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MVP Health Care

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
- Your costs for covered services
- Your catastrophic protection out-of-pocket maximum
Section 5. Benefits
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
- When you have other health 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
Rates

Pages 1--64

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

MVP Health Care http:// www. mvphealthcare. com
2003
A Health Maintenance Organization
For changes
in benefits
see page 8.

Serving: Upstate New York and Vermont
Enrollment in this Plan is limited; see page 7 for requirements.

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

Enrollment codes for this Plan:

Eastern Region
GA1 Self Only GA2 Self and Family

Central Region
M91 Self Only M92 Self and Family

Mid-Hudson Region
MX1 Self Only MX2 Self and Family

Vermont Region
VW1 Self Only VW2 Self and Family

RI-73-465

Special Notice: MVP Health Care has added Sullivan
County to enrollment code MX (Mid-Hudson Region). 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. 3.
3 Page 4 5
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may
also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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 MVP Health Care Table of Contents
Table of Contents
Introduction.................................................................................................................................................................... 4
Plain Language .............................................................................................................................................................. 4
Stop Health Care Fraud! ................................................................................................................................................ 4
Section 1. Facts about this HMO plan .......................................................................................................................... 6
How we pay providers ................................................................................................................................. 6
Who provides my health care?..................................................................................................................... 6
Your Rights.................................................................................................................................................. 6
Service Area................................................................................................................................................. 7
Section 2. How we change for 2003 ............................................................................................................................. 8
Program-wide changes................................................................................................................................. 8
Changes to this Plan..................................................................................................................................... 8
Section 3. How you get care ........................................................................................................................................ 9
Identification cards....................................................................................................................................... 9
Where you get covered care......................................................................................................................... 9
Plan providers........................................................................................................................................ 9
Plan facilities ......................................................................................................................................... 9
What you must do to get covered care ......................................................................................................... 9
Primary care........................................................................................................................................... 9
Specialty care......................................................................................................................................... 9
Hospital care........................................................................................................................................ 10
Circumstances beyond our control............................................................................................................. 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services ................................................................................................................. 12
Copayments ......................................................................................................................................... 12
Deductible ........................................................................................................................................... 12
Coinsurance ......................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum .............................................................................. 12
Section 5. Benefits ...................................................................................................................................................... 13
Overview.................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 23
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 27
(d) Emergency services/ accidents......................................................................................................... 30
(e) Mental health and substance abuse benefits.................................................................................... 32
(f) Prescription drug benefits................................................................................................................ 34 5.
5 Page 6 7
2003 MVP Health Care Table of Contents
(g) Special features ............................................................................................................................... 36
After Hours MVP Unit
Services for deaf and hearing impaired
High Risk Pregnancies
Travel Benefit/ Overseas
Out-of-Area Student Benefits
(h) Dental Benefits................................................................................................................................ 37
(i) Non-FEHB benefits available to Plan members.............................................................................. 39
Section 6. General exclusions --things we don't cover .............................................................................................. 40

Section 7. Filing a claim for covered services ............................................................................................................ 41
Section 8. The disputed claims process ...................................................................................................................... 42
Section 9. Coordinating benefits with other coverage ................................................................................................ 44
When you have other health coverage
What is Medicare................................................................................................................................ 44
Medicare managed care plan .............................................................................................................. 47
TRICARE and CHAMPVA................................................................................................................ 47
Workers' Compensation ..................................................................................................................... 48
Medicaid ............................................................................................................................................. 48
Other Government agencies................................................................................................................ 48
When others are responsible for injuries............................................................................................. 48
Section 10. Definitions of terms we use in this brochure ............................................................................................. 49
Section 11. FEHB facts ................................................................................................................................................ 50
Coverage information ................................................................................................................................ 50
No pre-existing condition limitation ................................................................................................... 50
Where you get information about enrolling in the FEHB Program .................................................... 50
Types of coverage available for you and your family......................................................................... 50
Children's Equity Act ......................................................................................................................... 51
When benefits and premiums start...................................................................................................... 51
When you retire .................................................................................................................................. 51
When you lose benefits.............................................................................................................................. 51
When FEHB coverage ends................................................................................................................ 51
Spouse equity coverage ...................................................................................................................... 52
Temporary Continuation of Coverage (TCC)..................................................................................... 52
Converting to individual coverage...................................................................................................... 52
Getting a Certificate of Group Health Plan Coverage......................................................................... 52
Long term care insurance is still available................................................................................................................... 54
Index ............................................................................................................................................................................ 55
Summary of benefits.................................................................................................................................................... 60
Rates ............................................................................................................................................................. Back Cover

3 6.
6 Page 7 8

2003 MVP Health Care Introduction/ Plain Language 4
Introduction
MVP Health Care, Inc.
625 State Street
Schenectady, NY 12305

This brochure describes the benefits of MVP Health Plan, Inc. under our contract (CS 2362) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. 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 are
summarized on page 57. 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 MVP Health Plan.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve 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.

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: 7.
7 Page 8 9
2003 MVP Health Care Introduction/ Plain Language 5
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 888/ 687-6277 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 MVP Health Care Section 1 6
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to 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 and/ or coinsurance 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.

