam to determine the need for vision correction for children through age 18.
$19 per office visit

Eyeglasses
Standard frames (preselected collection) Nothing

Single vision lenses $20

Vision services --continued on next page 16
16 Page 17 18
2002 Foundation Health -Florida 17 Section 5( a)
Vision services (testing, treatment, and supplies) (cont.) You pay
Bifocal lenses $25

Trifocal lenses $30
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit

Medically necessary contact lenses (evaluation and fitting) Nothing
Daily wear contact lenses (Bausch & Lomb, Biomedics) $10

Extended wear contact lenses (Bausch & Lomb, Biomedics) $15
Disposable lenses (2 boxes of all clear spherical lens) $48
All eyewear (including contact lenses) outside of the Select Plan. 25% discount
Eye exam to determine the need for vision correction for children through age 18 (see Preventive care, children) $10

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

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

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

$10 per office visit

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

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

treatment is by open cutting surgery)

All charges. 17
17 Page 18 19
2002 Foundation Health -Florida 18 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5( b) for coverage of the surgery

to insert the device.
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See 5( b) for coverage of the surgery to insert the device.

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

Nothing

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

prosthetic replacements provided less than 3 years after the last
one we covered

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps;
diabetic strips

Note: Call us at 800-441-5501 as soon as your Plan physician prescribes this equipment.

Nothing

Durable Medical Equipment – continued on next page 18
18 Page 19 20
2002 Foundation Health -Florida 19 Section 5( a)
Durable medical equipment (DME) (continued) You pay
Not covered:
Motorized wheel chairs unless medically necessary to meet the
minimum functional requirements of the member.

All charges.

Home health services
Home health care ordered and performed by a Plan physician $10 per visit
Home Health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

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

12 visits without a referral per calendar year, additional visits require referral from PCP

$10 per office visit

Not covered:
All services not deemed medically necessary

All charges.

Alternative treatments
Biofeedback – for migraine headaches $10 per office visit

Not covered:
acupuncture
naturopathic services
hypnotherapy

All charges.

Educational classes and programs
Coverage is limited to:
Smoking Cessation –The program includes up to $100 for smoking cessation drugs per member per lifetime
$10 per office visit

Diabetes self-management Nothing 19
19 Page 20 21
2002 Foundation Health -Florida 20 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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A N
T

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

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

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

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

precertification and identify which surgeries require precertification.

I M
P O
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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 prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information.

$10 per office visit
$200 per calendar year for inpatient hospital admissions

$50 per outpatient surgery

Voluntary sterilization $200 copayment
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.

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

All charges. 20
20 Page 21 22
2002 Foundation Health -Florida 21 Section 5( b)
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.
$200 per calendar year for inpatient hospital.

$50 per outpatient surgery

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

See above.

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

Surgeries related to sex transformation

All charges

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

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit

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

All charges. 21
21 Page 22 23
2002 Foundation Health -Florida 22 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

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

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

Centers for Excellence
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.

$200 per calendar year for inpatient hospital.

Organ/ tissue transplants
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
Professional services provided in –
Hospital (inpatient)
Hospital (outpatient department)

Nothing

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

$10 per office visit 22
22 Page 23 24
2002 Foundation Health -Florida 23 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
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 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.

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.

$200 per calendar year for inpatient hospital

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms

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

Nothing; included in the inpatient hospital copay

Not covered:
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

All charges. 23
23 Page 24 25
2002 Foundation Health -Florida 24 Section 5( c)
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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

$50 copay per outpatient surgery

Extended care benefits/ skilled nursing care facility benefits You pay
The Plan provides a comprehensive range of benefits for up to 100 days
per calendar year when you are hospitalized under the care of a Plan doctor. All necessary services are covered

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

Nothing

Not covered: custodial care All charges.
Hospice care
The Plan covers supportive and palliative care for a terminally ill
member. Coverage is provided in the home or a hospice facility. Services include inpatient, outpatient care and family counseling; these

services are provided under the direction of a Plan doctor who certifies
that the patient is in 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 24
24 Page 25 26
2002 Foundation Health -Florida 25 Section 5( d)
Section 5 (d). Emergency services/ accidents
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.

