Pages 1--56

Serving: Greater New York City Area

Enrollment codes for this Plan:
511 High Option Self Only 512 High Option Self and Family
514 Standard Option Self Only 515 Standard Option Self and Family

This Plan has Commendable
Accreditation from the NCQA. See the
2003 Guide for more information on accreditation.

Special notice: We are offering a new plan option for the first time under the Federal Employees Health Benefits Program during the 2003 Open Season. If you were
enrolled in HIP/ HMO coverage during 2002, that option is now known as High Option.
You will remain in the HIP/ HMO High Option coverage unless you elect the Standard Option coverage or another health plan during Open Season.

RI 73-001

A Health Maintenance Organization
This Plan has Commendable Accreditation
from the NCQA. See the 2003 Guide for more
information on accreditation.

For changes in benefits
see page 7. Enrollment in this Plan is limited. You must live in our
Geographic service area to enroll. See page 6 for requirements. 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how OPM
may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assis-tance
regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any pur-pose
that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has already
acted based on your permission.

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and
OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your
personal medical information that was given to you or your personal representative, any information that you authorized OPM to
release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box
instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your
request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM's FEHB Program privacy official for this purpose. 3.
3 Page 4 5
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical infor-mation
is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The pri-vacy
practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
Introduction .............................................................................................................................................................................................. 4
Plain Language .......................................................................................................................................................................................... 4
Stop Health Care Fraud!............................................................................................................................................................................ 4
Section 1. Facts about this HMO plan.................................................................................................................................................. 6
How we pay providers ........................................................................................................................................................ 6
Who provides my health care? ............................................................................................................................................ 6
Your Rights.......................................................................................................................................................................... 6
Service Area ........................................................................................................................................................................ 6
Section 2. How we change for 2003 .................................................................................................................................................... 7
Program-wide changes ........................................................................................................................................................ 7
Changes to this Plan ............................................................................................................................................................ 7
Section 3. How you get care ................................................................................................................................................................ 8
Identification cards .............................................................................................................................................................. 8
Where you get covered care ................................................................................................................................................ 8
Plan providers ................................................................................................................................................................ 8
Plan facilities .................................................................................................................................................................. 8
What you must do to get covered care................................................................................................................................ 8
Primary care.................................................................................................................................................................... 8
Specialty care.................................................................................................................................................................. 8
Hospital care .................................................................................................................................................................. 9
Circumstances beyond our control ...................................................................................................................................... 9
Services requiring our prior approval................................................................................................................................ 10
Section 4. Your costs for covered services ........................................................................................................................................ 11
Copayments .................................................................................................................................................................. 11
Deductible .................................................................................................................................................................... 11
Coinsurance .................................................................................................................................................................. 11
Your catastrophic protection out-of-pocket maximum...................................................................................................... 11
Section 5. Benefits .............................................................................................................................................................................. 12
Overview............................................................................................................................................................................ 12
(a) Medical services and supplies provided by physicians and other health care professionals ............................ 13-21
(b) Surgical and anesthesia services provided by physicians and other health care professionals.......................... 22-24
(c) Services provided by a hospital or other facility, and ambulance services ........................................................ 25-26
(d) Emergency services/ accidents ............................................................................................................................ 27-28
(e) Mental health and substance abuse benefits ...................................................................................................... 29-30
(f) Prescription drug benefits .................................................................................................................................... 31-32

Table of Contents

2003 Health Insurance Plan (HIP/ HMO) Table of Contents 2 5.
5 Page 6 7
(g) Special features ...................................................................................................................................................... 33
Medical Case Management .................................................................................................................................. 33
Service for deaf and hearing impaired .................................................................................................................. 33
Travel benefit/ services overseas ............................................................................................................................ 33
(h) Dental benefits .......................................................................................................................................................... 34
(i) Non-FEHB benefits available to Plan members .......................................................................................................... 35
Section 6. General exclusions things we don't cover.................................................................................................................... 36
Section 7. Filing a claim for covered services .................................................................................................................................. 37
Section 8. The disputed claims process ........................................................................................................................................ 38-39
Section 9. Coordinating benefits with other coverage ................................................................................................................ 40-43
When you have other health coverage .............................................................................................................................. 40
What is Medicare........................................................................................................................................................ 40
Medicare managed care plan .................................................................................................................................... 42
TRICARE and CHAMPVA........................................................................................................................................ 42
Workers' Compensation.............................................................................................................................................. 43
Medicaid .................................................................................................................................................................... 43
Other Government agencies........................................................................................................................................ 43
When others are responsible for injuries.................................................................................................................... 43
Section 10. Definitions of terms we use in this brochure .............................................................................................................. 44-45
Section 11. FEHB facts .................................................................................................................................................................. 46-48
Coverage information ........................................................................................................................................................ 46
No pre-existing condition limitation .......................................................................................................................... 46
Where you get information about enrolling in the FEHB Program .......................................................................... 46
Types of coverage available for you and your family ................................................................................................ 46
Children's Equity Act ............................................................................................................................................ 46-47
When benefits and premiums start ............................................................................................................................ 47
When you retire .......................................................................................................................................................... 47
When you lose benefits .................................................................................................................................................... 47
When FEHB coverage ends........................................................................................................................................ 47
Spouse equity coverage .............................................................................................................................................. 47
Temporary Continuation of Coverage (TCC) ............................................................................................................ 47
Converting to individual coverage.............................................................................................................................. 48
Getting a Certificate of Group Health Plan Coverage................................................................................................ 48
Long term care insurance is still available.............................................................................................................................................. 49
Index ........................................................................................................................................................................................................ 50
Summary of benefits .............................................................................................................................................................................. 51
Rates .......................................................................................................................................................................................... Back cover

2003 Health Insurance Plan (HIP/ HMO) Table of Contents 3 6.
6 Page 7 8
2003 Health Insurance Plan (HIP/ HMO) Introduction/ Plain Language/ Advisory 4
Introduction
This brochure describes the benefits of HIP/ HMO under our contract (CS 1040) with the Office of Personnel Management (OPM),
as authorized by the Federal Employees Health Benefits law. The address for HIP Health Plan of New York (HIP) administrative
offices is:

HIP Health Plan of New York
7 West 34th Street
New York, NY 10001

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclu-sions
of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family cov-erage,
each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized
on page 52. Rates are shown at the end of this brochure.

Plain Language
FEHB brochures are written in plain language 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 HIP.

