Pages 1--64

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

This Plan has new health plan accreditation from NCQA. See the 2003 Guide for more
information on accreditation.

Enrollment codes for this Plan: Albany Capital District, Hudson Valley Area
X41 Self Only X42 Self and Family

New York City Area 6V1 Self Only
6V2 Self and Family

For changes in benefits,
see page 11. 1.
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2003 GHI HMO 2.
2 Page 3 4
2003 GHI HMO
Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to
tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected, To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and

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

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

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM
has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal

medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that

you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
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. 3.
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2003 GHI HMO
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.
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2003 GHI HMO
Table of Contents
Introduction................................................................ 7
Plain Language .............................................................. 7
Stop Health Care Fraud!................................................................................................ 7
Section 1. Facts about this HMO plan.......................................................................................................................... 9
How we pay providers ................................................................................................................................ 9
Who provides my health care?.. 9
Your Rights ................................................................................................................................................. 9
Service Area.............................................................................................................................................. 10
Section 2. How we change for 2003............................................................... 11
Program-wide changes .............................................................................................................................. 11
Changes to this Plan .................................................................................................................................. 11
Section 3. How you get care ...................................................................................................................... 12
Identification cards.................................................................................................................................... 12
Where you get covered care ...................................................................................................................... 12
Plan providers ..................................................................................................................................... 12
Plan facilities ...................................................................................................................................... 12
What you must do to get covered care ...................................................................................................... 12
Primary care........................................................................................................................................ 12
Specialty care...................................................................................................................................... 13
Hospital care ....................................................................................................................................... 13
Circumstances beyond our control ............................................................................................................ 14
Services requiring our prior approval........................................................................................................ 14
Section 4. Your costs for covered services................................................................................................................. 16
Copayments ........................................................................................................................................ 16
Deductible........................................................................................................................................... 16
Coinsurance ........................................................................................................................................ 16
Your catastrophic protection out-of-pocket maximum ............................................................................. 16
Section 5. Benefits.............................................................. 17
Overview................................................................................................................................................... 17
(a) Medical services and supplies provided by physicians and other health care professionals .......... 18
(b) Surgical and anesthesia services provided by physicians and other health care professionals....... 28
(c) Services provided by a hospital or other facility, and ambulance services..................................... 32
(d) Emergency services/ accidents ........................................................................................................ 35
(e) Mental health and substance abuse benefits ................................................................................... 37

5 5.
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2003 GHI HMO
Table of Contents (Continued)
(f) Prescription drug benefits .............................................................................................................. 40
(g) Special features ................................................................................................................................ 44
Flexible benefits option
(h) Dental benefits................................................................................................................................ 45
Section 6. General exclusions --things we don't cover............................................................................................. 46
Section 7. Filing a claim for covered services............................................................................................................ 47
Section 8. The disputed claims process...................................................................................................................... 48
Section 9. Coordinating benefits with other coverage ............................................................................................... 50
When you have other health coverage....................................................................................................... 50
What is Medicare ............................................................................................................................... 50
Medicare managed care plan ............................................................................................................. 53
TRICARE and CHAMPVA............................................................................................................... 53
Workers' Compensation ..................................................................................................................... 54
Medicaid ............................................................................................................................................ 54
Other Government agencies ............................................................................................................... 54
When others are responsible for injuries ............................................................................................ 54
Section 10. Definitions of terms we use in this brochure ........................................................................................... 55
Section 11. FEHB facts .............................................................................................................................................. 57
Coverage information................................................................................................................................ 57
No pre-existing condition limitation ................................................................................................. 57
Where you get information about enrolling in the FEHB Program................................................... 57
Types of coverage available for you and your family ....................................................................... 57
Children's Equity Act...................................................................................................................... 57
When benefits and premiums start .................................................................................................... 58
When you retire................................................................................................................................ 58
When you lose benefits ............................................................................................................................. 58
When FEHB coverage ends .............................................................................................................. 58
Spouse equity coverage.................................................................................................................... 58
Temporary Continuation of Coverage (TCC) .................................................................................. 59
Converting to individual coverage ................................................................................................... 59
Getting a Certificate of Group Health Plan Coverage ...................................................................... 59
Long term care insurance is still available .................................................................................................................. 61
Index ............................................................................................................................................................. 62
Summary of benefits ................................................................................................................................................... 63
Rates.. Back cover

6 6.
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2003 GHI HMO 7 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of GHI HMO under our contract (CS2655) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for GHI HMO administrative offices is:

GHI HMO 25 Barbarosa Lane
Kingston, NY 12401
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003 and changes are summarized on page 11. 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 GHI HMO.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let 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. 7.
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2003 GHI HMO 8 Introduction/ Plain Language/ Advisory
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 877-244-4466 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.
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2003 GHI HMO 9 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments and 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.