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
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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. 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 is not reasonably possible to do so. It is your
responsibility to ensure that the Plan has been notified timely

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 in 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.

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

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

Emergencies outside our service area:
Benefits are available for any medically necessary 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 in 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. 25
25 Page 26 27
2002 Foundation Health -Florida 26 Section 5( d)
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 $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$50 per visit (waived if admitted), or

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
$25 per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit (waived if admitted)
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.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance (unless pre-approved by the Plan) All charges. 26
26 Page 27 28
2002 Foundation Health -Florida 27 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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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
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan approved by Psych/ Care. 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 Psych/ Care approves.

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

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit

Diagnostic tests Nothing if you receive these services during your office visit;
otherwise, $10 per visit
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based

intensive outpatient treatment

$200 per calendar year for inpatient hospital.

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 of the following authorization processes:
Foundation Health requires you to call Psych/ Care directly at 800-221-5487. An
assessment of your condition( s) will determine the type of services you will need.

Limitation We may limit your benefits if you do not obtain a treatment plan. 27
27 Page 28 29
2002 Foundation Health -Florida 28 Section 5( f)
Section 5 (f). Prescription drug benefits
I M

P O
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A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable
only when we determine they are medically necessary.

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

Medicare.

I M
P O
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A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You may fill the prescription at a participating pharmacy, please see the complete listing of participating pharmacies in our provider directory.

We use a formulary. A formulary is a mandatory listing of covered prescription medications which are preferred for use by this Plan and will be dispensed through participating pharmacies to covered persons. All
medications are listed by generic name with brand names listed for reference. We cover non-formulary drugs
prescribed by a Plan doctor. If a physician prescribes a drug that is not on the formulary, you will be responsible for a higher copayment of $34. If a physician would like to make a recommendation for a

formulary revision they may contact the Plan directly.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. If no generic is

available the cost will be a copayment amount of $14. 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 800-441-5501.

These are the dispensing limitations.
Retail drugs are dispensed in increments of 34-day supply or Foundation Health's Drug Utilization System is
set to alert the dispensing pharmacy whenever a maintenance medication is presented for refill very early after the last dispersion, of if the patient has waited beyond the specified days supply for their previous fill. If

a physician prescribes a medication that does not have a generic equivalent the member is responsible to pay
the brand name copay. Drugs to treat sexual dysfunction are limited to 4 pills or dosage units per month. Prior approval is required.

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name
brand. If you receive a name brand drug when a Federally-approved generic drug is available, you have to pay the brand name copay + the difference in cost between the name brand drug and the generic.

Why use generic drugs?
Generic drugs offer a safe and economic way to meet your prescription drug needs.
When you have to file a claim.
See Filing a claim for covered services (Section 7). 28
28 Page 29 30
2002 Foundation Health -Florida 29 Section 5( f)
Benefit Description You pay After the calendar year deductible…
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those
listed as Not covered.
Insulin
Disposable needles and syringes for the administration of covered
medications
Contraceptive drugs and devices

$ 7 per generic formulary;
$ 14 per formulary brand when a generic is not available;

$34 per non-formulary drug

Note: If there is no generic equivalent available, you will still have to pay the
brand name copay.

Drugs for sexual dysfunction (Viagra, limited to 4 pills per month, (Prior authorization required)) $34 per prescription

Drugs for smoking cessation (combined with all s moking cessation
related services)
$100 per person per lifetime

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines

All charges. 29
29 Page 30 31
2002 Foundation Health -Florida 30 Section 5( g)
Section 5 (g). Special features
Feature Description

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

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

The decision to offer an alternative benefit is solely ours, and we may withdraw
it at any time and resume regular contract benefits.