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 OPM know. Visit OPM's "Rate Us" feed-back
area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program (FEHB) Program
premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor,
other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it
paid.
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service. 7.
7 Page 8 9
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrep-resented
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 1-877-TELL-HIP and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 unless he/ she is disabled and incapable of self support.
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM
if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try
to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

2003 Health Insurance Plan (HIP/ HMO) Introduction/ Plain Language/ Advisory 5

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 8.
8 Page 9 10
2003 Health Insurance Plan (HIP/ HMO) Section 1 6
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. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treat-ment
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
HIP is a mixed model plan. 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 coin-surance.

Who provides my health care
At the present time, approximately 18,000 professional medical providers participate in HIP/ HMO and provide medical services to
more than 800,000 enrollees. Our network covers 74 medical specialities ranging from family practice to urology. In addition to serv-ices
from participating medical providers, you can receive paramedical services including social services, nutrition and health educa-tion
at group centers.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our net-works,
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.

The HIP Health Plan of New York (HIP) was organized over 50 years ago as a non-profit corporation.
On December 1, 1978, HIP became a New York certified Health Maintenance Organization (HMO).
Responsibility for HIP/ HMO policy and operations is vested in an unpaid Board of Directors. This Board is composed of distin-guished
representatives of labor, consumers, doctors and the general public. The Board selects the principal administrative offi-cer,
the President, and holds him responsible for the enforcement of Board policy and for the operations of the Plan.

HIP/ HMO has Commendable Accreditation from the National Committee for Quality Assurance (NCQA).
If you want more information about us and you are a current member, call 1-800-HIP-TALK (1-800-447-8255). If you are a potential
member, please call 1-888-866-7461 for more information, or write to The HIP Health Plan of New York, 7 West 34th Street, New York,
NY 10001. You may visit our website at http:// www. hipusa. com.

Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is: New York City (the
Boroughs of Manhattan, Brooklyn, Bronx, Queens, and Staten Island), all of Nassau, Orange, Rockland, Suffolk and Westchester
Counties.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that
has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change
plans. Contact your employing or retirement office. 9.
9 Page 10 11
2003 Health Insurance Plan (HIP/ HMO) Section 2 7
Section 2. How we change for 2003
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
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program
enrollment.

Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
Your share of the non-Postal premium for High Option will increase by 23.4% for Self Only or 23.2% for Self and Family.
We now have two benefits packages. We are now offering a High Option (511, 512) and Standard Option (514, 515) coverage pack-age.
Those enrollees who had HIP/ HMO coverage during 2002 will remain in the High Option coverage unless they elect the
HIP/ HMO Standard Option coverage or another health plan during Open Season.

The prescription drug copay for non-formulary drugs has increased from $35.00 to $40.00 per 30-day supply under the High Option
coverage. Section 5( f).

The High Option urgent care center or hospital emergency room copay has increased from $25.00 to $50.00. Section 5( d) 10.
10 Page 11 12
2003 Health Insurance Plan (HIP/ HMO) Section 3 8
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 con-firmation
(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 enroll-ment,
or if you need replacement cards, call us at 1-800-HIP-TALK (1-800-447-8255).

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

Plan providers Plan providers are physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. We credential Plan
providers according to the National Committee of Quality Assurance (NCQA) and other
Industry standards.

We list Plan providers in the provider directory, which we update quarterly. For a current
directory listing, members should call 1-800-HIP-TALK (1-800-447-8255). Potential
members should call 1-888-866-7461. The list is also available on our Web site at
http:// www. hipusa. com.

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

What you must do It depends on the type of care you need. First, you and each family member must choose to get covered care a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care.
Our directory lists the locations and phone numbers of our primary care doctors. It also
indicates whether or not a doctor is accepting new patients. After you select a specific
provider from the directory, you should call the provider to verify that he or she still par-ticipates
with HIP and is accepting new patients. You may also call our Customer Service
Department at 1-800-HIP-TALK (1-800-447-8255) to find out if your doctor participates
with HIP.

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

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you
receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your pri-mary
care physician gives you a referral. 11.
11 Page 12 13
2003 Health Insurance Plan (HIP/ HMO) Section 3 9
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional refer-rals.
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 serv-ices
from your current specialist until we can make arrangements for you to see some-one
else.

If you have a chronic or disabling condition and lose access to your specialist because
we:
terminate our contract with your specialist for other than cause; or

drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB Plan; or

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrange-ments
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 1-800-HIP-TALK (1-800-447-8255). 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 hos-pital
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 92nd 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. 12.
12 Page 13 14
2003 Health Insurance Plan (HIP/ HMO) Section 3 10
Services requiring Your primary care physician has authority to refer you for most services. For certain our prior approval services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted
medical practice.

The following are other services that require prior approval:
Skilled nursing facility services Hospice care
Inpatient mental health Inpatient hospital admissions (non-emergent)
Ambulatory surgery services Inpatient physical and occupational therapies
Outpatient hospital services Inpatient substance abuse
Home health care services Organ transplants
Durable medical equipment Growth hormone 13.
13 Page 14 15
2003 Health Insurance Plan (HIP/ HMO) Section 4 11
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per
office visit and when you go to the Emergency Room, you pay $50 per visit.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies
before we start paying benefits for them.

Example: The Standard Option coverage has a $100 prescription drug deductible that you
must meet each calendar year.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. We
do not have coinsurance.

Your catastrophic protection out-of-pocket maximum We do not have a catastrophic protection out-of-pocket maximum. 14.
14 Page 15 16
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and page 52 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claims
forms, claims filing advice, or more information about our benefits, contact us at 1-800-HIP-TALK (1-800-447-8255) or at our Web
site at http:// www. hipusa. com. If you are a potential member, call us at 1-888-866-7641.

(a) Medical services and supplies provided by physicians and other health care professionals .................................................... 13-21
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

(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................................. 22-24
Surgical procedures
Reconstructive surgery

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

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

(e) Mental health and substance abuse benefits ................................................................................................................................ 29-30
(f) Prescription drug benefits ............................................................................................................................................................. 31-32
(g) Special features ................................................................................................................................................................................ 33
Medical Case Management Program
Services for deaf and hearing impaired
Travel benefit/ services overseas

(h) Dental benefits .................................................................................................................................................................................. 34
(i) Non-FEHB benefits available to Plan members ................................................................................................................................ 35
Summary of benefits .............................................................................................................................................................................. 52

2003 Health Insurance Plan (HIP/ HMO) Section 5 12

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

Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance 15.
15 Page 16 17
I M
P O
R T
A N
T

I M
P O
R T
A N
T

2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 13

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

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible for services described in this section.
Providers other than your Primary Care Physician are specialists under the Standard Option
coverage.

