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HealthAmerica Pennsylvania, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits OVERVIEW
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- Coverage information
- When you lose benefits
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for the HealthAmerica Pennsylvania, Inc. - 2003
2003 Rate Information

Pages 1--60

Page 1


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

HealthAmerica Pennsylvania, Inc. http:// www. healthamerica. cvty. com
2003

Serving: Greater Pittsburgh Area, Northwestern Pennsylvania Area, Central, South Central & Northeast Pennsylvania
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
Greater Pittsburgh Area, Northwestern Area 261 Self Only
262 Self and Family
Central, South Central & Northeast Pennsylvania SW1 Self Only
SW2 Self and Family

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

RI 73-255

For changes in benefits
see page 8. 1.
1 Page 2 3
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 assistance 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 purpose 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). 3.
3 Page 4 5

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.

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 information 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
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 HealthAmerica Pennsylvania, Inc 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of HealthAmerica Pennsylvania, Inc. under our contract (CS 2078) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for administrative
services is:
HealthAmerica Pennsylvania, Inc. 3721 TecPort Drive
Harrisburg, PA 17111
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions 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 coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 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 8. Rates are shown at the end of this brochure.

Plain Language
All 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 HealthAmerica Pennsylvania, Inc.

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" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2003 HealthAmerica Pennsylvania, Inc 5 Stop Health Care Fraud
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (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. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following: Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at (800) 735-4404 in the Greater Pittsburgh region or at (800) 788-8445 in South Central, Central and Northeast Pennsylvania 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.

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 HealthAmerica Pennsylvania, Inc 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. 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 treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. Our providers are paid on
a capitated basis or a fee for service basis according to negotiated contracts. We do not participate in any withholds/ bonus or incentive programs.

Your Rights
OPM requires that all FEHB Plans to provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.
We are compliant with federal and state licensing requirements. We have been a licensed HMO since 1975.
We have over 27 years in existence.
We are a for-profit HMO.
We have participated with the FEHB program since 1977.
If you want more information about us, call (800) 735-4404 for the Greater Pittsburgh region, or (800) 788-8445 in Central, South Central and Northeast Pennsylvania, or write to 3721 TecPort Drive, Harrisburg PA 17111. You may also contact us by visiting our

website at www. healthamerica. cvty. com.
Service Area
To enroll in this Plan, you must live or work in our Service Area. This is where our providers practice. Our service area is divided into two enrollment codes, 26 and SW. Enrollment code 26 (Greater Pittsburgh area, Northwest area) includes the following Pennsylvania
counties:
Allegheny Armstrong
Beaver Butler
Cambria Crawford
Erie Fayette
Forest 9.
9 Page 10 11
2003 HealthAmerica Pennsylvania, Inc 7 Section 1
Greene Indiana
Lawrence Mercer
Somerset Venango
Washington Warren
Westmoreland

Enrollment code SW (Central, South Central, Northeast Pennsylvania) includes the following Pennsylvania counties:
Adams Berks
Blair Centre
Clinton Columbia
Cumberland Dauphin
Franklin Huntingdon
Juniata Lancaster
Lebanon Luzerne
Lycoming Mifflin
Montour Northumberland
Perry Schuylkill
Snyder Union
York
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care 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 must 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. 10.
10 Page 11 12
2003 HealthAmerica Pennsylvania, Inc 8 Section 2
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
For enrollment code 26, your share of the non-Postal premium will increase by 18. 8% for Self Only or 39. 3% for Self and Family.

For enrollment code SW, your share of the non-Postal premium will increase by 14. 2% for Self Only or 19. 9% for Self and Family.
We use ValueOptions to coordinate Mental Health and Substance Abuse services. See Section 5( e). 11.
11 Page 12 13

2003 HealthAmerica Pennsylvania, Inc 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 735-4404 in Greater
Pittsburgh or (800) 788-8445 in Central, South Central, and Northeast Pennsylvania. You may also request replacement cards through our website at www. healthamerica. cvty. com.

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

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our website.
It depends on the type of care you need. First, you and each family member must choose a Primary Care Physician. This decision is important since your Primary Care Physician
provides or arranges for most of your health care. You can complete a PCP Selection Card and mail it or you can call us.

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

Specialty care Your Primary Care Physician will refer you to a specialist for needed care. When you receive a referral from your Primary Care Physician, you must return to the Primary Care
Physician after the consultation, unless your Primary Care Physician authorized a certain number of visits without additional referrals. The Primary Care Physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits unless your Primary Care Physician gives you a referral.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your Primary Care Physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional referrals. Your Primary Care Physician will use our criteria when creating your
treatment plan (the physician may have to get an authorization or approval beforehand).