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

High risk pregnancies Foundation Health offers a dedicated OB Case Management unit, coordinating and monitoring all phases of care through the member's pregnancy.
Centers of excellence for transplants/ heart
surgery/ etc.

Foundation Health utilizes United Resource Network (URN) for transplants. URN centers are utilized on a case by case basis. URN has centers of excellence nation-wide
for various of transplants.

HIV/ AIDS Foundation Health encourages members to get regular testing during their annual exam. With early detection and intervention we assist members via educational
material, assist the member with obtaining necessary resources.

Congestive Heart Failure (CHF) Foundation Health offers members with Congestive Heart Failure dedicated Case Management services. We also provide educational material to the member to
assist in the improvement of their condition. 30
30 Page 31 32
2002 Foundation Health – Florida 31 Section 5 (h)
Section 5 (h). Dental benefits
I M
P O
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A N
T

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

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

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

Medicare.

I M
P O
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A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must
result from an accidental injury.
$10 per office visit

Services rendered in a hospital emergency room or urgent care center. $50 per visit
Dental benefits
We have no other dental benefits. 31
31 Page 32 33
2002 Foundation Health -Florida 32 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

Medicare Prepaid Plan Enrollment – This Plan offers Medicare beneficiaries (whether actively working or
annuitant) the opportunity to enroll in the Plan through Medicare. As indicated on page 39, certain annuitants and former spouses who are covered by both Medicare Parts A and B and FEHB, may elect to drop their FEHB coverage

and later reenroll in FEHB. Prior to dropping your FEHB enrollment to change to a Medicare prepaid health plan,
you should contact your retirement system for more information. Contact us at 877/ FHS-6899 or by fax at 954/ 846-8873, for information on the Medicare prepaid plan and the cost of that enrollment.

If you are entitled to Medicare Benefits, you may also choose to enroll in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan. If you are interested in this option and would like more
information on the benefits available under the Medicare HMO and how they coordinate with your FEHB benefits,
contact us at 877/ FHS-6899 or by fax at 954/ 846-8873.

Expanded Vision Care – Discounts on vision services are available to Foundation Health members. Services
include Eye exams; Contact lenses; Eyeglasses, Designer glasses, Sunglasses, etc. Non-Medically necessary Contact Lenses evaluation and fitting services are provided by participating providers, there is a maximum charge of $45 for

Foundation Health members.
For details on specific services and discounts, please call our Member Services Department at 877/ FHS-6899. 32
32 Page 33 34
2002 Foundation Health -Florida 33 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 33
33 Page 34 35
2002 Foundation Health -Florida 34 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical, hospital and drug In most cases, providers and facilities file claims for you. Physicians must file on the benefits form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 800/ 441-5501.
When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be
itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply, tax
identification

Dates you received the services or supplies;
Diagnosis code;
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;
For services received overseas, please provide a translation of services.
Submi t your claims to: Foundation Health
Attn: FEHB Claims Department 1340 Concord Terrace

Sunrise, Florida 33323

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 34
34 Page 35 36
2002 Foundation Health -Florida 35 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 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: Foundation Health, a Florida Health Plan, Inc., 1340 Concord Terrace, Sunrise, Florida
33323; and

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

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 35
35 Page 36 37
2002 Foundation Health -Florida 36 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

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

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

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

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

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

uphold or overturn our decision. You may recover only the amount of benefits in dispute.

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 800/ 441-5501and we will expedite our review; or

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

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 36
36 Page 37 38
2002 Foundation Health -Florida 37 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under another group coverage health plan or have automobile insurance that pays health care expenses without regard
to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

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

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

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

check.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription
drugs. When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care

Your care must continue to be authorized by your Plan PCP, or precertified as required. We will not waive any of our copayments or coinsurance.
(Primary payer chart begins on next page.)