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

MVP Health Plan is licensed in the States of New York and Vermont to operate as an HMO.
MVP Health Plan has been in operation since 1983
MVP Health Plan is a not-for-profit, federally qualified HMO

If you want more information about us, call 888/ 687-6277, or write to MVP Health Care, 625 State Street,
Schenectady, NY 12305. You may also contact us by fax at 518/ 386-7700 or visit our website at
http:// www. mvphealthcare. com 9.
9 Page 10 11
2003 MVP Health Care Section 1 7
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is as follows:

Eastern Region (GA1 Self only, GA2 Self and family): The New York counties of Albany, Fulton, Hamilton,
Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington.

Central Region (M91 Self only, M92 Self and family): The New York counties of Broome, Chenango, Delaware,
Herkimer, Lewis, Madison, Oneida, Onondaga, Otsego, and Tioga.

Mid-Hudson Region (MX1 Self only, MX2 Self and family): The New York counties of Columbia, Dutchess, Greene,
Orange, Putnam, Sullivan and Ulster.

Vermont (VW1 Self only, VW2 Self and family): The Vermont counties of Addison, Bennington, Caledonia,
Chittenden, Essex, Franklin, Grand Isle, Lamoille, Orange, Orleans, Rutland, Washington, Windham, and Windsor.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 10.
10 Page 11 12
2003 MVP Health Care 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 change
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

If you are in Enrollment Code GA, your share of the non-Postal premium will increase by 3.6% for Self Only and increase by 3.6% for Self and Family

If you are in Enrollment Code M9, your share of the non-Postal premium will increase by 8.1% for Self Only and increase by 0.4% for Self and Family.
If you are in Enrollment Code MX, your share of the non-Postal premium will increase by 5.4% for Self Only and decrease by 7.3% for Self and Family.
If you are in Enrollment Code VW, your share of the non-Postal premium will decrease by 24.9% for Self Only and decrease by 20.8% for Self and Family.
Sullivan County is now part of enrollment code MX, which is the Mid-Hudson Region. (Section 1)
Our mail order prescription vendor is now Express Scripts Mail Pharmacy Service 3684 Marshall Lane Bensalem, PA 19020-5914. (Section 5( f))

We cover up to 60 visits of medically necessary speech therapy per calendar year. (Section 5( a))
The office visit copay has increased from $10.00 to $15.00. (Section 5( a))
Members will be responsible for a $240 copayment for each inpatient hospital admission. (Section 5( c))
Members pay a $100 or 20% facility copay (which ever is less) for outpatient surgery. (Section 5( c))
The hospital emergency room and urgent care center copay has increased from $35.00 to $50.00. (Section 5( d))

Members must pay $40.00 for prescription drugs that are not on the MVP Health Care formulary. (Section 5( f))
Infertility services are subject to the $15.00 office visit copay. Previously, members paid 50% of the allowable charges for advanced infertility services. Infertility drugs are covered at the applicable prescription
drug copay. 11.
11 Page 12 13

2003 MVP Health Care Section 3 9
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 888/ 687-
6277 or write to us at MVP Health Care 625 State Street Schenectady,
NY 12305. You may also request replacement cards through our website
at www. mvphealthcare. com.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at www. mvphealthcare. com.

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

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician (PCP). This decision is
important since your PCP provides or arranges for most of your health
care. Please use our provider directory or our website to choose your
PCP.

Primary care Your primary care physician can be a doctor in Family or General Practice, Internal Medicine, OB/ GYN, or Pediatrics. Your primary care
physician will provide most of your health care, or give you a referral to
see a specialist.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize any follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you
may see any Plan gynecologist for routine office visits, or care related to
pregnancy without a referral. 12.
12 Page 13 14
2003 MVP Health Care Section 3 10
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
and must obtain authorization from a Plan Medical Director. Your
PCP will submit his/ her recommendation to our Medical Director and
then the Medical Director will notify both you and your PCP of our
decision in writing. Please contact our Member Services Department
at 1-888-687-6277 if you have any questions about this process.

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us, or if we drop out of
the FEHB 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 Member Services Department immediately at 1-888-687-6277. If
you are new to the FEHB Program, we will arrange for you to receive
care. 13.
13 Page 14 15
2003 MVP Health Care Section 3 11
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 hospital benefits of the hospitalized
person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the
necessary care.

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

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

Inpatient Hospital Admissions
Organ/ Tissue Transplants
Cardiac rehabilitation programs
Pulmonary rehabilitation programs
Skilled nursing facility care
Home health care
Health education and nutritional counseling
Sexual dysfunction services and prescriptions
Elective inpatient, and certain outpatient procedures
Growth Hormone Therapy
Mental health and substance abuse treatment

Your physician will contact our medical review staff in order to obtain
our approval. We may contact you and ask you some questions about
your condition and the treatment you have received in the past.

If our Medical Director does not approve this procedure, you may follow
the disputed claims process detailed in Section 8. 14.
14 Page 15 16
2003 MVP Health Care Section 5 12
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment
of $15 per office visit and when you go in the hospital, you pay $240 per
inpatient admission.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for those services. We do not
have a deductible.

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

After your copays are equal to or greater than two times the cost of the total
annual plan premium for two or more family members, you do not have to
make any additional payments for certain services for the rest of the year.
This amount is called your out-of-pocket maximum. Your out-of-pocket
maximum does not include your prescription drug copays. You must
continue to make copays for prescription drugs. Be sure to keep accurate
records of your copays since you are responsible for informing us when you
reach the maximum.