What you must do to get covered care 12.
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2003 HealthAmerica Pennsylvania, Inc 10 Section 3
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 see a participating gynecologist for your annual examination or an obstetrician for maternity care you do not need a referral from your Primary Care Physician. All
other gynecological services MUST be coordinated through your Primary Care Physician. If you are not sure contact your specialist, PCP or HealthAmerica to ensure
the services you are receiving are considered obstetrical or gynecological.
If you are seeing a specialist and your specialist leaves the Plan, call your Primary Care Physician, who will arrange for you to see another specialist. You may receive
services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan Primary Care Physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or
other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 735-4404 for the Greater Pittsburgh region, or
(800) 788-8445 in Central, South Central and Northeast Pennsylvania. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 13.
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2003 HealthAmerica Pennsylvania, Inc 11 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Your Primary Care Physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

The following are health care services which require precertification:
Inpatient hospital admissions, Outpatient surgeries,
Home health care, Durable medical equipment,
Out of network referral requests, Transplant requests,
Complex diagnostic testing such as Magnetic Resonance Imaging, Chiropractic care,
Rehabilitative service, Infertility treatment and
Oral surgery
You must contact ValueOptions before seeking mental health and substance abuse treatment. ValueOptions will help develop a treatment plan that you must follow. We will
not cover services that ValueOptions has not approved.

Services requiring our prior approval 14.
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2003 HealthAmerica Pennsylvania, Inc 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your Primary Care Physician you pay a copayment of $10 per office visit and when you see a specialist you pay a $15 copay per office visit.
Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before benefits are paid. We do not have a deductible
Coinsurance Coinsurance is the percentage of negotiated fee that you pay for your care. In our plan, you pay a $300 copay or 50% of the cost, whichever is less, for infertility services.

Your catastrophic protection out-of-pocket maximum Your catastrophic protection out of pocket expenses for benefits covered under this Plan
are limited to the stated copayments and coinsurance required for some benefits. 15.
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2003 HealthAmerica Pennsylvania, Inc 13 Section 5
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 54 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
claim forms, claims filing advice, or more information about our benefits, contact us at (800) 735-4404 for the Greater Pittsburgh region, or (800) 788-8445 in Central, South Central and Northeast Pennsylvania or at our website at www. healthamerica. cvty. com.

(a) Medical services and supplies provided by physicians and other health care professionals........................................................ 14-22
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................................ 23-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services.............................................................................. 27-28
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents ................................................................................................................................................. 29-30 Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................ 31-32
(f) Prescription drug benefits ........................................................................................................................................................ 33-35
(g) Special features ............................................................................................................................................................................. 36

Flexible Benefit Option Member Services TDD
Complex Case Management
High-risk pregnancy Centers of Excellence

(h) Dental benefits ............................................................................................................................................................................... 37
(i) Non-FEHB benefits available to Plan members ........................................................................................................................... 38
Summary of benefits ............................................................................................................................................................................. 54 16.
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2003 HealthAmerica Pennsylvania, Inc 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical opinion

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility

Nothing

Professional services of physicians after posted office hours $20 per office visit to your Primary Care Physician
$30 per office visit to a Specialist
At home $10 per office visit to your Primary Care Physician $15 per office visit to a Specialist

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 17.
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2003 HealthAmerica Pennsylvania, Inc 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including

Fecal occult blood test

Nothing if you receive these services during your office visit; otherwise,
$10 per office visit to your Primary Care Physician or
$15 per office visit to a Specialist
Sigmoidoscopy, screening every five years starting at age 50 Nothing

Prostate Specific Antigen (PSA test) one annually for men age 40 and older Nothing
Routine pap test
Note: The office visit is covered if a non-routine pap test is received on the same day; see Diagnosis and Treatment, above.
$10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist
Routine mammogram covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period
One per calendar year age 40 and above

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations such as:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccines, annually, age 50 and over at physicians discretion for those determined to be high risk.
Pneumococcal vaccine, age 65 and over

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist
Well-child care charges for routine examinations, immunizations and care (through age 22)

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist 18.
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2003 HealthAmerica Pennsylvania, Inc 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your

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

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

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

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist
Note: You pay the office visit copay for your first visit only. We waive the office

visit copay after your initial maternity care visit.

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary Sterilization (See Surgical procedures Section 5( b))
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist

Voluntary sterilization $ 50. 00 per vasectomy
$100. 00 per tubal ligation
Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges. 19.
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2003 HealthAmerica Pennsylvania, Inc 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI) intracervical insemination (ICI)

intrauterine insemination (IUI)

$300 copay per member or 50% of the cost of the service, whichever is less

Not covered:
Fertility Drugs
Assisted reproductive technology (ART) procedures, such as:
embryo transfer, gamete GIFT and zygote ZIFT Zygote transfer

In vitro fertilization
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment $10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist
Allergy injection
Allergy serum
Nothing

Not covered: provocative food testing and sublingual allergy desensitization All charges. 20.
20 Page 21 22
2003 HealthAmerica Pennsylvania, Inc 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 26.
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 and determine that it is medically necessary. Your doctor will need to

submit medical information to support that GHT is medically necessary. You must obtain authorization for GHT before you begin treatment
because we only cover GHT services from the date we determine it is medically necessary. We do not cover GHT or related services and
supplies if we determine it isn't medically necessary. See Services requiring our prior approval in Section 3.

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist

Physical & Occupational therapies
Up to two consecutive months per condition for the services of each of the following:

qualified physical therapists and occupational therapists.

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury and
if significant improvement can be expected within two consecutive months.

Cardiac rehabilitation following a heart transplant, bypass surgery or
a myocardial infarction, is provided for up to two consecutive months per condition, per contract year.

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist
Nothing per visit if services are provided by a participating Physical Therapist

Nothing per visit during covered inpatient admission.