Who provides my health care?
GHI HMO, an individual practice prepayment plan, is a New York State certified, for-profit community-sponsored, primary care network model Health Maintenance Organization (HMO).

GHI HMO organizes preventative and routine health care as well as needed services for serious illness or injury. Care and coverage is provided by approximately two thousand nine hundred and ninety nine (2,999) individually affiliated
primary care doctors, seventy (70) area hospital, eleven thousand nine hundred and eighty eight (11,988) local specialist.

GHI HMO administrative offices are located at 25 Barbarosa Lane and 120 Wood Road, Kingston, NY 12401; and at 80 Wolf Road, Albany, NY 12205. Affiliated primary care doctors, specialists and other health care providers are
conveniently located throughout the service area.

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.
Years in existence -GHI HMO is a subsidiary of GHI, the largest, not-for-profit health services corporation operating state-wide in New York, and has been operating in 26 counties of NYS since July 1999.
Company profit status -GHI HMO is a for-profit HMO.
Drug Formulary -GHI HMO offers an open drug formulary.
Percentage of Board Certified Physicians -86% of GHI HMO physicians are Board Certified.

If you want more information about us, call 1-877-244-4466, or write to GHI HMO, Customer Service, 120 Wood Road, Kingston, NY 12401. You may also contact us by fax at (845) 334-8950 or visit our website at
http:// www. ghihmo. com. 9.
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2003 GHI HMO 10 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:

Albany Capital District Area: Albany, Broome, Columbia, Delaware, Fulton, Greene, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington Counties.
Hudson Valley Area: Dutchess, Orange, Putnam, Rockland, Sullivan, and Ulster Counties.
New York City Area: Bronx, Brooklyn, Manhattan, Nassau, Queens, Richmond, Suffolk and Westchester.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will only pay 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 should 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.
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2003 GHI HMO 11 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes

A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 40.0% for Self Only or 46.4% for Self and Family for Code 6V. Your share will increase by 22.6% for Self Only or 14.2% for Self and Family for Code X4.

This plan is now offered to Federal employees who reside in Nassau, Richmond and Suffolk Counties. 11.
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2003 GHI HMO 12 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-877-244-
4466 or write to us at GHI HMO, Customer Service, 120 Wood Road, Kingston, NY 12401.

Where you get covered care You get care from " Participating Plan providers" and "Participating Plan facilities." You will only pay copayments, or coinsurance, and you will
not have to file claims
Plan providers Plan providers are physicians, including primary care physicians and specialists 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 directory is divided alphabetically by county. Primary
Care Physicians are listed first, Specialty Care Physicians are listed second and all other providers (ancillary) are listed third under each
county. The list is also on our website www. ghihmo. 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.

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care. Primary care physicians are listed in our
provider directory and also on our web site. You may also call our Customer Service Department (1-877-244-4466) and they may assist you
in selecting a provider near your home or office.

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

What you must do to get covered care 12.
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2003 GHI HMO 13 Section 3
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may see your OB/ GYN twice a year without a referral and a participating
optometrist for a routine vision exam annually without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will work with specialists to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

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

-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or if we drop out of
the program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-877-244-4466. If you
are new to the FEHB Program, we will arrange for you to receive care. 13.
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2003 GHI HMO 14 Section 3
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 prior authorization from the GHI HMO Medical
Director. These services may include but are not limited to:
a. Specialist Referrals b. Ambulatory Surgery
c. Hospital/ Nursing Home admissions and any care rendered during stay d. Physical Therapy and Cardiac Rehabilitation
e. Home Care and Hospice f. Durable Medical Equipment over $250 and all Orthotics
g. Non-Participating Providers h. Member requests for experimental or investigative health care
services. i. Mental Health and Substance Abuse (MH/ SA)