Your catastrophic out-of-pocket
maximum 15.
15 Page 16 17

2003 MVP Health Care Section 5 13
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 60 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; as they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
888/ 687-6277 or at our web site at http:// www. mvphealthcare. 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...................................................... 27-29
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Hospice care
Ambulance

(d) Emergency services/ accidents .................................................................................................................. 30-31
Medical emergency Ambulance

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

After Hours MVP Unit
Services for the deaf and hearing impaired
High risk pregnancies

Travel benefit/ Overseas
Out-of-area student coverage (to age 22)

(h) Dental benefits................................................................................................................................................. 37-38
(i) Non-FEHB benefits available to Plan members ................................................................................................... 39

Summary of benefits.................................................................................................................................................... 60 16.
16 Page 17 18
2003 MVP Health Care Section 5( a) 14
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
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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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office, including office medical consultations and second surgical opinions

Initial examination of a newborn child covered under a family enrollment

$15 per office visit

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

Nothing

At home $15 per visit
Not covered:
Dental treatment of temporomandibular joint( TMJ) syndrome
Costs for which a member fails to keep an appointment
All charges. 17.
17 Page 18 19
2003 MVP Health Care Section 5( a) 15
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these
services during your office visit;
otherwise, $15 per visit

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years, ages 19 through 64

Colorectal Cancer Screening, including
Fecal occult blood test

$15 per office visit

Sigmoidoscopy, screening every five years starting at age 50
Routine Prostate Specific Antigen (PSA) test one annually for men age 40
and older

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

$15 per office visit

Routine mammogram covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period
From age 40 through 49, one every one or two calendar years
At age 50 and older, one every calendar year

Nothing

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

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

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing if you receive these
services during your office visit;
otherwise, $15 per visit

Not covered: Immunizations or vaccinations for employment,
educational, insurance, or travel purposes
All Charges 18.
18 Page 19 20
2003 MVP Health Care Section 5( a) 16
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care charges for routine examinations, immunizations and care (through age 22)
Examinations, such as:
-Examinations done on the day of immunizations (through age 22)

Nothing

-Eye exams through age 17 to determine the need for vision
correction.

-Ear exams through age 17 to determine the need for hearing
correction (exams for screening only)

$15 per office visit (for refraction
only)

$15 per office visit (for screening
only)

Maternity care
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).

$15 copay for the initial office
visit only and nothing thereafter

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

$15 per office visit 19.
19 Page 20 21
2003 MVP Health Care Section 5( a) 17
Family planning (Continued) You pay
Not covered:

reversal of voluntary surgical sterilization,
genetic counseling, voluntary abortions, embryo transfer, GIFT, ZIFT, in-vitro fertilization

All charges.

Infertility services
Basic infertility services include those services provided for the initial
evaluation and testing for infertility.

Advanced infertility services such as:
Semen analysis
Post-coital examinations
Hysterosalpingograms
Varicocele surgery
Artificial insemination:
-intravaginal insemination (IVI)
-intra-cervical insemination (ICI)
-intrauterine insemination (IUI)
Note: We cover infertility services for members between twenty-one
(21) and forty-four (44) years of age. You must obtain a referral from
your PCP in order to see a Plan specialist for infertility services.

Note-We cover fertility drugs such as HCG, Progesterone injections,
Menotropins, Urofollitropins, Serophene (Clomid) under the
prescription drug benefits (Section 5( f)). You pay the applicable
prescription drug copays.

$15 per office visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:

-in-vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer

Services and supplies related to excluded ART procedures
Cost of donor sperm or sperm banking
Cost of donor egg
Gender Selection
External pump for administration of infertility drugs
Reversal of vasectomy or tubal ligation

All charges. 20.
20 Page 21 22
2003 MVP Health Care Section 5( a) 18
Allergy care You pay
Testing and treatment
Allergy injection
$15 per office visit

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

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/ Tissue Transplants on page 24.

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

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment.
Call 1-888-687-6277 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

$15 per office visit

Not covered: treatment that is not authorized or provided by a Plan
doctor
All charges.

Physical and occupational therapies
Two consecutive months per acute 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.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 36 sessions

$15 per outpatient visit
Nothing per visit during covered
inpatient admission

Not covered:
long-term rehabilitative therapy exercise programs
All charges. 21.
21 Page 22 23
2003 MVP Health Care Section 5( a) 19
Speech Therapy You pay
60 visits per calendar year for both habilitative and rehabilitative. $15 per office visit

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 (see Preventive care, children). Exams for screening purposes only. $15 per office visit

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

All charges.

Vision services (testing, treatment, and supplies)
Routine eye refractions, covered once every 24 months
Note: You do not need a referral for the refraction exam. You will
need a referral from your Primary Care Physician for any eye exams
involving a diagnosed or suspected illness.

$15 per office visit

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

All charges.

Foot care
Non-routine foot care such as care that you receive when you are under
active treatment for a metabolic or peripheral vascular disease, such as
diabetes. You are limited to ten visits per year.

$15 per office visit

Not covered:
Routine foot care such as 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)
Foot orthotic devices such as arch supports and shoe inserts

All charges. 22.
22 Page 23 24
2003 MVP Health Care Section 5( a) 20
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

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

20% of charges

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic repair or replacements unless authorized by MVP
Wigs and other hair prostheses

All charges. 23.
23 Page 24 25
2003 MVP Health Care Section 5( a) 21
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds
Wheelchairs;
Crutches;
Walkers;
Braces

20% of charges

Blood glucose monitors; and
Insulin pumps.
20% of the cost or a $15 copay
(whichever is less) for services and
equipment necessary for the treatment
of diabetes

Note: Call us at 888/ 687-6277 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Note: Services and equipment necessary for the treatment of diabetes is
limited to a 31-day supply per each copay.