Not covered:
long-term rehabilitative therapy or beyond two consecutive months per condition.

exercise programs

All charges. 21.
21 Page 22 23
2003 HealthAmerica Pennsylvania, Inc 19 Section 5( a)
Speech therapy You pay
Up to two consecutive months per condition for the services provided by a qualified speech therapist $10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist
Hearing services (testing, treatment, and supplies)
Hearing testing (one per contract year). $10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist
Not covered: all other hearing testing
hearing aids, testing and examinations for them
All charges.

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
Nothing

Annual eye refractions Note: You must contact National Vision Administrators (NVA) prior to
your exam. NVA will send you a list of participating eye doctors and a vision claim form. Call NVA at (800) 672-7723.
$15 per office visit

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

All charges.

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

See the "Not covered" section under orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist

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

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

treatment is by open cutting surgery)

All charges. 22.
22 Page 23 24
2003 HealthAmerica Pennsylvania, Inc 20 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, limbs, pacemakers, and surgically implanted breast implant following
mastectomy, when authorized in accordance with the plan's policies and procedures. Note: 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 when

rheumatoid arthritis, ankylosing spondylitis, or disseminated lupus erythmatosus.

Note: You must receive our preauthorization. Call us at (800) 735-4404 for the Greater Pittsburgh region or (800) 788-8445 in South Central,
Central and Northeast Pennsylvania as soon as you Plan physician prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing

Not covered:
Orthopedic and corrective shoes

Arch supports
Foot orthotics (except for diabetics)
Heel pads and heel cups
Corsets, trusses, elastic stockings, support hose, and other
supportive devices

Cochlear implant devices

Replacement due to neglect
Any dental care involved with the treatment of
tempormandibular joint (TMJ) pain dysfunction syndrome or joint disorders

Dental prosthesis
Lumbar supports
Wigs

All charges. 23.
23 Page 24 25
2003 HealthAmerica Pennsylvania, Inc 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs; base model necessary to cover your needs
crutches;
walkers;
Diabetes equipment such as blood glucose monitors, insulin infusion devices and orthotics

Nothing

Not covered: Disposable items such as incontinent pads, catheters, irrigation
kits, electrodes, ace bandages, elastic stockings and dressings Equipment which serves for comfort or convenience functions or is
primarily for the convenience of a person caring for a member Air conditioners
Corrective appliances that do not require prescription specifications or are used primarily for recreational sports
Humidifiers Electric air cleaners
Exercise or fitness equipment Elevators
Hot tubs Hoyer lifts
Shower/ bath bench Routine servicing, e. g., testing, cleaning, regulating and checking
of equipment Special clothing of any type
Hearing devices of any type Replacement due to neglect

All charges.

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

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

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist
Home health services continued on next page 24.
24 Page 25 26
2003 HealthAmerica Pennsylvania, Inc 22 Section 5( a)
Home health services (continued) You pay
Not covered: Nursing care requested by, or for the convenience of, the patient or

the patient's family Services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication Homemaker services

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.
Services or supplies furnished by a person who is the spouse or relative of member or by non home health provider

All charges.

Chiropractic
Up to 15 visits per member per calendar year for
Manipulation of the spine and extremities or
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$15 per office visit

Not covered: Visits that exceed 15 per calendar year All charges
Alternative treatments
Biofeedback when approved in conjunction with an approved pain management program or for the treatment of urinary and or fecal

incontinence.
$10 per office visit
$15 per office visit to a Specialist

Not covered:
Naturopathic services Acupuncture

Hypnotherapy
Biofeedback not shown as covered

All charges.

Educational classes and programs
Outpatient diabetes self-management training and education (including nutritional therapy) for persons with diabetes, when prescribed by a

Plan Physician. Coverage includes:
visits medically necessary upon the diagnosis of diabetes; visits where a Plan physician identifies and diagnoses a significant

change in the patient's symptoms or conditions that necessitates changes in a patient's self-management; and
visits where a licensed physician identifies that a new medication or therapeutic process relating to the person's treatment or diabetes
management is medically necessary.

$10 per office visit to your Primary Care Physician
$15 per office visit to a Specialist 25.
25 Page 26 27
2003 HealthAmerica Pennsylvania, Inc 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and
identify which surgeries require precertification.

I M
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T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Operative procedures

Treatment of fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery) Surgical treatment of morbid obesity 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 or Body Mass Index (BMI) is greater than 40.
Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.
Treatment of Burns Circumcisions for male newborns

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

Nothing

Surgical procedures continued on next page. 26.
26 Page 27 28
2003 HealthAmerica Pennsylvania, Inc 24 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization (such as tubal ligation & vasectomy). $50 copay for vasectomy

$100 copay for tubal ligation

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

All charges.

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

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

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

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

Nothing

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

Surgeries related to sex transformation

All charges. 27.
27 Page 28 29
2003 HealthAmerica Pennsylvania, Inc 25 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate
Excision of lesions of the mandible, mouth, lip, or tongue
Incision of accessory sinuses, mouth, salivary glands or duct;
Manipulation of dislocations of the jaw
Reconstruction or repair of the mouth or lips necessary to correct functional impairment caused by congenital condition and birth

abnormalities;
Treatment of tumors
Extractions of impacted third molars when partially or totally covered by bone

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.