The Original Medicare Plan
(Part A or Part B) 37
37 Page 38 39
2002 Foundation Health -Florida 38 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is… A. When either you – or your covered spouse --are age 65 or over and …

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

disability),

2) Are an annuitant,

3) Are a re-employed annuitant with the Federal government when…
a) The position is excluded from FEHB, or

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

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

covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

(except for claims related to Workers'

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

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

2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,

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

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 38
38 Page 39 40
2002 Foundation Health -Florida 39 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will pay the balance of covered charges. You will not need to do anything. To find out if you

need to do something about filing your claims, contact us at 800-441-5501 or
www. fhfl. com

We do not waive any costs when you have Medicare.

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

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare
managed care plan and also remain enrolled in our FEHB plan. In this case, we do not waive any of our copayments, coinsurance.

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 or coinsurance. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the

Original Medicare Plan or in a Medicare managed care plan so we can correctly
coordinate benefits with Medicare.

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

If you do not have one or both Parts of Medicare, you can still be covered 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.

If you do not enroll in
Medicare Part A or Part B 39
39 Page 40 41
2002 Foundation Health -Florida 40 Section 9
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both TRICARE
and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you
have questions about TRICARE coverage.

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

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

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

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

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

If you do not seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures. 40
40 Page 41 42
2002 Foundation Health -Florida 41 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 10

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 10
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services to support and generally maintain the patient's condition, provide for the patient's comfort or ensure the manageability of the patient.

Services, supplies, drugs and procedures which have not demonstrated to be safe,
effective, medically appropriate for use in the treatment of illness or injury. Also include services, supplies, drugs and procedures that are determined to be the subject of clinical

trial.

Group health coverage Healthcare insurance that covers a group of people (e. g. FEHB) under one master contract.

Medical necessity Services which are necessary and appropriate for the treatment of an illness or injury according to professionally recognized standards of practice and are consistent with
Foundation's medical policies.
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our
allowance as follows:

Covered benefits that require coinsurance are based on our Plan's allowance.

Us/ We Us and we refer to Foundation Health, a Florida Health Plan, Inc.
You You refers to the enrollee and each covered family member.

Experimental or
investigational services 41
41 Page 42 43
2002 Foundation Health -Florida 42 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the
first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective

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

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

divorce, or when your child under age 22 marries or turns 22. If you or one of your
family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan. 42
42 Page 43 44
2002 Foundation Health -Florida 43 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premium 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 the following records are confidential will have access to it:

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

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

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

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

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

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

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

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

of Coverage and Former Spouse Enrollees, or other information about your coverage
choices.

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

after you retire , if you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll. 43
43 Page 44 45
2002 Foundation Health -Florida 44 Section 11
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage
or did not pay your premium, you cannot convert);

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

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other

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

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

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB website www. opm. gov/ insure/ health: refer to the "TCC and HIPAA" frequently asked questions.

These highlight HIPAA rules, such as the requirement that Federal employees must
exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies you can

contact for more information. 44
44 Page 45 46
2002 Foundation Health -Florida 45 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October
2002. As part of its educational effort, OPM asks you to consider these questions:

It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or injury, or an age-related disease
such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your home, adult day care, hospice care, and more. It

can supplement care provided by family members, reducing the burden you place on them.

Welcome to the club!
76% of Americans believe they will never need long term care, but the facts are that about half them will. And it's not just the old folks. About 40% of people needing

long term care are under age 65. They may need chronic care due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan just in
case. Many people now consider long term care insurance to be vital to their financial and retirement planning.

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

Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your
FEHB brochure. Health plans don't cover custodial 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.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.

Retirees will receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can learn more about the program on our web site at www. opm. gov/ insure/ ltc.

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

What is long term care
(LTC) insurance?

I'm healthy. I won't need
long term care. Or, will I?

Is long term care expensive?
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?

When will I get more information
on how to apply for this new
insurance coverage?