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 cover-age,
including Medicare.

Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per office visit
In an urgent care center
Office medical consultations
Second surgical opinion

Professional services of physicians
During a hospital stay Nothing Nothing
In a skilled nursing facility
At home

Not covered: Physical Examinations that are not necessary for All charges. All charges.
medical reasons, such as those required for obtaining or
continuing employment or insurance

You pay Benefit Description
High Option Standard Option

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals

$10 per office visit to your primary care
physician or
$20 per office visit to a specialist 16.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 14
Lab, X-ray and other diagnostic tests High Option Standard Option
You Pay You Pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Preventive care, adult
Routine screenings, such as: $10 per office visit
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including:
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Prostate Specific Antigen (PSA) test one annually for men $10 per office visit
age 40 and older
Annual standard diagnostic testing of prostate cancer,
including but not limited to a digital rectal examination and a
prostate-specific antigen testing for men age 50 and over who
are asymptomatic and for men age 40 and over with a family
history of prostate cancer or other prostate cancer risks.

Routine pap test $10 per office visit
Note: The office visit is covered if pap test is received on
the same day; see Diagnosis and Treatment, above.

Routine mammogram covered for women age 35 and older, $10 per office visit
as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

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

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

Nothing if you receive
these services during
your office visit;
otherwise, $10 per
office visit to your
primary care physician
or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist 17.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 15
Preventive care, adult (continued) High Option Standard Option
You Pay You Pay

Routine immunizations, limited to: $10 per office visit

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

Influenza vaccine, annually, age 65 and over
Not covered:
-Autgenous vaccines All charges. All charges.
-Adult immunizations related to foreign travel

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

Well-child care charges for routine examinations, Nothing Nothing
immunizations and care

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

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist 18.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 16
Maternity Care High Option Standard Option
You Pay You Pay

Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will
extend your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during
the covered portion of the mother's maternity stay. We will
cover other care of an infant who requires non-routine
treatment only if we cover the infant under a Self and Family
enrollment.
We pay hospitalization and surgeon services (delivery)
the same as for illness and injury. See Hospital benefits
(Section 5c) and Surgery benefits (Section 5b).

Not covered: Routine sonograms to determine fetal age, size All charges. All charges.
or sex

Family Planning
A broad range of voluntary family planning services, limited to: $10 per office visit
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

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

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

Infertility Services
Diagnosis and treatment of infertility, such as: $10 per office visit
Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)

Fertility drugs (injectables)

Note: We cover injectable fertility drugs under medical benefits
and oral fertility drugs under the prescription drug benefit.

$10 first office visit;
waived in subsequent
visits.

$10 first office visit;
waived in subsequent
visits.

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist 19.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 17
$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

Infertility Services (continued) High Option Standard Option
You Pay You Pay

Not covered: All charges. All charges.
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

Allergy Care

Testing and treatment $10 per office visit
Allergy injection

Allergy serum Nothing Nothing
Not covered: Provocative food testing and sublingual allergy All charges. All charges.
desensitization 20.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 18
Treatment therapies High Option Standard Option You Pay You Pay
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous
bone marrow transplants are limited to those transplants listed
under Organ/ Tissue Transplants on page 24.

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

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

Note: We will only cover GHT when we preauthorize the
treatment. Growth Hormone must meet the medical necessity
guidelines in order for services to be approved.

Physical and occupational therapies
Up to 2 months per condition if significant improvement can $10 per office visit $20 per office visit
be expected 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.

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

Not covered: All charges. All charges.
long-term rehabilitative therapy
exercise programs

Speech therapy
Up to 2 months of speech therapy each calendar year for $10 per office visit $20 per office visit
services from the following: licensed or certified speech
therapists.

Hearing services (Testing, treatment and supplies)
First hearing aid and testing only when necessitated by $10 per office visit
accidental injury
Hearing testing for children through age 17 (see
Preventive care, children)

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

Nothing per visit
during covered
inpatient admission

Included in hospital
admission copay.

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist 21.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 19
Vision services (Testing, treatment and supplies) High Option Standard Option
You Pay You Pay

Annual eye refractions $10 per office visit $20 per office visit
Diagnosis and treatment of diseases of the eye
Lenses following cataract removal

Not covered: All charges. All charges.
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot Care
Routine foot care when you are under active treatment for a $10 per office visit
metabolic or peripheral vascular disease, such as diabetes.

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

Not covered: All charges. All charges.
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)

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose $10 per office visit
Externally worn breast prostheses and surgical bras,
including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints,
pacemakers, cochlear implants, and surgically implanted
breast implant following mastectomy.

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

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

Note: Call us at 1-800-HIP-TALK (1-800-447-8255) as soon as
your Plan physician prescribes this equipment. We will arrange
with a health care provider to rent or sell you the equipment at
discounted rates and will tell you more about this services when
you call.

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist

Nothing for the
equipment

Nothing for the
equipment 22.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 20
Orthopedic and prosthetic devices (continued) High Option Standard Option
You Pay You Pay

Not covered: All charges. All charges.
Orthopedic and corrective shoes unless we determine
that the Member's condition requires a corrective shoe
that can only be made from a mold or cast of his or her foot.

Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other
supportive devices

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and Nothing Nothing
adjustment, of durable medical equipment prescribed by your
Plan physician, such as oxygen and dialysis equipment. Under
this benefit, we also cover:

hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Prior approval is required. Call us at
1-800-HIP-TALK (1-800-447-8255) as soon as your Plan
physician prescribes this equipment. We will arrange with a
health care provider to rent or sell you durable medical equipment
at discounted rates and will tell you more about this service when
you call.

Not covered: All charges. All charges.
Motorized and customized wheel chairs

Home health services
Home health care ordered by a Plan physician and provided Nothing Nothing
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.

Note: Standard Option coverage has a 200 visit limit per calendar
year. High Option does not have a visit limit per calendar year.

Not covered: All charges. All charges.
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 (i. e. hygiene, feeding,
exercising, moving the patient, homemaking,
companionship or giving oral medication). 23.
23 Page 24 25
2003 Health Insurance Plan (HIP/ HMO) Section 5( a) 21
Chiropractic High Option Standard Option
You Pay You Pay

Manipulation of the spine and extremities $10 per office visit $20 per office visit
Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application

Note: You do not need a referral from your primary care doctor.