Nothing

Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival, and alveolar bone)
Orthodontia
Treatment of TMJ if dental related
Orthognathic or prognathic surgery when it is performed only to improve the appearance of a functioning structure.

All charges. 28.
28 Page 29 30
2003 HealthAmerica Pennsylvania, Inc 26 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and

peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas
Note: Transplant services must be performed at a participating Center of Excellence. We approve and designate where all transplants must be

performed including hospitals for specific transplant procedures. If you would like to know about a specific facility, please contact Member
Services.
Note: We cover related medical and hospital expenses of the donor when the expenses are not covered by the donor's insurance and when

the transplant recipient is a HealthAmerica member approved for transplant services.

Nothing

Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Donor expenses related to donating organs or tissue to a non-member
recipient Implants of artificial organs
Experimental or investigational transplants
Transplants not listed as covered

All charges.

Anesthesia Professional services provided in
Hospital (inpatient) Hospital outpatient department
Skilled nursing facility Ambulatory surgical center

Nothing

Professional services provided in
Office
$10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist 29.
29 Page 30 31
2003 HealthAmerica Pennsylvania, Inc 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

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

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

I M
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T

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

general nursing care; and meals and special diets.

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

Nothing

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

Nothing

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

Private nursing care

All charges.

. 30.
30 Page 31 32
2003 HealthAmerica Pennsylvania, Inc 28 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma
Blood and blood plasma, if not donated or replaced
Packed red blood cells, cryoprecipite, Factor VII, and platelets;
Other clotting factors or blood components such as Factor VIII or Factor IX, whether naturally or artificially derived are covered for

acute traumatic events or when medically necessary.
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 procedure itself.

Nothing

Not covered: blood and blood derivatives replaced by the member All charges.
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF) or Extended care benefits:
Up to 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically

appropriate as determined by a Plan doctor and approved by us. Services include:

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

doctor

Nothing

Not covered: custodial care, rest cures, domiciliary or convalescent care All charges.
Hospice care Supportive and palliative care for a terminally ill member is covered in
the home or a hospice facility. Services include inpatient and outpatient care, and family counseling. Hospice services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or
less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate Nothing 31.
31 Page 32 33
2003 HealthAmerica Pennsylvania, Inc 29 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

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

We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

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

What to do in case of emergency within or outside our service area:
If you experience the sudden onset of a medical condition or injury with symptoms that you think may result in serious impairment, please go to the nearest emergency room or call 911. Otherwise if your symptoms allow , call your Primary
Care Physician. Your primary care physician is available to advise you about an urgent or emergency situation 24 hours a day, seven days a week by phone. Your PCP's phone number is on your ID card. Be sure to call your Primary Care
Physician before going to a hospital emergency room or urgent care center whenever possible. If it is not possible, go straight to the nearest hospital emergency room or call 911 or the local emergency phone number. Be sure to tell the
emergency room personnel that you are a HealthAmerica Plan member. Please be sure that you contact your PCP within 24 hours of being treated or admitted. Your PCP will make sure that:

Medical information about you is given to the hospital emergency room doctor;
Your care continues without delay; and
Your follow-up care is coordinated.
If you are outside the service area and a Plan doctor believes that your care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full. To be covered by this Plan, any follow-up

care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers. 32.
32 Page 33 34
2003 HealthAmerica Pennsylvania, Inc 30 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 office visit during posted office hours or

$20 office visit after posted office hours
Emergency care at a Specialist's office $15 office visit during posted office hours or
$30 office visit copay after posted hours
Hospital emergency room or urgent care center treatment $50 copay per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office $10 per office visit during posted office hours or

$20 per office visit after posted office hours
Emergency care at a Specialist's office $15 per office visit during posted office hours or
$30 after posted hours
Hospital emergency room or urgent care center treatment $50 copay per visit

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

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

All charges

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance See 5( c) for non-emergency service. Nothing 33.
33 Page 34 35
2003 HealthAmerica Pennsylvania, Inc 31 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
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.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
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T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

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

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

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

Medication management
Note: Psychiatrists, Psychologists, or clinical social workers are specialty providers. The office visit copay for Specialists applies to

services from these providers.

$10 per office visit to your Primary Care Physician or
$15 per office visit to a Specialist or
Nothing for inpatient services

Mental health and substance abuse benefits -continued on next page 34.
34 Page 35 36
2003 HealthAmerica Pennsylvania, Inc 32 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests $10 per office visit to your Primary Care Physician

$15 per office visit to a Specialist
Nothing for inpatient services

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

hospitalization, facility based intensive outpatient treatment

Nothing

Not covered:
Services we have not approved.
Evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and

appropriate.
Testing for learning disabilities, school related issues, or for the purposes of obtaining or maintaining employment.

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

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
ValueOptions, Inc. will coordinate your Mental Health and Substance Abuse services. If you need help, call your Primary Care Physician. Your doctor will work with Value
Options to coordinate the care that you need. You may also call ValueOptions directly without referral from your Primary Care Physician.

If you need to seek mental health care services on an emergency basis, ValueOptions is available to you 24 hours a day, 7 days a week. Their normal business hours are from
8: 00 am to 5: 00 pm. You can reach ValueOptions toll free at (866) 834-1717, TDD (800) 334-1987.