GHI HMO may request supporting documentation from your provider to substantiate Medical Necessity of the requested service. All inpatient
admissions are reviewed to evaluate that the services are covered services, Medically Necessary and being rendered at the appropriate level
of care.
You have the right to designate a representative for utilization review. GHI HMO will notify you and your provider, by phone and in writing for
prospective, concurrent and retrospective utilization review decisions. If we deny services or won't pay your claim, you may ask us to
reconsider our decision. Your request must: 14.
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2003 GHI HMO 15 Section 3
1. Be in writing 2. Refer to specific brochure wording in explaining why you believe our
decision is wrong; and 3. Be made within six months from the date of our initial denial or
refusal. We many extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control.

We have 30 days from the date we receive your reconsideration request to:
1. Maintain our denial in writing; 2. Pay the claim;
3. Arrange for a health care provider to give you the service; or 4. Ask for more information

If we ask your medical provider for more information, we will send you a copy of our request. We must make a decision within 30 days after we
receive the additional information. If we do not receive the requested information within 60 days, we will make our decision based on the
information we already have. 15.
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2003 GHI HMO 16 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you
pay nothing.
Deductible We do not have a deductible
Coinsurance Coinsurance is the percentage of our negotiated that you must pay for your care.

Example: In our plan you pay 50% of our allowance for infertility services. Also, you pay 20% for durable medical equipment up to a
maximum of $1500 per person, per year.

Your catastrophic protection We do not have a catastrophic protection out-of-pocket maximum. out-of-pocket maximum 16.
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2003 GHI HMO 17 Section 5
Section 5. Benefits OVERVIEW
(See page 11 for how our benefits changed this year and page 63 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-877-2GH-IHMO or 1-877-244-4466 or at our website at www. ghihmo. com.

(a) Medical services and supplies provided by physicians and other health care professionals. 18-27
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
Diabetic supplies
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....................... 28-31
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services..................................................... 32-34
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Hospice care
Ambulance

(d) Emergency services/ accidents ........................................................................................................................ 35-36
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ................................................................................................... 37-39
(f) Prescription drug benefits ............................................................................................................................... 40-43
(g) Special features..................................................................................................................................................... 44
Flexible benefits option
Services for the deaf and hearing impaired
Center of Excellence for transplant/ heart surgeries
PHIP Personal Health Improvement Program (h) Dental benefits...................................................................................................................................................... 45

Summary of benefits.................................................................................................................................................... 63 17.
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2003 GHI HMO 18 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office

Physical examinations
Routine eye exams
Chiropractic services (with referral from PCP)

Routine cervical Cytology (PAP smear)
Well Baby and Well Child Care visits (including immunizations)

Mammogram Exam

$10 per office visit
Nothing

Professional services of physicians
In an urgent care center
Office medical consultations
Second surgical opinion

$10 per office visit

During a hospital stay
In a skilled nursing facility / 120 day limit

Nothing

Diagnostic and treatment services --Continued on next page 18.
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2003 GHI HMO 19 Section 5( a)
Diagnostic and treatment services (Continued) You pay
At Home

Not covered:
Routine foot care and foot orthotics
Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or
insurance, attending school or camp, or travel

Long-term rehabilitative therapy
Homemaker services

Nothing
All Charges

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
Non-routine mammograms
Ultrasound
Electrocardiogram and EEG

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

CAT Scans/ MRI
X-ray

$10 copay

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening -every five years starting at age 50
Routine Prostate Specific Antigen (PSA) -one annually for men age 40 and older

$10 per office visit

Routine pap test
Note: The pap test is covered if the office visit is on the same day the office copay still applies; see Diagnostic and Treatment on page 18.
$10 per office visit

Preventive Care -Adult --continued on next page 19.
19 Page 20 21
2003 GHI HMO 20 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

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, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccines, annually
Pneumococcal vaccine, age 65 and over

$10 per office visit

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

Examinations, such as:
-Eye exams through age 19 to determine the need for vision correction.