Alternative treatments

No benefit. We do not cover treatments such as but not limited to: All charges. All charges.
naturopathic services
hypnotherapy
acupuncture
biofeedback

Educational classes and programs
Coverage is limited to: $10 per office visit
Smoking Cessation In a HIP Free & Clear Smoking
Cessation Program -Up to $100 for one smoking cessation
program per member per lifetime, including all related
expenses such as drugs.

Diabetes self-management

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist 24.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( b) 22

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

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible for services described in this section.
Providers other than your Primary Care Physician are specialists under the High Option and Standard
Option coverage.

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 precer-tification
and identify which surgeries require precertification.

Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

Surgical procedures
A comprehensive range of services, such as: Nothing Nothing
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.
Voluntary sterilization
Treatment of burns

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

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

You pay Benefit Description
High Option Standard Option 25.
25 Page 26 27
2003 Health Insurance Plan (HIP/ HMO) Section 5( b) 23
Reconstructive surgery High Option Standard Option
You Pay You Pay

Surgery to correct a functional defect Nothing Nothing
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.

All stages of breast reconstruction surgery following a Nothing Nothing
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.

Not covered: All charges. All charges.
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

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Nothing Nothing
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.

Not covered: All charges. All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva,
and alveolar bone) 26.
26 Page 27 28
2003 Health Insurance Plan (HIP/ HMO) Section 5( b) 24
Organ/ tissue transplants High Option Standard Option
You Pay You Pay

Limited to: Nothing Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell
and peripheral stem cell support) for the following
conditions: acute lymphocytic or non-lymphocytic
leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced neuroblastoma; breast
cancer; multiple myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine
with the liver or small intestine with multiple organs such as
the liver, stomach, and pancreas

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

Not covered: All charges. All charges.
Donor screening tests and donor search expenses, except
those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in Nothing Nothing
Hospital (inpatient)

Professional services provided in Nothing Nothing
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 27.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( c) 25

Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

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 and you must be hospitalized in a Plan facility.
We do not have a calendar year deductible for services described in this section.
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 ambu-lance
service for your surgery or care. Any costs associated with the professional charge (i. e., physicians,
etc.) are covered in Sections 5( a) or (b).

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

Inpatient hospital
Room and board, such as Nothing
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 semi-private
room rate.

Other hospital services and supplies, such as: Nothing
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

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

You pay Benefit Description
High Option Standard Option

$500 per inpatient
hospital admission

Nothing (included in
the $500 inpatient
hospital admission
copay) 28.
28 Page 29 30
2003 Health Insurance Plan (HIP/ HMO) Section 5( c) 26
Outpatient hospital or ambulatory surgical center High Option Standard Option
You Pay You Pay

Operating, recovery, and other treatment rooms Nothing Nothing
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.

Not covered: blood and blood derivatives not replaced by All charges. All charges.
the member

Extended care/ skilled nursing care facility benefits
Skilled nursing facility (SNF): A comprehensive range of Nothing Nothing
benefits with no day limit when full-time skilled nursing care
is necessary and confinement in a skilled nursing facility is
medically necessary as determined by a Plan doctor and
approved in advance by the Plan.

Not covered: custodial care, rest cures, domiciliary or All charges. All charges.
convalescent care

Hospice care
Up to 210 days in an approved hospice program for a Nothing Nothing
terminally ill member when a Plan doctor certifies that the
member is terminal and has a life expectancy of six months or
less. Covered services as follows when provided and billed
by the hospice:

Inpatient and outpatient care
Professional services of a physician
Prescription drugs and medical supplies and
Bereavement counseling for immediate family members

Not covered: All charges. All charges.
Independent nursing, homemaker services
Services or supplies not listed in the Hospice Program
Services for respite care
Nutritional supplements, non-prescription drugs or
substances, vitamins and minerals

Ambulance
Local professional ambulance service when medically Nothing Nothing
appropriate 29.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( d) 27

Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure.

We do not have a calendar year deductible for services described in this section.
We waive your emergency room copay if you are admitted to the hospital for inpatient treatment.
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.

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: Call your Primary Care Physician. In extreme emergencies, if you are unable to contact your PCP, call 911 or go to the nearest
hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so that they notify the Plan.
You or a family member should notify the Plan within 48 hours. You can call 1-888-HIP-AUTH (1-888-447-2884).

Emergencies outside our service area: You must notify us within 48 hours or on the first working day after your admission, unless it was not reasonable possible to do so. If a Plan doctor believes that care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any transportation charges covered in full. All follow-up care
must be provided by participating providers.

Claims for emergency medical treatment must be sent to HIP/ HMO within 45 days of the date you receive emergency services.
The claim must include all supporting documentation.

Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care center $50 per visit $50 per visit

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

Not covered: Elective care or non-emergency care All charges. All charges.

$10 per office visit $10 per office visit
You pay Benefit Description
High Option Standard Option 30.
30 Page 31 32
2003 Health Insurance Plan (HIP/ HMO) Section 5( d) 28
Emergency outside our service area High Option Standard Option
You Pay You Pay

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

Emergency care at an urgent care center $50 per visit $50 per visit

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

Not covered: All charges. All charges.
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

Ambulance
Local ambulance service in an emergency condition or when Nothing Nothing
approved by the plan.

See 5( c) for non-emergency service.

Not covered: air ambulance All charges. All charges. 31.
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You pay Benefit Description
High Option Standard Option

2003 Health Insurance Plan (HIP/ HMO) Section 5( e) 29

Section 5 (e). Mental health and substance abuse benefits
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:
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.

We do not have a calendar year benefit.
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 ben-efits
description below.

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

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

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

Medication management

Note: Psychiatrist, psychologists, licensed clinical social
workers, etc. are specialists. The office visit copay for
specialists applies to services from these professionals.

Diagnostic tests

Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

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

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

$10 per office visit to
your primary care
physician or

$20 per office visit
to a specialist or

Nothing for inpatient
visits

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

Nothing if you receive
these services during
your office visit;
otherwise, $10 per office
visit to your primary care
physician or $20 per
office visit to a specialist

$10 per office visit
or

Nothing for inpatient
visits

$500 per inpatient
hospital admission
or nothing for
outpatient services. 32.
32 Page 33 34
2003 Health Insurance Plan (HIP/ HMO) Section 5( e) 30
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
For mental health or substance abuse treatment, call 1-888-447-2526 for authorization and
help in selecting a provider. For mental health services only, you may call a HIP mental
health center directly. A trained professional will assess your treatment needs and make
all necessary arrangements for you to see a participating provider at the center. You do not
need a referral from your primary care physician for mental health and substance abuse
services.