We have a comprehensive network of professionals and facilities available for mental health and chemical dependency treatment. Please refer to the list of providers in the
Mental Health/ Chemical Dependency section of your Provider Directory. If you need a directory or assistance with finding a provider call Western Pennsylvania (800) 735-
4404 or Eastern Pennsylvania (800) 788-8445 or (717) 540-6315.

Limitation We may limit your benefits if you do not obtain a treatment plan. 35.
35 Page 36 37

2003 HealthAmerica Pennsylvania, Inc 33 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

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

We do not have a calendar year deductible.
Selected products and certain prescription drugs require our prior approval. In general, drugs that require our prior approval (1) are not suggested for first-line therapy, (2) require special tests before starting them,

or (3) have very limited approval for use.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
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A N
T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or referral plan doctor must write the prescription.
Where you can obtain them. You may fill the prescription at a local Plan participating pharmacy or by mail at our participating mail-order pharmacy for a plan-approved maintenance medication. Our Plan

pharmacies are listed in our directory.
We use a formulary. It is a list of approved medications. Our Prescription Drug Formulary is a list of drugs and other items that we approve for your use and which will be dispensed through participating

pharmacies to members. We periodically review and modify our formulary. The list of approved drugs is available for review in the participating physician's office. You may also obtain them formulary list by
contacting the Plan's Member Services Department or our website at www. healthamerica. cvty. com. We cover non-formulary drugs prescribed by a Plan doctor.

These are the dispensing limitations. You may obtain up to a 31-day supply or 100-unit supply; whichever is less, at a Plan Participating retail pharmacy. For commercially prepackaged drugs such as topicals,
inhalers, and vials, you will pay one copay for each container. Selected products or prescription drugs may require prior approval from the Plan. These medications may include those that (1) are not suggested for
first-line therapy (2) may require special tests before starting them (3) have very limited approval for use. Sexual dysfunction drugs have specific quantity limitations. When generic substitution is permissible, but
you or your doctor choose the name brand drug over the generic drug, you pay the price difference between the generic drug and name brand drug as well as the appropriate copay per prescription unit or refill. Your
prescription drug copay will never exceed the retail price of the drug.
Prescriptions by Mail-Order. You can order up to a 3-month supply of approved maintenance medications through the mail and pay just two times the retail pharmacy copay. For commercially prepackaged drugs

such as topicals, inhalers, and vials, you will pay one mail order copay for each three (3) containers. Maintenance medications are those that you must take for long-term conditions such as high blood pressure
or an estrogen hormone imbalance. Simply ask your doctor to write your maintenance medication prescription for up to a 90-day supply. You will need to complete a mail order envelope (which you can
obtain from Member Services) and mail it to the address on the front of the envelope. All maintenance medications are not available by mail-order. For a list of maintenance medications that you can obtain by
mail, please contact us at (800) 735-4404 for the Greater Pittsburgh region or (800) 788-8445 in South Central, Central and Northeast Pennsylvania.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name. The name brand is the name under which the
manufacturer advertises and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you and us less
than a name brand prescription. 36.
36 Page 37 38

2003 HealthAmerica Pennsylvania, Inc 34 Section 5( f)
When you have to file a claim.
Prescription drugs prescribed for emergency services and filled by a Non-Participating pharmacy are covered only for a quantity sufficient to treat the acute phase of the illness/ injury. Coverage for such prescription Drugs

prescribed in relation to Emergency Services and provided by a Non-Participating pharmacy is limited to one hundred percent (100%) of the Reasonable and Customary Charge less applicable copayments and other
appropriate charges as noted above such as when a brand drug is dispensed and an FDA approved generic is available.

Members must submit claims for reimbursement of prescription drugs purchased from a Non-Participating pharmacy on a Direct Reimbursement Form (available from HealthAmerica's Member Services Department). All
claims for reimbursement must be received by HealthAmerica or its agent within ninety (90) days of the date of purchase of the prescription drugs. Claim forms are also available from our website
(www. healthamerica. cvty. com) under the Downloadable Rx Forms Section.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not

Covered.
Full range of FDA approved birth control, including but not limited to oral, injectable or implantable contraceptives and contraceptive

diaphragms
Insulin with a charge and copay for each vial
Plan approved diabetic supplies and pharmacological agents, or devices used to assist in insulin injection (injection aids) including

insulin syringes and needles, blood glucose test strips and lancets
Selected injectables as specified by the Plan (Imitrex, Glucagon and Bee Sting Kits)

Disposable needles and syringes for the administration of covered medications
Potassium Supplement to prevent/ treat low potassium (prescription only)
Note: Please check section 5( a) when checking coverage for intravenous fluids and medications for home use, some injectable drugs, diabetic equipment
(glucose monitor) and some FDA approved contraceptive devices.

At a Plan Retail Pharmacy:
$8 copay for generic formulary,
$14 copay for name brand formulary,
$35 copay non-formulary

or
Through our Mail Order Pharmacy:
$16 copay for generic,
$28 copay brand,
$70 copay for non-formulary
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.
Note: For commercial containers through mail order, you pay the appropriate copay

for each (3) containers. 37.
37 Page 38 39
2003 HealthAmerica Pennsylvania, Inc 35 Section 5( f)
Covered medications and supplies (continued) You pay
Sexual dysfunction drugs require prior approval and have specific quantity limits. For complete details, please call Member Services
using the phone number shown on your ID card.
Note: These drugs are not available by mail-order.