Not covered:
Motorized wheel chairs
Exercise Equipment
Car or Van Lifts
Hearing aids
Personal comfort items

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.

$15 per visit 24.
24 Page 25 26
2003 MVP Health Care Section 5( a) 22
Not covered:
nursing care requested by, or for the convenience of, the patient or the patient's family;

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

All charges.

Chiropractic You pay
Spinal manipulation only.
Note: You must obtain a referral from your primary care physician
$15 per office visit

Alternative treatments
We do not cover alternative treatments including but not limited to:
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback

All charges

Educational classes and programs
Coverage is limited to:

Diabetes self-management
You may attend educational classes in most participating Plan hospitals
please contact the hospital directly for details. You need a referral from
your PCP to attend a class.

$15 copay 25.
25 Page 26 27
2003 MVP Health Care 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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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.
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 charge (i. e.

hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR 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. Will only be covered with Plan
preauthorization and when medically necessary.

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

$15 per office visit

Surgical procedures continued on next page. 26.
26 Page 27 28
2003 MVP Health Care 24 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization
Treatment of burns

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

$15 per office visit

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

All charges.

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

-the condition can reasonably be expected to be corrected by such
surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

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 this procedure
performed on an inpatient basis and remain in the hospital up to
48 hours after the procedure.

Note: See Orthopedic and Prosthetic Devices for information on the
actual breast prostheses. You pay 20% of charges for breast prostheses.

$15 per office visit

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 MVP Health Care 25 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to nondental treatment:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

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

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

$15 per office visit

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

Any dental care involved in the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges.

Organ/ tissue transplants
Non-experimental transplants are limited to:
Cornea
Heart
Kidney
Liver
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

Nothing
Note-Hospital admissions are
subject to a $240.00 inpatient
copay. See Section5( c).

Organ/ tissue transplants continued on next page 28.
28 Page 29 30
2003 MVP Health Care 26 Section 5( b)
Organ/ tissue transplants (Continued) You pay
Note: You must receive prior approval from the MVP Medical
Director.

Note: National Transplant Program (NTP) We contract with Centers of
Excellence network for all transplant services. The network we use is the
United Resource Network (URN). URN selects facilities for participation in
their network by using criteria such as: transplant experience, transplant
volume, survival rates, geographic location, and medical education of the
center and its' staff.

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

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in

Hospital (inpatient)
Hospital outpatient department
Ambulatory surgical center

Nothing

Professional services provided in
Skilled nursing facility
Office

$15 per visit 29.
29 Page 30 31
2003 MVP Health Care 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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A N
T

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

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

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.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated

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

YOUR PHYSICIAN MUST RECEIVE OUR APPROVAL FOR ALL HOSPITAL STAYS. Please refer to Section 3 for a list of services that require

preauthorization.

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

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

Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home

$240 per admission

Not covered:
Custodial care, rest cures, domiciliary or convalescent 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 MVP Health Care 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, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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

$100 or 20% (which ever is less)
per outpatient surgery or
procedure

Not covered: Blood and blood derivatives not replaced by the member
Personal comfort items such as telephone and television
All charges

Extended care benefits/ skilled nursing care facility benefits
Extended care benefits/ skilled nursing care facility benefits: We cover up
to 45 days per calendar year when full-time skilled nursing care is
necessary. All necessary services are covered including:

Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan
doctor.
Note: When there are no skilled nursing facilities near you, we may
approve skilled nursing care in a hospital. When this happens, the inpatient
hospital days count toward your 45-day skilled nursing facility annual
maximum benefit.

Nothing, after the $240 inpatient
hospital copay

Not covered:
custodial care, rest cures, domiciliary or convalescent care
All charges 31.
31 Page 32 33
2003 MVP Health Care 29 Section 5( c)
Hospice care You pay
We cover up to 210 days of hospice care for a terminally ill member in the
home or a hospice facility. 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. Covered services must be
billed by the hospice and include:

Inpatient hospice care
Outpatient care, including drugs and medical supplies
Five visits for bereavement counseling of the immediate family

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance services when appropriate, medically necessary, and ordered or authorized by a Plan doctor Nothing 32.
32 Page 33 34
2003 MVP Health Care 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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A N
T

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

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:
Please call your primary care doctor when you are in an emergency situation. In extreme emergencies, if you
are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to
the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan
member so they can notify us. You or a family member should notify us within 48 hours by calling 1-888-
687-6277. It is your responsibility to ensure that the Plan has been timely notified. If you need to be
hospitalized, we must be notified within 48 hours or on the first working day following your admission, unless
it was not reasonably possible to notify the Plan within that time.

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

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition. However, follow-up
care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers. 33.
33 Page 34 35
2003 MVP Health Care 31 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $15 per office visit

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

$50 per urgent care center
visit or hospital
emergency room visit
Note: We waive this
copay if you are
admitted to the hospital

Not covered:
Elective care or non-emergency care
Prescriptions written by non-Plan doctors

All charges.

Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Nothing

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
Prescriptions written by non-Plan doctors

All charges.

Ambulance
Professional ambulance service when medically appropriate and
ordered or authorized by a Plan doctor

See 5( c) for non-emergency service.