Limitation We may limit your benefits if you do not obtain a treatment plan.

Mental health and substance abuse benefits High Option Standard Option
(continued) You Pay You Pay

Not covered: Services we have not approved. All charges. All charges.
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. 33.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( f) 31

Section 5 (f). Prescription drug benefits
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.

Under HIP/ HMO Standard Option coverage, each member must satisfy a $100 calendar year
prescription drug deductible. You do not have a prescription drug deductible under the High
Option coverage.

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.

There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan doctor or referrral doctor must write the prescription
Where you can obtain them. You may fill the prescription at a participating pharmacy. You may obtain generic mainte-nance
drugs by mail order.

We use a formulary. Our formulary is a list of effective medications and other items that we have approved for our mem-bers'
use. A special committee of medical and pharmacy professionals reviews the formulary annually. We add or delete
items on the list based on their findings. We have found that the drugs on our formulary are safe, effective and therapeutic in
the treatment of disease or illness. We also believe that our formulary improves patient outcomes while controlling drug
costs. Please call 1-800-HIP-TALK (1-800-447-8255) for a copy of our formulary. We cover non-formulary drugs when pre-scribed
by a Plan doctor after you pay to a $40.00 non-formulary copay.

These are the dispensing limitations. A participating pharmacy will provide up to a 30-day supply of your prescription.
Under the High Option Plan, you will pay $10.00 for generic formulary drugs or $15.00 for name brand formulary drugs, or
$40.00 for non-formulary drugs. Under the Standard Option plan, you pay $10.00 for generic formulary drugs, or $20.00 for
name brand formulary drugs, or $40.00 for non-formulary drugs once a $100.00 deductible is met. You may obtain up to a
90-day supply of certain formulary maintenance drugs through our mail order service. We will reduce your formulary copay
by 50% when you use our mail order service. Sexual dysfunction drugs are not available by mail-order and require prior
approval. There are also limits on the number of pills that the pharmacy will fill. Please contact 1-800-HIP-TALK (1-800-
447-8255) for details. For further information on using our mail order program, contact Express Scripts at 1-800-224-5502.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the
original brand name product. Generic drugs cost you and us less money than a brand name drug.

When you have to file a claim. Please call 1-800-HIP-TALK (1-800-447-8255) and we will send you a claim form. Under
normal circumstances, you do not have to file prescription drug claims. You simply present your HIP/ HMO card to the
participating pharmacy and pay the appropriate copay. 34.
34 Page 35 36
You pay Benefit Description
High Option Standard Option

2003 Health Insurance Plan (HIP/ HMO) Section 5( f) 32
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 below
Insulin
Disposable needles and syringes for the administration of
covered medications
Nutritional supplements for the treatment of
phenylketonuria, branched chain ketonuria, galactosemia,
and homocystinuria
Drugs for sexual dysfunction (see Prior authorization below)
Fertility drugs (oral and injectable)

Note: Non-formulary drugs are not available under our mail
order program.

Not covered: All charges. All charges.
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
Medical supplies

For up to a 30-day
supply at a participating
Retail Pharmacy:
$10 for generic
formulary drugs;
$15 for brand name
formulary drugs; or
$40 for non-formulary
drugs

Up to a 90-day
supply by Mail order:
$15.00 for generic
formulary drugs or
$22.50 name brand
formulary drugs

For up to a 30-day
supply at a participating
Retail Pharmacy:
(After the $100 calendar
year deductible is met)
$10 for generic
formulary drugs;
$20 for brand name
formulary drugs; or
$40 for non-formulary
drugs

Up to a 90-day
supply by Mail order:
(After the $100 calendar
year deductible is met)
$15.00 for generic
formulary drugs or
$30.00 name brand
formulary drugs 35.
35 Page 36 37
2003 Health Insurance Plan (HIP/ HMO) Section 5( g) 33
Section 5 (g). Special features
Services for deaf and hearing impaired
Medical Case Management
Travel benefit/ services overseas

The telephone number for the hearing impaired is 1-888-HIP-4TDD
(1-888-447-4833).

We offer case management for members with chronic or catastrophic
illnesses or injuries.

Please refer to the HIP Member Handbook.

Feature Description 36.
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2003 Health Insurance Plan (HIP/ HMO) Section 5( h) 34

Section 5 (h). Dental benefits
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 do not have a calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the patient. See
Section 5 (c) for inpatient hospital benefits. 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 cover-age,
including with Medicare.

Accidental injury benefit High Option Standard Option
You Pay You Pay

We cover restorative services and supplies necessary to Nothing Nothing
promptly repair (but not replace) sound natural teeth
within 12 months of the date of the accident. The need for
these services must result from an accidental injury.

Dental benefits
We have no other dental benefits. 37.
37 Page 38 39
2003 Health Insurance Plan (HIP/ HMO) Section 5( i) 35
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this part 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.

HIP VIP Medicare HMO Benefits HIP VIP Medicare Plan is our Medicare + Choice Plan. You may enroll in it if we offer it in the area where you live and you are
enrolled in Medicare A and B. If you have FEHB coverage and enroll in HIP VIP Medicare Plan, you receive the following benefits:
You are entitled to all benefits under the FEHB Program.
You are entitled to coverage for everything Medicare covers.
You will have no copays for the following covered services:
PCP and specialty care
Prescriptions for generic and brand name formulary only
Worldwide emergency and urgently needed care
One pair of free eyeglasses every 12 months
$500 towards the purchase of a hearing aid every 36 months

You may still enroll in HIP VIP Medicare if you are enrolled in Medicare Parts A and B but have suspended your FEHB Program
coverage. However, your benefits will be different than those listed above. You may find out more information about HIP VIP
Medicare benefits by calling 1-888-866-7461.