At a Plan Retail Pharmacy:
$8 copay for generic formulary,

$14 copay for name brand formulary, $35 copay non-formulary

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

Vitamins, and minerals (both OTC and legend), except legend prenatal vitamins and liquid or chewable legend pediatric vitamins
Supplies such as dressings and antiseptics
Drugs to aid in smoking cessation
Drugs used for the primary purpose of treating infertility, including those given in connection with artificial insemination

Oral dental preparations and fluoride rinses
Drug therapy for weight loss (e. g. Xenical)
Nonprescription medicines
Drugs for investigational and experimental purposes

All charges. 38.
38 Page 39 40
2003 HealthAmerica Pennsylvania, Inc 36 Section 5( g)
Section 5 (g). Special features
Feature Description

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

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

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

Member Services TDD for deaf and hearing impaired Telecommunications Device for the Deaf and hearing impaired members who have access to a TDD-Compatible telephone. Members call (800) 207-1262 from 7 am -
6 pm Monday-Friday or from 9 am -1 pm on Saturday

Complex Case Management Complex Case Management programs promote quality of care to reduce the likelihood of extended, more costly health care. Our specially trained nurse case
managers work directly with the patients and their doctors. Some of the programs include Cardiovascular, Endocrinology, Oncology, Trauma/ Medical-Surgical.

High risk pregnancies This program is set up to identify women at risk for developing complications that may affect their pregnancy. The program promotes quality of care to reduce the
likelihood of extended, more costly health care and focus on patients at risk, early intervention, coordination of care between patient and health care team, continuing

education and regular follow up to ensure the patient is following the plan of care properly. For more information call (800) 735-4404 in Western PA and (800) 788-8445
in Eastern PA.

Centers of Excellence HealthAmerica has a nationally recognized organ transplant network through Coventry's Transplant Centers of Excellence to coordinate care for members who
may need a transplant. The network provides you and your family with access to the hospitals across the country, which specialize in specific transplant procedures.

For information and access to these Centers of Excellence call Member Services. Care provided outside the Centers of Excellence network will not be covered unless
approved by the Plan. 39.
39 Page 40 41
2003 HealthAmerica Pennsylvania, Inc 37 Section 5( h)
Section 5 (h) Dental Benefits
I M
P O
R T
A N
T

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

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

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

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must

result from an accidental injury. We will only cover services that you receive within 24 hours of the accident.

Note: We do not cover services rendered more than 24 hours after the accidental injury whether or not the treatment is a continuation or
completion of a treatment plan initiated at time of injury.

Nothing

Not covered:
Services provided after the initial 24 hours post
Orthodontia and all other dental related services
Services provided by non-participating dentists
Other dental services shown as not covered.

All charges

Dental Benefits
We have no other dental benefits. All Charges 40.
40 Page 41 42

2003 HealthAmerica Pennsylvania, Inc 38 Section 5( i)
Section 5 (i). Non-FEHB Benefits Available to Plan Members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

HealthAmerica Dental Plan
HealthAmerica has partnered with Dominion Dental Services, Inc. to provide HealthAmerica Federal Government members with discounted dental services. You Pay an office visit copay for cleanings and exams and you receive
discounts on other dental procedures. To receive these benefits you must use a participating dentist.
This dental benefit is an optional dental benefit and is available at no additional premium when you choose HealthAmerica's HMO medical option. To apply for federal HealthAmerica dental coverage, you must be enrolled in
the HealthAmerica HMO medical option and you must complete a dental enrollment form.
If you have any questions or need additional information simply call Dominion Dental Services at (888) 518-5338. Or you can access their website at www. DominionDental. com/ ha.

Other Benefits and Services
Vision Coverage -All HealthAmerica members automatically qualify for a "20/ 20" vision benefit, which provides a 20% discount off the normal retail price for lenses, frames and contact lenses at Plan participating vision providers.

Health Education Classes -Classes include Weight Management, Diabetic Education, Prenatal Education, Stress Management and Smoking Cessation.
Health Club Discounts -HealthAmerica members are eligible for discounted initiation fees and discounted monthly membership fees at Plan participating health clubs.
American Specialties Health Network (ASHN)-A discount program offering complimentary and alternative care for members to broaden their health care options. Some services include massage therapy, acupuncture, nutritional
supplements and vitamins and discounts on health club memberships.
To obtain an approved listing of programs available or request a provider directory or call our customer service department at (800) 735-4404 for the Greater Pittsburgh region or (800) 788-8445 in South Central, Central and
Northeast Pennsylvania. Or you can receive additional information regarding any of our programs by accessing the HealthAmerica website at www. healthamerica. cvty. com.

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 41.
41 Page 42 43
2003 HealthAmerica Pennsylvania, Inc 39 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service. 42.
42 Page 43 44
2003 HealthAmerica Pennsylvania, Inc 40 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at (800) 735-4404 for the greater Pittsburgh region or (800) 788-8445 in South Central, Central and Northeast Pennsylvania.