-Ear exams through age 19 to determine the need for hearing correction by a primary care physician

$10 per office visit

-Examinations done on the day of immunizations (under age 22)
-Well-child care charges for routine examinations, immunizations and care (under age 22)
Nothing 20.
20 Page 21 22
2003 GHI HMO 21 Section 5( a)
Maternity Care You Pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your

baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

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

other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.
Circumcision is a surgical benefit.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

$10 initial visit only, nothing for other pre and post natal visits.

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

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges 21.
21 Page 22 23
2003 GHI HMO 22 Section 5( a)
Infertility services You Pay
Diagnosis of infertility $10 per office visit
Treatment of Infertility, such as:
Artificial insemination
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)

50% of charges

Not covered:
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer
Services and supplies related to excluded ART procedures

Fertility Drugs
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment

Allergy injection
$10 per office visit

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

Diabetic Supplies and Equipment
Blood glucose monitors, data management systems, test strips for glucose monitoring, insulin, injection aids, cartridges for legally

blind, syringes, insulin pumps, insulin infusion devices, oral agents for controlling blood sugar
$10 copay for supplies 22.
22 Page 23 24
2003 GHI HMO 23 Section 5( a)
Treatment therapies You Pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 30.
Respiratory and inhalation therapy
Dialysis -hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Nothing

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 or have your physician call 1-877-2GH-IHMO or 1-
877-244-4466 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. This benefit is provided under our Prescription Drug Benefits. See Services requiring our prior approval in Section 3.

$10 copay for prescriptions

Not covered:
Treatment for experimental or investigational procedures
Therapy necessary for transsexual surgery

All charges 23.
23 Page 24 25
2003 GHI HMO 24 Section 5( a)
Physical and occupational therapies You pay
Up to two consecutive months per condition if significant improvement can be expected within two months for the following
services:
qualified physical therapists;
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. Physical and occupational therapy is provided on an inpatient or outpatient basis for up to two consecutive months per
condition if significant improvement can be expected within two months; you pay $10 copay per outpatient visit. Speech therapy is
limited to treatment if certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member
to achieve and maintain self-care and improved functioning in other activities of daily living.

Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 30 visits within 60 days.

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

Not covered:
Long term rehabilitative therapy
Exercise programs

All charges

Speech therapy
Up to two consecutive months per condition when medically necessary. $10 per office visit

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

Hearing testing for children through age 17 (see Preventive care, children)
$10 per office visit

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

All charges 24.
24 Page 25 26
2003 GHI HMO 25 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Eye exam to determine the need for vision correction (see preventive care)

Annual eye refractions
Note: See preventive care, children for eye exam

$10 per office visit

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

All charges

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

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

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

treatment is by open cutting surgery)

All charges

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

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see Section 5 (c) for payment information. See 5( b) for
coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) paid dysfunction syndrome.

20% coinsurance up to the Plan's maximum benefit of $1,500 per
person, per calendar year

Orthopedic and prosthetic devices -Continued on next page 25.
25 Page 26 27
2003 GHI HMO 26 Section 5( a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

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

All charges

Durable medical equipment (DME)
Rental or purchase, as determined by GHI HMO, 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;
standard wheelchairs;
apnea monitors;
nebulizers;
crutches and;
walkers;

Note: Call us at 1-877-244-4466 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 and will tell you more about this service when you call.

20% coinsurance up to the Plan's maximum benefit of $1,500 per
person, per calendar year

Not covered:
Motorized wheel chairs
Hearing aids

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.), or other

Home Health Care Agency personnel licensed vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Nothing

Home health services -Continued on next page 26.
26 Page 27 28
2003 GHI HMO 27 Section 5( a)
Home health services (Continued) You pay
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family;

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

All charges

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

Chiropractic services when authorized by PCP

$10 per office visit

Alternative treatments
Not covered:
Acupuncture services Naturopathic services
Hypnotherapy Biofeedback

All charges

Educational classes and programs
No Benefit 27.
27 Page 28 29
2003 GHI HMO 28 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

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

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

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

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

which services require prior authorization and identify which surgeries require prior authorization .

I M
P O
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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

Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns
Note: Generally we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for

a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing for hospital visits

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

All charges 28.
28 Page 29 30
2003 GHI HMO 29 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and

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

$10 per office visit; nothing for hospital visits

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

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

See above

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

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

All charges

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

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

Temporanmandibular Joint treatment (TMJ); and Other surgical procedures that do not involve the teeth or their
supporting structures.