Fitness Program -HIP offers members discounts to fitness centers and tennis clubs in the New York metropolitan area.
Alternative Medicine -The alternative medicine provides you with access to discounted Acupuncture, Massage and Yoga Therapy
services through an agreement with OneBody, a leading national alternative medicine services organization.*

Should you choose to seek such services, you will have access to the large OneBody network of quality screened providers at discount
rates. You pay no additional plan premiums. The fees you are charged will be at a discount off of the provider's usual rates. Present your
HIP ID card to the OneBody network provider in order to obtain the discounted rate. Call 1-888-HIP-ALMD (1-888-447-2563) for a
list of OneBody network providers.

Dental Care -We cover the following diagnostic and preventive services when provided by participating HIP General Dentists:
One examination (comprehensive or periodic every six months) -$5 per visit
One prophylaxis (cleaning) every six months -$10 per visit
One topical fluoride (for children age 16 and under) every six months -$5 per visit

If you require other additional services, such as x-rays, fillings, crowns or dentures, your participating HIP General Dentist will
provide them at a discounted rate. Please contact HIP's Dental Provider, Careington International, at 1-800-290-0523 for a complete
schedule of current reduced member fees. All member fees must be paid directly to the participating HIP General Dentist.

Optical
At a participating provider members pay a $45 copay for a complete pair of eyeglasses (from a select group of frames) every 24 months.

Questions?
If you have a question concerning Plan benefits or how to arrange for care, contact the Plan's Customer Service Department or you may
write to the Plan at HIP/ HMO, 7 West 34th Street, New York, NY 10001. A special number, 1-888-HIP-4TDD (1-888-447-4833), is
available for use by the hearing impaired. You may also contact us at our Web site at http:// www. HIPUSA. com or call us at 1-800-HIP-TALK
(1-800-447-8255).

* Through HIP's agreement with OneBody, this program provides HIP members with discounts for services provided by OneBody alter-native
medicine providers. OneBody is responsible for credentialing and managing all program practitioners. This program is not a
covered benefit and HIP makes no representations or guarantees regarding the efficacy or appropriateness of the services made avail-able.
Use of these services is strictly the member's decision and HIP is not responsible for any acts or omissions of any OneBody
alternative medicine provider. 38.
38 Page 39 40
2003 Health Insurance Plan (HIP/ HMO) Section 6 36
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; or
Expenses you incurred while you were not enrolled in this Plan;
Services, drugs, or supplies you receive without charge while in active military service. 39.
39 Page 40 41
2003 Health Insurance Plan (HIP/ HMO) Section 7 37
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible. You will only
need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check
with the provider. If you need to file the claim, here is the process:

Medical, hospital and In most cases, providers facilities file claims for you. Physicians must file on the form drug benefits HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For
claims questions and assistance, call us at 1-800-HIP-TALK (1-800-447-8255).
When you must file a claim such as for services you receive outside of the Plan's
service area submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer
such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.

Submit your claims to: HIP Health Insurance Plan of New York
7 West 34th Street
New York, New York 10001

Prescription drugs Under normal circumstances, you do not have to file claims for your prescription drugs. Please call 1-800-HIP-TALK for specific instructions and a claim form.

Submit your claims to: HIP Health Insurance Plan of New York
7 West 34th Street
New York, New York 10001

Other supplies or services Submit your claims to: HIP Health Insurance Plan of New York 7 West 34th Street
New York, New York 10001
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 fil-ing
was prevented by administrative operations of Government or legal incapacity, pro-vided
the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 40.
40 Page 41 42
2003 Health Insurance Plan (HIP/ HMO) Section 8 38
Section 8. The disputed claims process
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: HIP Health Plan of New York, 7 West 34th Street, New York, NY 10001; 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, Health Benefits Contracts Division
3, 1900 E Street, NW, Washington, DC 20415-3630

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

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

Note: If you want OPM to review more than one claim, 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.

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: 41.
41 Page 42 43
2003 Health Insurance Plan (HIP/ HMO) Section 8 39
Step Description
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.

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, ben-efits,
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 1-800-HIP-TALK
(1-800-447-8255) and we will expedite our review; or

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

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 42.
42 Page 43 44
2003 Health Insurance Plan (HIP/ HMO) Section 9 40
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We, like other
insurers, determine which coverage is primary according to the National Association of
Insurance Commissioners' guidelines.

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your
spouse worked for at least 10 years in Medicare-covered employment, you should be able
to qualify for premium-free Part A insurance. (Someone who was a Federal employee on
January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older,
you may be able to buy it. Contact 1-800-MEDICARE for more information.

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

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

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in the United
(Part A and Part B) States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. You still pay the stated copays for your
covered health care services under the FEHB Program.

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 then provide sec-ondary
benefits for covered charges. You will not need to do anything. To find out if
you need to do something to file your claims, call us at 1-800-HIP TALK

We do not waive any costs if the Original Medicare Plan is your primary payer.
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 then provide sec-ondary
benefits for covered charges. You will not need to do anything. To find out if
you need to do something to file your claims, call us at 1-800-HIP TALK

We do not waive any costs if the Original Medicare Plan is your primary payer. 43.
43 Page 44 45
2003 Health Insurance Plan (HIP/ HMO) Section 9 41
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
A. When either you or your covered spouse are age 65 or over and Then the primary payer is
Original Medicare This Plan

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

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

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

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

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

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

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

(except for claims
related to Workers'
Compensation.) 44.
44 Page 45 46
2003 Health Insurance Plan (HIP/ HMO) Section 9 42
Medicare Managed Care Plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare ben-efits
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 man-aged
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 cov-ers.
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 man-aged
care plan and also remain enrolled in our FEHB plan. In this case, we do waive some
of our copayments, coinsurance, or deductibles for your FEHB coverage. Please contact
us for further details.

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 under the FEHB coverage. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits
with Medicare.

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

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Medicare Part A or Part B Program. We will not require you to enroll in Medicare Part B and, if you can't get pre-mium-
free Part A, we will not ask you to enroll in it.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPVA program. CHAMPVA pro-vides
health coverage to disabled Veterans and their eligible dependents. If TRICARE or
CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any appli-cable
plan premiums.) 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 under the
program. 45.
45 Page 46 47
2003 Health Insurance Plan (HIP/ HMO) Section 9 43
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.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored pro-gram
of medical assistance: If you are an annuitant or former spouse, you can suspend
your FEHB coverage to enroll in one of these state programs, eliminating your FEHB
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 under the state program.

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

When others are responsible When you receive money to compensate you for medical or hospital care for injuries or for injuries 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. 46.
46 Page 47 48
2003 Health Insurance Plan (HIP/ HMO) Section 10 44
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 11.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care which does not require the continuing attention of trained medical personnel. Custodial care includes any service which can be learned and provided by an
average individual who does not have medical training.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 11.