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: Harrisburg -HealthAmerica Attn: Member Services Department
3721 TecPort Drive, P. O. Box 67103 Harrisburg PA 17106

Pittsburgh -HealthAmerica Attn: Member Services Department
Cranberry Business Park 120 East Kensinger
Cranberry Township PA 16066
Prescription drugs Must complete a claim reimbursement form. Contact the plan in the Harrisburg Area at (717) 540-4260 or (800) 788-8445 or in the Pittsburgh Area at (412) 553-7300 or (800)

735-4404.
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 43.
43 Page 44 45
2003 HealthAmerica Pennsylvania, Inc 41 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at:
South Central, Central, Northeast Region HealthAmerica, Attn: Member Services Department,

3721 TecPort Drive P. O. Box 67103
Harrisburg, PA 17106 or
Greater Pittsburgh Region HealthAmerica, Attn: Member Services Department,
Cranberry Business Park 120 East Kensinger
Cranberry Township, PA 16066
(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. 44.
44 Page 45 46
2003 HealthAmerica Pennsylvania, Inc 42 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

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

Note: If you want OPM to review 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.

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, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to
uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at (800) 735-4404 for the Greater Pittsburgh region or (800) 788-8445 in South Central, Central and Northeast Region. 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 am and 5 pm eastern time. 45.
45 Page 46 47
2003 HealthAmerica Pennsylvania, Inc 43 Section 9
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.

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

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

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

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

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.
When you are enrolled in this Plan and Original Medicare, you still need to follow the rules in this brochure for us to cover your care. Tell us if you are enrolled in Medicare
Part A or B. Medicare will determine who is responsible for paying first for medical services. If Medicare pays first, we coordinate our payment for covered services. Under
your FEHB coverage, we do not waive any of the copayments.

The Original Medicare Plan (Part A or Part B) 46.
46 Page 47 48
2003 HealthAmerica Pennsylvania, Inc 44 Section 9
Claims process when you have the Original Medicare Plan You should not have to file a claim form when you have both our Plan and Medicare as long as you use our providers. In some cases, you may need to file
a claim form when you have both our Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the balance
of covered charges. It is possible that you will have to provide us with the Explanation of Medicare Benefits. To find out if you need to do something about filing your
claims, call us at (800) 735-4404 in the Greater Pittsburgh region or at (800) 788-8445 in South Central, Central and Northeast Pennsylvania.

We do not waive your FEHB copays when you have Medicare.
Primary payer chart begins on next page. 47.
47 Page 48 49
2003 HealthAmerica Pennsylvania, Inc 45 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

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

OriginalMedicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability),

2) Are an annuitant,

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

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

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

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

(except for claims related to Workers'

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 48.
48 Page 49 50

2003 HealthAmerica Pennsylvania, Inc 46 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like
HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care
plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you enroll in a Medicare managed care plan, the following options are available to you:

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

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

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

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides 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 a Medicare managed care plan If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable 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.

If you do not enroll in Medicare Part A or Part B 49.
49 Page 50 51
2003 HealthAmerica Pennsylvania, Inc 47 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they

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

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program 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 for injuries or illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 50.
50 Page 51 52
2003 HealthAmerica Pennsylvania, Inc 48 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided by non-medical personnel that does not attempt to cure your condition but will help you perform daily living activities. Some examples of custodial care include
helping you walk, dress, bathe, eat or take your medication.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 12.

Experimental or We gather appropriate information to determine whether a procedure, service, or supply investigational services is experimental or investigational. The gathered information includes all appropriate
medical records, reviews of current medical and scientific evidence publications, as well as information from government regulatory bodies. Appropriate medical professionals
participate in the extensive evaluation process to determine whether a procedure is/ is not considered experimental or investigational. After the determination is made, you will be
notified of our decision. You can obtain a copy of our Experimental Procedures Determinations Policy by contacting HealthAmerica's Member Services Department.

Group health coverage Group Health Coverage is protection that provides payment of benefits for covered sickness or injury.
Medical necessity A service or treatment which is appropriate and consistent with diagnoses, and which, in accordance with accepted standards of practice in the medical community of the area in
which the health services are rendered, could not have been omitted without adversely affecting the member's condition or the quality of medical care rendered.

Primary Care Physician Primary Care Physician (PCP) is a family practitioner, internist or a pediatrician. Your PCP provides all routine care and will manage your preventive care, hospital care, and
referrals to Specialists.

Specialist A medical doctor or provider other than your Primary Care Physician (PCP) whose education and work experience focus on a particular area of medicine. For example, a
cardiologist sees patients with heart disease and a neurologist deals with disorders that affect our central nervous system.

Us/ We Us and we refer to HealthAmerica
You You refers to the enrollee and each covered family member.

Experimental or investigational services 51.
51 Page 52 53

2003 HealthAmerica Pennsylvania, Inc 49 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you 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
follows: 52.
52 Page 53 54

2003 HealthAmerica Pennsylvania, Inc 50 Section 11
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 that 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 identified 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
coverage 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 premiums start during Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the
effective date of coverage.