Nothing

Not covered: air ambulance if not medically necessary All charges. 34.
34 Page 35 36
2003 MVP Health Care 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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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.

coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Call us at 1-888-687-6277 before seeking mental health and substance abuse care. 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

$15 per visit

Mental health and substance abuse benefits -Continued on next page 35.
35 Page 36 37
2003 MVP Health Care 33 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing if you receive these
services during your office
visit; otherwise, $15 per visit

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

$240 per inpatient hospital
admission or

$100 or 20% (whichever is
less) for outpatient procedures

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
Call our Member Services Department at 1-888-687-6277 before seeking treatment.
Limitation We may limit your benefits if you do not obtain a treatment plan. 36.
36 Page 37 38

2003 MVP Health Care 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
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O R

T
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.
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.
We administer an open prescription drug formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may
prescribe a name brand drug from a formulary list. This list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower cost. To order a
copy of our prescription drug formulary please call us at 1-888-687-6277.

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There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail for a
covered maintenance medication. Please call our Member Services Department at 1-888-687-6277
or visit our website at www. mvphealthcare. com to determine whether or not a maintenance
medication is available through our mail order program.
We use a formulary. Our formulary is a list of medications that we approved for your use. Our Plan doctors prescribe drugs and Plan pharmacies dispense them in accordance with our formulary.

A committee of primary care and specialty physicians, pharmacists and other healthcare professionals
used clinical data to develop our formulary. They periodically review it and choose the most
effective drugs for treating illness and disease. We will cover non-formulary drugs when prescribed
by a Plan doctor. If you have questions about our formulary, please visit our website at
www. mvphealthcare. com or call our Member Services Department at 1-888-687-6277
These are the dispensing limitations.

-You may obtain up to a 30-day supply per copay from a participating Retail pharmacy.
-Under our mail-order program, we limit prescription drug amounts to a 90-day supply per copay.
You may contact our Member Services Department at 1-888-687-6277 or visit our website at
www. mvphealthcare. com to find out if a certain drug is covered through our mail order
program. You will also need an order form which you can download from our website to use this benefit. Unfortunately, all drugs are not available through the mail-order program.

-Ask your doctor to write two prescriptions when your doctor prescribes a drug eligible for the mail
order program one for up to 30-days to be filled at your local pharmacy, and one to last up to 90-
days which should be filled through familymeds. com. Complete and sign an order form and attach
the 90-day prescription. Then, mail everything to Express Scripts Mail Pharmacy Service 3684
Marshall Lane Bensalem, PA 19020-5914

Why use generic drugs?
You can save money by using generic drugs. However, you and your physician have the option to
request a name-brand if a generic option is available. Using the most cost-effective medication
saves money.

Prescription drug benefits begin on the next page. 37.
37 Page 38 39
2003 MVP Health Care 35 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a
Plan physician and obtained from a Plan pharmacy or through our
mail order program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded

below.
Enteral formulas when medically necessary (contact Plan for details)
Drugs for sexual dysfunction (see note below)
Contraceptive drugs

Note: We reserve the right to limit or restrict coverage of certain
prescription drugs (i. e. drugs to treat sexual dysfunction) in accordance
with policies governing medical necessity and quality of treatment.
Please contact Plan for dose limits and prior authorization.

Note: You may obtain up to a 90-day supply of maintenance medication
by Mail-order . All prescription drugs are not available through mail.
Infertility prescriptions shall only be available for members between
twenty-one (21) and forty-four (44) years of age.

Retail Pharmacy
$ 5 per Generic prescription unit
or refill from a participating
Retail pharmacy

$ 20 per Brand Name
prescription unit or refill from a
participating Retail pharmacy

$ 40 per Non-Formulary
prescription unit or refill from a
participating Retail pharmacy

Note: We do not waive the name
brand copay when a generic drug
is not available.

Mail-order Pharmacy (approved
maintenance medication only)

$10 per Generic prescription for
up to a 90-day supply by Mail
Order

$40 per Brand Name prescription
for up to a 90-day supply by Mail
Order

$80 per Non-Formulary
prescription for up to a 90-day
supply by Mail Order

Diabetic supplies such as insulin, needles and syringes, glucose test tablets and test tape, Benedict's solution or equivalent, glucose
monitors and acetone test tablets (31-day supply per dispensing)
Lesser of $15 or 20% for the cost
of insulin and other diabetic
supplies

Disposable needles and syringes for the administration of covered medications, as well as dressings and antiseptics 20% copay for disposable needles and syringes needed to
inject covered prescription
medications
Not covered:
Drugs and supplies for cosmetic purposes Drugs to enhance athletic performance

Drugs obtained at a non-Plan pharmacy (except for out-of-area emergencies)
Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Refills due to a lost or misused prescription drug supply
Drugs used in connection with the provision of a non-covered service or benefit

All Charges 38.
38 Page 39 40
2003 MVP Health Care 36 Section 5( g)
Section 5 (g). Special Features
Feature Description
After Hours MVP Unit For any of your health concerns, or if you have a question concerning your benefits, from 8: 00 am Midnight, 7 days a week, you may call
1-888-687-6277 and talk with a registered nurse or Member Services
Representative who will discuss treatment options and answer your
health questions.

Services for deaf and hearing impaired If you are hearing impaired and wish to speak with a Member Services Representative please first contact a relay operator at 1-800-662-1220
and then they will call our Member Services Unit (at 1-888-687-6277)
and help you during your conversation with our representative.