Durable Medical Equipment, A "Covered Appliance" is one of the following items which is prescribed by your Plan Prosthetic Devices and physician, dispensed by a Plan provider and approved by HIP. HIP maintains a list of
Orthopedic Devices Covered Appliances that contains items in each of the categories listed below. This list is prepared by HIP and periodically reviewed and modified. HIP will determine whether a
Covered Appliance should be customized, rented, purchased or repaired.
1. Durable Medical Equipment, which is:
A. Primarily and customarily used to serve a medical purpose;
B. Generally not useful to a person in the absence of illness or injury;
C. Appropriate for use in the home;
D. Medically necessary for the care and treatment of the Member's illness or injury.

2. Prosthetic devices which replace all or part of an internal body organ or external limb.
However, dental prosthetics needed due to an accidental injury to sound natural teeth
if the service is provided within twelve (12) months of the accident and necessary in
treatment due to congenital disease or anomaly will be covered.

3. Orthopedic devices which are required for the treatment of injuries or disorders of the
skeletal system and associated muscles, joints and ligaments.

Experimental or Experimental or investigational service means any evaluation, treatment, services therapy, investigational services or device which involves the application, administration or use, of procedures, techniques,
equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceu-ticals,
or chemical compounds if, as determined solely by the Plan:

1) Such evaluation, treatment, therapy, or device cannot be lawfully marketed without
approval of the United States Food and Drug Administration or the New York
Department of Health and Rehabilitative Services, and approval for marketing has
not, in fact been given at the time such is furnished to the covered person; or

2) Reliable evidence, as determined by the Plan, shows that such evaluation, treatment,
therapy, or device (a) is the subject of an ongoing Phase I or II clinical investigation,
or experimental or research arm of a Phase III clinical investigation, or under study
to determine: maximum tolerated dosage( s), toxicity, safety, efficacy, or efficacy as
compared without the standard means for treatment or diagnosis of the condition in 47.
47 Page 48 49
2003 Health Insurance Plan (HIP/ HMO) Section 10 45
question; or (b) has not been proven safe and effective for the treatment of the condition
in question, as evidenced in the most recently published medical literature in the United
States, Canada or Great Britain, using generally accepted scientific, medical or public
health methodologies or statistical practices; or (c) is not the standard evaluation, treat-ment,
therapy or device utilized by practicing physicians in treating other patients with the
same or similar condition; or

3) There is no consensus among practicing physicians that the evaluation, treatment,
therapy or device is safe or effective for the treatment in question; or

4) The consensus of opinion among experts is that further studies, research, or clinical
investigations are necessary to determine maximum tolerated dosage( s), toxicity, safe-ty,
efficacy or efficacy as compared with the standard means for treatment or diagnosis
of the condition in question.

Group health coverage An organization such as your employer arranged for your coverage under this contract. The member's group has chosen to engage HIP to make arrangements through which
Medical Services and Hospital Services will be delivered in accordance with the terms and
conditions of the certificate of coverage.

Medically necessary and Medically necessary and appropriate means those health care services or supplies, deter-appropriate mined solely by HIP or its designee, that are necessary to prevent, diagnose, correct or cure
conditions in the member that cause acute suffering, endanger life, result in illness or infir-mity,
interfere substantially with the member's capacity for normal activity or threaten
some significant disability and that could not have been omitted under generally accepted
medical standards or provided in a less intensive setting.

Us/ We "Us" and "we" refer to HIP Health Plan of New York
You "You" refers to the enrollee and each covered family member. 48.
48 Page 49 50
2003 Health Insurance Plan (HIP/ HMO) Section 11 46
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you enrolled
limitation 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 your
about enrolling in the questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures
FEHB Program for other plans, and other materials you need to make an informed decision about your
FEHB coverage. These materials tell you:

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

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

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

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

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

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

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of
2000. This law mandates that you be enrolled for Self and Family coverage in the Federal
Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or
administrative order requiring you to provide health benefits for your child (ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you involuntarily as fol-lows: 49.
49 Page 50 51
2003 Health Insurance Plan (HIP/ HMO) Section 11 47
If you have no FEHB coverage, your employing office will enroll you for Self and
Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option;
If you have a Self only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment
to Self and Family in the same option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children live,
your employing office will change your enrollment to Self and Family in the Blue
Cross and Blue Shield Service Benefit Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at least one child iden-tified
in the order who is still eligible under the FEHB Program, you cannot cancel your
enrollment, change to self only, or change to a plan that doesn't serve the area in which
your children live, unless you provide documentation that you have other coverage for the
children. If the court/ administrative order is still in effect when you retire, and you have
at least one child still eligible for FEHB coverage, you must continue your FEHB cover-age
into retirement (if eligible) and cannot make any changes after retirement. Contact
your employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan during premiums start Open Season, your coverage begins on the first day of your first pay period that starts on
or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined
at any other time during the year, your employing office will tell you the effective date of
coverage.

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.
Spouse equity coverage You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
If you are divorced from a Federal employee or annuitant, you may not continue to get
benefits under your former spouse's enrollment. This is the case even when the court has
ordered your former spouse to supply health coverage to you. But, you may be eligible
for your own FEHB coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). 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. You can also download the
guide from OPM's website, www. opm. gov/ insure.

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

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll. 50.
50 Page 51 52
2003 Health Insurance Plan (HIP/ HMO) Section 11 48
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 web site (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. 51.
51 Page 52 53
2003 Health Insurance Plan (HIP/ HMO) Long Term Care Insurance 49
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance
Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your
premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you per-form
the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a severe
cognitive impairment such as Alzheimer's disease.