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. 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. 53.
53 Page 54 55

2003 HealthAmerica Pennsylvania, Inc 51 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

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

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
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 Group Health Plan Coverage Federal law that offers limited Federal protections for health coverage availability and
continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long
you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting
periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB website
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees
must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information. 54.
54 Page 55 56

2003 HealthAmerica Pennsylvania, Inc 52 Long Term Care Insurance
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 perform 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 website 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. 55.
55 Page 56 57
2003 HealthAmerica Pennsylvania, Inc 53 Index
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 37 Allergy tests 17
Alternative treatment 22 Allogenetic (donor) bone marrow transplant 26
Ambulance 28 Anesthesia 26
Autologous bone marrow transplant 18, 26 Biopsies 23
Blood and blood plasma 28 Breast cancer screening 15
Catastrophic protection 12 Changes for 2003 8
Chemotherapy 18 Childbirth 16
Chiropractic 22 Cholesterol tests 15
Claims 40 Coinsurance 12, 48
Colorectal cancer screening 15 Congenital anomalies 23
Contraceptive devices and drugs 16 Coordination of benefits 42
Copayments 12 Covered charges 45
Covered providers 6, 9 Crutches 21
Deductible 12, 48 Definitions 48
Dental care 37 Diagnostic services 14
Disputed claims review 41 Donor expenses (transplants) 26
Dressings 21 Durable medical equipment (DME) 21
Educational classes and programs 22 Effective date of enrollment 48
Emergency 29 Experimental or investigational 26, 39, 48
Eye exams 15, 19 Eyeglasses 19
Family planning 16

Fecal occult blood test 15 General Exclusions 39
Hearing services 15, 19, 21, 36 Home health services 21
Hospice care 28 Home nursing care 21
Hospital care 10 Immunizations 15
Infertility 17 Inhospital physician care 27
Inpatient Hospital Benefits 27 Insulin 34
Laboratory and pathological services 14
Machine diagnostic tests 14 Magnetic Resonance Imagings
(MRIs) 14 Mail Order Prescription Drugs 33
Mammograms 15 Maternity Benefits 16
Medicaid 47 Medically necessary 48
Medicare 43 Mental Conditions/ Substance
Abuse Benefits 31 Newborn care 16
Non-FEHB Benefits 38 Nurse
Licensed Practical Nurse 21 Registered Nurse 21
Nursery charges 16 Obstetrical care 16
Occupational therapy 18 Ocular injury 19
Office visits 14 Oral and maxillofacial surgery 25
Orthopedic devices 20 Ostomy and catheter supplies 21
Out-of-pocket expenses 12 Outpatient facility care 28
Oxygen 21

Pap test 15 Physical examination 15
Physical therapy 18 Physician 9
Pre-surgical testing 28 Precertification 9-11
Preventive care, adult 15 Preventive care, children 15
Prescription drugs 33 Preventive services 15
Prior approval 11 Prostate cancer screening 15
Prosthetic devices 20 Psychologist 31
Psychotherapy 31 Radiation therapy 18
Renal dialysis 18 Room and board 27
Second surgical opinion 14 Skilled nursing facility care 14
Smoking cessation 35,38 Speech therapy 19
Splints 27 Sterilization procedures 16
Subrogation 47 Substance abuse 31
Surgery Anesthesia 26
Oral 25 Outpatient 28
Reconstructive 24 Syringes 34
Temporary continuation of coverage 49
Transplants 26 Treatment therapies 18
Vision services 19 Well child care 15
Wheelchairs 21 Workers' compensation 47
X-rays 14 56.
56 Page 57 58
2003 HealthAmerica Pennsylvania, Inc 54 Summary of Benefits
Summary of benefits for the HealthAmerica Pennsylvania, Inc. -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.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 primary care; $15 Specialist 14

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

Nothing
Nothing

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

$50 per urgent care center or emergency room visit

29
29

Mental health and substance abuse treatment...................................... Regular cost sharing. 31
Prescription drugs:
Up to a 31-day supply from a Plan Retail Pharmacy............................

Up to a 90-day supply from Plan Mail Order Pharmacy.......................

$8 Formulary Generic,$ 14 Name Brand, $35 Non-Formulary per prescription unit or refill
$16 Generic Formulary $28 Name Brand Formulary, $70 Non-Formulary per
prescription unit or refill

Dental Care:
Accidental injury benefit only .......................................................... Nothing
37

Vision Care:
Limited to one annual eye refraction ................................................ $15 office visit copay
19

Special features: High Risk Pregnancy, Centers of Excellence, Member Services TDD, Complex Case Management 36
Protection against catastrophic costs Stated copays and coinsurance 12 57.
57 Page 58 59
2003 HealthAmerica Pennsylvania, Inc 55 Notes 58.
58 Page 59 60
2003 HealthAmerica Pennsylvania, Inc 56 Notes 59.
59 Page 60
2003 HealthAmerica Pennsylvania, Inc. 58 Rate Information
2003 Rate Information for HealthAmerica Pennsylvania, Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health
benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and 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.

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

Greater Pittsburgh
Self Only 261 $102. 77 $34.26 $222. 68 $ 74. 22 $121. 61 $ 15. 42

Self and Family 262 $249. 62 $106. 66 $540. 84 $231. 10 $294. 70 $ 61. 58
Central, South Central, and Northeast Pennsylvania

Self Only SW1 $106. 37 $ 35. 45 $230. 46 $ 76. 82 $125. 87 $ 15. 95

Self and Family SW2 $249. 62 $119. 13 $540. 84 $258. 12 $294. 70 $ 74. 05 60.

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