High risk pregnancies
MVP's Little Footprints is a special program for women who have had a
problem with a past pregnancy or who are at risk for having problems
during their current pregnancy. You must have at least three months left
in the pregnancy to be eligible to participate. As part of this program one
of our prenatal nurses will call you every month to discuss the progress of
your pregnancy and what can be done to help ensure a healthy pregnancy
and to answer any questions she may have.

You or your physician may contact us concerning this program. If you
feel you might benefit from this program please contact our Member
Services Department at 1-888-687-6277.

Travel benefit/ services overseas As an MVP member you are covered for emergency care anywhere in the world. If you or your family member ever have a medical
emergency, either outside of our service area or outside of the United
States, please go to the nearest hospital or medical facility. Please
contact our Member Services Department as soon as possible at 1-888-
687-6277 so that we may arrange for any necessary follow-up care that
you may need.

Out-of-area student benefit We offer extended out-of-area coverage for your dependent children up to age 22 as long as your child is a full-time student at an accredited
college (full-time means 12 or more credit hours per semester). This
benefit covers your child for care and services outside of our service
area that he or she would normally obtain within our service area such
as sick visits, outpatient surgery, and physical therapy. This benefit
does not include coverage for routine preventive care such as physical
exams, immunizations, and elective inpatient hospital services.

This benefit is limited to $2,500 maximum per year. We will
reimburse you for the cost of covered services minus your applicable
copay. You must submit claims to us within one year of the date of
service for us to consider them. Submit claims to: MVP Health Plan,
PO Box 2207, Schenectady, NY 12301. If you have any questions
about claims submission or this out-of-area benefit, please contact our
Member Services Department at 1-888-687-6277. 39.
39 Page 40 41
2003 MVP Health Care 37 Section 5( h)
Section 5 (h). Dental benefits
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Our preventive dental benefits are only for children under age 19.
You may bring your child to any dentist that you wish to receive these covered services
We cover hospitalization for dental procedures only when a non-dental 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.

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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. You pay nothing. Treatment must be
performed within 12 months of the accident.

Nothing for physician's services
Note: Hospital services are subject
to the $240 inpatient hospital
copay or the $100 copay or 20%
(whichever is less) for outpatient
services.

Not Covered:
Dental services not shown as covered
Dental services that result from injury while eating

All Charges

Dental Benefits
Service You pay

The following preventive and diagnostic services are covered for Plan
members under age 19:

One initial oral exam followed by periodic exams, once every six months
Bite wing x-rays, once every six months
Full mouth x-rays and panoramic x-rays, once every 36 months
Routine cleaning, scaling, and polishing of teeth, once every six months

Fluoride treatments, once every six months, to age 16
Pulp vitality testing and diagnostic casts, as needed
Space maintainers and recementation there of, as needed
Intra-oral and periepical x-rays, as needed
Sealants once per tooth per child (only covered to age 16)

$10 per office visit

Dental benefits -Continued on next page 40.
40 Page 41 42
2003 MVP Health Care 38 Section 5( h)
Dental Benefits (Continued) You pay
Note: You may see the dental provider of your choice to receive
benefits. Your dentist may require you to pay for the services at the
time they are rendered, in which case you should submit a claim to us
for full reimbursement, less your $10 copay. You may obtain a claim
form by calling us at 888/ 687-6277. Claim forms should be mailed to:
Dental Benefit Providers, 7200 Wisconsin Ave, Suite 800, Bethesda,
Maryland, 20814.

If you do not file your claims promptly, we will still accept them if they
are filed as soon as reasonably possible. We will neither accept nor
provide coverage for claims that are submitted later than one (1) year
after a service is performed.

Not covered:
Other dental services not shown as covered
Services which are not approved by the Council of Dental Therapeutics of the America Dental Association (ADA)

Services rendered by a medical department, clinic, or similar facility of the child's employer, labor union, mutual benefits
association, or other similar group
Charges for dental appointments that are not kept
Dental implants

All charges 41.
41 Page 42 43

2003 MVP Health Care Section 6 39
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.

Expanded vision care
You are entitled to various discounts on designated eyewear purchases just by being an MVP Member. Please see the
MVP Health Plan Something Extra brochure for listings of participating optical shops, and the type of discounts that
they offer.

Fitness programs
Also by being an MVP member you may receive discounts from local Health and Fitness Clubs and Weight Control
Centers on designated enrollment, membership or registration fees. Please see the MVP Health Plan Something Extra
brochure for a listing of participating Health and Fitness Clubs and Weight Control Centers.

Safety equipment
MVP Health Plan offers you discounts on safety equipment for the home and car, and for personal use when
purchased through our Something Extra program. Items such as bicycle helmets, child car seats and smoke detectors
are available by calling our Member Services Department at 888/ 687-6277 or by visiting our website at
www. mvphealthcare. com .

If you have any questions about any of these benefits, please contact the MVP Member Services Department at
888/ 687-6277.

Lasik Eye Surgery
You are entitled to discounts on lasik eye surgery just by being an MVP Member. Please see the MVP Health Plan
Something Extra brochure for listings of participating lasik eye surgeons, and the type of discounts that they offer.

Acupuncture
You are entitled to various discounts on acupuncture services just by being an MVP Member. Please see the MVP
Health Plan Something Extra brochure for listings of participating acupuncturists, and the type of discounts that they
offer. 42.
42 Page 43 44
2003 MVP Health Care Section 6 40
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. 43.
43 Page 44 45
2003 MVP Health Care Section 7 41
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

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

Medical, hospital and In most cases, providers and facilities file claims for you. Physicians prescription drug benefits must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-888-687-6277.