How can I find out more about the
program NOW? 45
45 Page 46 47
2002 Foundation Health -Florida 46 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 15
Alternative treatment 19 Allogeneic (donor) bone marrow
transplant 22 Ambulance 24, 26
Anesthesia 22 Autologous bone marrow transplant 22
Biopsies 20 Blood and blood plasma 23
Breast cancer screening (mammograms) 13
Casts 23, 24 Catastrophic protection 47
Changes for 2002 6 Chemotherapy 15
Chiropractic 19 Cholesterol tests 13
Claims 34 -36 Coinsurance 10
Colorectal cancer screening 13 Congenital anomalies 21
Contraceptive devices and drugs 14, 29 Covered services 34
Covered providers (Plan providers) 7 Crutches 18
Definitions 41 Dental care 31
Diagnostic services 12 Disputed claims review 35
Donor expenses (transplants) 22 Dressings 23, 24
Durable medical equipment (DME) 18 Educational classes and programs 19
Effective date of enrollment 43 Emergency 25
Experimental or investigational 33 Eyeglasses 16

Family planning 14 Fecal occult blood test 13
General Exclusions 33 Hearing services 16
Home health services 19 Hospice care 24
Hospital care 8, 23 Immunizations 13
Infertility 14 In hospital physician care 12
Inpatient Hospital Benefits 23 Insulin 29
Laboratory and pathological services 12 Magnetic Resonance Imagings (MRIs) 12
Mammograms 13 Maternity Benefits 14
Medicaid 40 Medically necessary 9
Medicare 37 Members 5
Mental Conditions/ Substance Abuse Benefits 27
Newborn care 14 Non-FEHB Benefits 32
Nurse Licensed Practical Nurse 19
Licensed Vocational Nurse 19 Registered Nurse 19
Nursery charges 14 Obstetrical care 14
Occupational therapy 16 Ocular injury 17
Office visits 5 Oral and maxillofacial surgery 21
Orthopedic devices 18 Out-of-pocket expenses 10
Outpatient facility care 24 Oxygen 18, 23, 24

Pap test 13 Physical therapy 16
Physician 7 Precertification 9
Preventive care, adult 13 Preventive care, children 13
Prescription drugs 28 Preventive services 13
Prior approval 9 Prostate cancer screening 13
Prosthetic devices 18 Psychologist 27
Radiation therapy 15 Renal dialysis 15
Room and board 23 Second surgical opinion 12
Skilled nursing facility care 22 Smoking cessation 19
Speech therapy 16 Splints 23
Sterilization procedures 14, 20 Subrogation 40
Substance abuse 27 Surgery 20
Anesthesia 22 Oral and Maxillofacial 21
Outpatient 24 Reconstructive 21
Syringes 29 Temporary continuation of coverage 43
Transplants 22 Treatment Therapies 15
Vision services 16 Well child care 13
Wheelchairs 18 Workers' compensation 40
X-rays 12, 23, 24 46
46 Page 47 48
2002 Foundation Health -Florida 47 Summary of Benefits
Summary of benefits for Foundation Health, a Florida Health Plan, Inc. -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ................... Office visit copay: $10 primary care; $10
specialist
12

Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
$200 per calendar year

$50 per outpatient surgery
23

24

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

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

$50 per emergency room visit (waived if admitted)

$50 per emergency room visit (waived if admitted)

25
25

Mental health and substance abuse treatment............................................ Regular cost sharing. 27
Prescription drugs........................................................................................... Generic formulary $7
Brand name formulary $14
Non-formulary $34

28

Dental Care................................................................................................... No benefit 31
Vision Care................................................................................................... $19 copay per visit for annual eye refraction. Various copays / discounts on frames and
lenses
16

Special features: High risk pregnancies, Centers for excellence, HIV/ AIDS and Congestive Heart Failure (CHF) 30
Protection against catastrophic costs (your out-of-pocket maximum) ................................................................ Nothing after $1,500/ Self Only or $3,000/ Family enrollment per year

Some costs do not count toward this protection
10 47
47 Page 48
2002 Rate Information for
Foundation Health Plan

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

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

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 5E1 $60.05 $20.01 $130.10 $43.36 $71.05 $9.01
Self and Family 5E2 $165.13 $55.04 $357.78 $119.26 $195.40 $24.77 48

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