You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends,
but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and
after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one
through the toll-free number or Web site listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and
their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired:
1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 52.
52 Page 53 54
2003 Health Insurance Plan (HIP/ HMO) Index 50
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury .................................. 34
Allergy tests .......................................... 17
Alternative treatment ...................... 21, 35
Allogenetic (donor) bone
marrow transplant.................................. 24
Ambulance ...................................... 26, 28
Anesthesia ............................................ 24
Autologous bone marrow transplant .... 24
Biopsies ................................................ 22
Blood and blood plasma........................ 26
Breast cancer screening ........................ 14
Casts ...................................................... 25
Catastrophic protection ........................ 11
Changes for 2003 .................................... 7
Chemotherapy ...................................... 18
Childbirth .............................................. 16
Chiropractic .......................................... 21
Cholesterol tests .................................... 14
Claims.................................................... 37
Coinsurance .................................... 11, 44
Colorectal cancer screening .................. 14
Congenital anomalies ............................ 23
Contraceptive devices and drugs .......... 16
Coordination of benefits........................ 40
Covered charges .................................... 11
Covered providers .................................. 8
Crutches ................................................ 20
Deductible ............................................ 44
Definitions ...................................... 44, 45
Dental care ............................................ 34
Diagnostic services ........................ 13, 14
Disputed claims review .................. 38, 39
Donor expenses (transplants) ................ 24
Dressings .............................................. 25
Durable medical equipment (DME)...... 20
Educational classes and programs ...... 21
Effective date of enrollment.................... 4
Emergency ...................................... 27, 28
Experimental or investigational ...... 44, 45
Eyeglasses ............................................ 19
Family planning .................................... 16
Fecal occult blood test .......................... 14
Fraud .................................................. 4, 5
General Exclusions................................ 36
Hearing services .................................... 18
Home health services ............................ 20
Hospice care .......................................... 26

Hospital .................................................. 9
Immunizations ...................................... 15
Infertility ........................................ 16, 17
Inpatient Hospital Benefits.................... 25
Insulin.................................................... 32
Laboratory and pathological
services................................................ 14
Machine diagnostic tests ...................... 14
Magnetic Resonance Imagings (MRIs) 14
Mail Order Prescription Drugs.............. 32
Mammograms........................................ 14
Maternity Benefits ................................ 16
Medicaid................................................ 43
Medically necessary .............................. 45
Medicare ................................ 35,40,41,42
Mental Conditions/ Substance
Abuse Benefits ................................ 29, 30
Neurological testing .............................. 14
Newborn care ........................................ 16
Non-FEHB Benefits .............................. 35
Nurse
Licensed Practical Nurse .................... 20
Nurse Anesthetist ................................ 25
Registered Nurse ................................ 20
Nursery charges .................................... 16
Obstetrical care...................................... 16
Occupational therapy ............................ 18
Ocular injury ........................................ 19
Office visits .......................................... 13
Oral and maxillofacial surgery.............. 23
Orthopedic devices.......................... 19, 20
Out-of-pocket expenses.......... 11,29,30,34
Outpatient facility care .......................... 26
Oxygen .................................................. 20
Pap test .................................................. 14
Physical examination ...................... 13, 14
Physical therapy .................................... 18
Physician .............................................. 13
Preventive care, adult ...................... 14, 15
Preventive care, children ...................... 15
Prescription drugs .......................... 31, 32
Preventive services .......................... 14, 15
Prior approval ........................................ 10
Prostate cancer screening ...................... 14
Prosthetic devices............................ 19, 20
Psychologist .......................................... 29
Psychotherapy ...................................... 29

Radiation therapy .................................. 18
Renal dialysis ........................................ 40
Room and board .................................... 25
Second surgical opinion ........................ 13
Skilled nursing facility care .................. 26
Smoking cessation ................................ 21
Speech therapy ...................................... 18
Splints.................................................... 25
Sterilization procedures ........................ 16
Subrogation .......................................... 43
Substance abuse .................................... 29
Surgery .................................................. 22
Anesthesia........................................ 24
Oral .................................................. 23
Outpatient ........................................ 26
Reconstructive ................................ 23
Syringes ................................................ 32
Temporary continuation of
coverage .............................................. 47
Transplants ...................................... 18, 24
Treatment therapies .............................. 18
Vision services ...................................... 19
Well child care ...................................... 15
Wheelchairs .......................................... 20
Workers' compensation ........................ 43
X-rays .................................................... 14 53.
53 Page 54 55
Notes
2003 Health Insurance Plan (HIP/ HMO) Notes 51 54.
54 Page 55 56
2003 Health Insurance Plan (HIP/ HMO) Summary of Benefits 52
Summary of benefits for the Health Insurance Plan (HIP/ HMO) 2003
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.

High Option Standard Option Page Benefits You Pay You Pay #
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ..
Inpatient hospital visits or consultations ............................

Services provided by a hospital:
Inpatient .............................................................................. Nothing $500 per admission

Outpatient ............................................................................ Nothing Nothing
Emergency benefits:
In-area.................................................................................. $50 per visit $50 per visit
Out-of-area .......................................................................... $50 per visit $50 per visit

Mental health and substance abuse treatment ..........................

Prescription drugs
Up to 30 day supply from a participating retail pharmacy ......

Up to a 90 day supply of maintenance drugs by mail-order ........
Dental Care (Accidental Injury Only) ...................................... Nothing Nothing
Vision Care ................................................................................ $10 copay per visit. $20 copay per visit.
One annual eye refraction

Special features: Service for deaf and hearing impaired, Medical Case Management Programs,
Travel benefit/ services overseas

Protection against catastrophic costs Nothing
(your catastrophic protection out-of-pocket maximum)

Office visit copay:
$10 primary care or
$10 specialist

Office visit copay:
$10 primary care or
$20 specialist

Regular cost
Sharing
Regular cost
Sharing

$10 per generic
formulary; $15 per
brand name formulary;
$40 non-formulary

$15 generic formulary;
$22.50 brand name
formulary

After $100 deductible
$10 per generic
formulary; $20 per
brand name formulary;
$40 non-formulary

$15 generic formulary;
$30 brand name
formulary

13
25

27
29
31

34
19

33
11 55.
55 Page 56
2003 Health Insurance Plan (HIP/ HMO) Rates 53
2003 Rate Information for HIP Health Plan of New York
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that cat-egory
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 a special FEHB guide is published 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.

Type of Enrollment Code
Non-Postal Premium
Biweekly Monthly
Postal Premium
Biweekly

Greater New York City Area
High Option
Self Only

High Option
Self & Family

511
512
$100.80 $ 33.60 $218.40 $ 72.80 $119.28 $ 15.12
$249.62 $127.37 $540.84 $275.97 $294.70 $ 82.29

Gov't Your Gov't Your USPS Your
Share Share Share Share Share Share

Standard Option
Self Only

Standard Option
Self & Family

514
515
$ 80.63 $ 26.87 $174.69 $ 58.23 $ 95.41 $ 12.09
$225.77 $ 75.25 $489.16 $163.05 $267.16 $ 33.86

10-5288 56.

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