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: MVP Health Care
625 State Street
Schenectady, NY 12305

Dental services For children's preventive dental benefit, the dentist may have you pay the cost of the entire visit. If so, please call Member Services at 1-888-687-
6277 to obtain a claim form. As long as the visit was for covered care,
you will be reimbursed the cost of the visit less your $10 copay.

Submit your claims to: Dental Benefit Providers 7200 Wisconsin Avenue, Suite 800

Bethesda, MD 20814
We will not accept, or provide coverage for claims that are submitted
more than one year after the date of service.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 44.
44 Page 45 46
2003 MVP Health Care 42 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: MVP Health Plan, 625 State Street, Schenectady, NY 12305; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits
Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630. 45.
45 Page 46 47
2003 MVP Health Care 43 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 1-
888-687-6277 and we will expedite our review; or

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

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 46.
46 Page 47 48
2003 MVP Health Care 44 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 The Original Medicare Plan (Original Medicare) is available everywhere (Part A or Part B) in the United States. It is the way everyone used to get Medicare benefits and is
the way most people get their Medicare Part A and Part B benefits now. You may
go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are not covered
under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you till need
to follow the rules in this brochure and use our providers in order for us to
cover your care. We will not waive any of our copayments or coinsurance. 47.
47 Page 48 49
2003 MVP Health Care 45 Section 9
Claims process when you have the Original Medicare Plan You probably
will never have to file a claim form when you have both our Plan and the
Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your
claim first. In most cases, your claims will be coordinated automatically
and we will then provide secondary benefits for covered charges. You will
not need to do anything. To find out if you need to do something to file
your claims, call us at 1-888-687-6277 or send us questions via our website
at www. mvphealthcare. com. 48.
48 Page 49 50
2003 MVP Health Care 46 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.

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

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

2) Are an annuitant,

3) Are a reemployed annuitant with the Federal government when a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you)

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

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

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

(except for claims
related to Workers'
Compensation.)

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

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

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD,

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

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

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 49.
49 Page 50 51

2003 MVP Health Care 47 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 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 or the managed care plan's network
and/ or service area (if you use our Plan providers), but we will not waive any
of our copayments, coinsurance, or deductibles. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.

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

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

TRICARE 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 CAMPVA Health Benefits Advisor if you
have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in 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 under the program.

Workers' Compensation We do not cover services that: 50.
50 Page 51 52
2003 MVP Health Care 48 Section 9
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, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital for injuries care for injuries or illness caused by another person, you must reimburse us for
any expenses we paid. However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 51.
51 Page 52 53
2003 MVP Health Care 49 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 Includes any service which can be learned and provided by an average individual who does not have medical training. Examples of custodial

care include: help with walking or getting out of bed, or assistance in
daily living activities such as feeding, dressing, and personal hygiene.
Custodial care that lasts beyond 90 days could be considered Long Term
Care. Please refer to the Long Term Care section in the back of this
brochure.

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

those services. See page 12.
Experimental or investigational services Services that are generally not accepted by informed health care

providers in the United States as effective in treating the condition for
which their use is being recommended.

We will only provide coverage for these type of services if the proposed
treatment has shown promising results in treating the underlying
condition through a nationally recognized program, and a group of
experts has reviewed the proposed treatment and thinks that it is
appropriate.

If an appeal agent, outside of our Plan approves coverage for
experimental or investigational services for you, and you would be part
of a scientific trial or test, than our Plan would only provide limited
benefits for these services, and you would be responsible for the rest.

Group health coverage Coverage you are eligible to receive through your employer. This Plan is offered as group health coverage to you, and all other eligible employees

of the Federal Government.
Medical necessity Covered services that we determine are necessary to prevent, detect, correct, or cure conditions that cause you or a family member acute

suffering, endanger your life, result in illness, interfere with your
capacity for normal activity or threaten you with a significant medical
handicap

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine and base our allowance

on the reasonable and customary charge that most providers would bill
you for the service, procedure or office visit in question. Our
participating providers have agreed to accept payment from us in full
you and your family members are only responsible for your copay.

Us/ We Us and we refer to MVP Health Plan
You You refers to the enrollee and each covered family member. 52.
52 Page 53 54

2003 MVP Health Care 50 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about 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 for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

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

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 53.
53 Page 54 55
2003 MVP Health Care 51 Section 11
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:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option,
if you have a Self only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing

office will change your enrollment to Self and Family in the same
option of the same plan; or

if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to

Self and Family in the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at
least one child 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 you 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. 54.
54 Page 55 56
2003 MVP Health Care 52 Section 11
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 of coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

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

Converting to individual coverage You may convert to a non-FEHB individual policy if:

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 is Group Health Plan Coverage a 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 55.
55 Page 56 57

2003 MVP Health Care 53 Section 11
waiting periods, limitations, or exclusions for health related conditions
based on the information in the certificate, as long as you enroll within
63 days of losing coverage under this plan. If you have been enrolled
with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27. Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked questions. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 56.
56 Page 57 58

2003 MVP Health Care 54 Section 11
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. 57.
57 Page 58 59
2003 MVP Health Care 55 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 37 Allergy tests 18
Alternative treatment 22 Ambulance 29
Anesthesia 26 Autologous bone marrow
transplant 25 Biopsies 23
Blood and blood plasma 27 Casts 23
Changes for 2001 8 Chemotherapy 18
Childbirth 16 Cholesterol tests 15
Claims 13, 36, 38 Coinsurance 12
Colorectal cancer screening 15 Congenital anomalies 23, 24
Contraceptive devices and drugs 16, 35 Coordination of benefits 44
Covered charges 12 Covered providers 9-10
Crutches 21
Deductible 12 Definitions 49

Dental care 37, 38 Diagnostic services 14
Disputed claims review 42, 43 Donor expenses (transplants) 26
Dressings 28, 35 Durable medical equipment
(DME) 21 Educational classes and programs 22
Effective date of enrollment 51 Emergency 30, 31, 36
Experimental or investigational 49 Eyeglasses 19
Family planning 16, 17 Fecal occult blood test 15
General Exclusions 40

Hearing services 19 Home health services 21
Hospice care 29 Home nursing care 21
Hospital 27, 28 Immunizations 16, 36
Infertility 17 In-hospital physician care 27
Inpatient Hospital Benefits 27 Insulin 21, 35
Laboratory and pathological services 15, 27
Machine diagnostic tests 14, 15 Magnetic Resonance Imagings
(MRIs) 15 Mail Order Prescription Drugs 35
Mammograms 15 Maternity Benefits 16
Medically necessary 49 Medicaid 48
Medicare 44-47 Members 47
Mental Conditions/ Substance Abuse Benefits 32, 33
Newborn care 16 Non-FEHB Benefits 39
Nurse Licensed Practical Nurse 21
Nurse Anesthetist 27 Registered Nurse 21, 36
Nursery charges 16 Obstetrical care 16
Occupational therapy 18 Office visits 14
Oral and maxillofacial surgery 25 Orthopedic devices 20
Out-of-pocket maximum 12 Outpatient facility care 28, 33
Oxygen 21, 23, 29 Pap test 15

Physical examination 16, 37 Physical therapy 19
Pre-admission testing 23 Precertification 23
Preventive care, adult 15 Preventive care, children 16
Prescription drugs 34, 35 Preventive services 15, 16
Prior approval 23 Prostate cancer screening 15
Prosthetic devices 20 Psychologist 32
Psychotherapy 32 Radiation therapy 18
Rehabilitation therapies 18 Renal dialysis 18
Room and board 27 Second surgical opinion 14
Skilled nursing facility care 28 Speech therapy 19
Splints 27 Sterilization procedures 16,
24 Substance abuse 32, 33
Surgery 23-29 Anesthesia 26-28
Oral 25 Outpatient 23
Reconstructive 24 Syringes 35
Temporary continuation of coverage 52
Transplants 26, 26 Treatment therapies 18
Vision services 19 Well child care 16
Wheelchairs 21 Workers' compensation 48
X-rays 15, 27, 37 58.
58 Page 59 60
2003 MVP Health Care 56
NOTES: 59.
59 Page 60 61
2003 MVP Health Care 57
NOTES 60.
60 Page 61 62
2003 MVP Health Care 58
NOTES 61.
61 Page 62 63
2003 MVP Health Care 59
NOTES: 62.
62 Page 63 64
60
Summary of benefits for the MVP Health Plan -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................. $15 per office visit 13

Services provided by a hospital:
Inpatient............................................................................................
Outpatient .........................................................................................
$240 per admission copay
$100 or 20% copay per surgery
(which ever is less)

27
28

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

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

$15 per office visit or $50 per
Urgent Care Center or Hospital
Emergency Room

Nothing

31
31
Mental health and substance abuse treatment ....................................... Regular cost sharing. 32
Prescription drugs:
Retail Pharmacy (up to a 30 day supply) ..............................................

Mail Order (up to a 90 day supply).......................................................
$5 Generic/$ 20 Name Brand/$ 40
Non-Formulary per prescription
unit or refill

$10 Generic/$ 40 Name Brand/$ 80
Non-Formulary per prescription
unit or refill

Dental Care
Preventive Care for children up to age 19.........................................
Accidental Injury ..............................................................................
$10 per office visit
Nothing for physician services
(see inpatient/ outpatient hospital
benefits above)

Vision Care (one covered eye exam every 24 months)..................... $15 per office visit 19
Special features: MVP After Hours Unit; Little Footprints; Out-area-student benefit; Travel benefit/ services
overseas
36

Protection against catastrophic costs
(your out-of-pocket maximum)......................................................... Stated copays for covered benefits 12 63.
63 Page 64
61
2003 Rate Information for
MVP Health Plan

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB guides
are published for Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).

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

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

Eastern New York
Self Only GA1 $ 89.09 $29.70 $193.04 $64.34 $105.43 $13.36

Self and Family GA2 $ 230.12 $ 76.71 $498.60 $166.20 $272.31 $34.52
Central New York

Self Only M91 $ 96.05 $ 32.01 $208.10 $ 69.36 $113.65 $ 14.41

Self and Family M92 $248.06 $ 82.68 $537.45 $179.15 $293.53 $37.21
Mid-Hudson

Self Only MX1 $102.50 $ 34.17 $222.09 $ 74.03 $121.29 $15.38

Self and Family MX2 $249.62 $103.37 $540.84 $223.97 $294.70 $58.29
Vermont

Self Only VW1 $109.30 $ 67.06 $236.82 $145.29 $129.03 $47.33

Self and Family VW2 $249.62 $205.87 $540.84 $446.06 $294.70 $160.79 64.

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