$10 per office visit

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

as the periodontal membrane, gingiva, and alveolar bone)
All other procedures involving the teeth or intra-oral areas surrounding the teeth are not covered, including any dental care

involved in the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

All charges 29.
29 Page 30 31
2003 GHI HMO 30 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogenic (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
National Transplant Program (NTP) GHI HMO will cover transplants approved as safe and effective for a specific disease by

the Federal Drug Administration (FDA) or National Institute of Health or which GHI HMO's Medical Director determines is
medically necessary, appropriate and advisable on a case-by-case basis. GHI HMO will cover the medical and hospital services, and
related organ acquisition costs. Eligibility for transplants shall be determined solely by GHI HMO's Medical Director upon
recommendation of an Enrollee's Primary Care Physician. Eligibility for transplants must be approved in advance of surgery
by GHI HMO's Medical Director. Additionally, all transplants must be performed at hospitals specifically approved and designated by
GHI HMO to perform these procedures. Specialty physician experts from our designated centers of excellence will provide clinical
review and support to the Medical Director's decision.
Limited Benefits Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved

clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

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

Nothing

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

All Charges 30.
30 Page 31 32
2003 GHI HMO 31 Section 5( b)
Anesthesia You Pay
Professional services provided in

Hospital (inpatient)
Nothing

Professional services provided in
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 31.
31 Page 32 33
2003 GHI HMO 32 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

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

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by 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 GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services
require prior authorization precertification

I M
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T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets

special duty nursing and private rooms during inpatient hospitalization when medically necessary and approved by GHI
HMO Medical Director

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

Nothing

Inpatient hospital continued on next page. 32.
32 Page 33 34
2003 GHI HMO 33 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines Diagnostic laboratory tests and X-rays

Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items

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

Nothing

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

Private nursing care

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment if in
connection with an accidental injury to sound natural teeth within twelve (12) months of the accident, or in the judgement of GHI HMO's
Medical Director, a hazardous concurrent medical condition requires hospitalization. Hospital care is only available when a medical
condition necessitates such care. We do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges 33.
33 Page 34 35
2003 GHI HMO 34 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): Limited to 120 days per person per calendar year :

Bed, board and general nursing care Drugs, biologicals, supplies and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by your plan doctor.

Nothing

Not covered: custodial care All charges
Hospice care
Supportive and palliative care for the terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care
and family counseling. Benefits are limited to 210 days; bereavement counseling services are covered up to five (5) days.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 34.
34 Page 35 36
2003 GHI HMO 35 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

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

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

coverage, including with Medicare.

I M
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A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of

immediate medical attention to result in a condition 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. These conditions would be defined as urgent care. 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:
Emergencies within our service area:
In the event of a medical emergency you should seek immediate medical treatment at the nearest emergency facility anywhere in the world whether or not they participate with GHI HMO. You do not need prior
approval by GHI HMO or your PCP to receive emergency treatment. However, you or a family member must contact your PCP, unless it not reasonably possible to do so. If you are unable to contact your PCP, please
call GHI HMO at 1-877-244-4466. It is your PCP's responsibility to contact GHI HMO with this information. All emergency room visits that do not result in a hospital admission will require an emergency room copay of
$35.

Urgent care is defined as a sudden onset of illness or accident that does not require acute care treatment and would not result in a several disability. Examples of conditions we do not consider to be emergencies are but
are not limited to: head colds, influenza, tension headaches, toothaches, minor cuts and bruises, muscle strain, hemorrhoids and intoxication. You must contact your PCP prior to obtaining care. Your PCP will provide
care for your situation, arrange for you to receive care in a GHI HMO affiliated facility or refer you to the nearest emergency room. You will be responsible for the full cost of the visit if you do not contact your PCP.
If referred to the emergency room by PCP, you will pay a $35 copay. If you are unable to reach your PCP, please call GHI HMO at 1-877-244-4466.

Emergencies outside our service area:
If you are out of the GHI HMO Service Area, your PCP or the on-call physician will authorize your care at the nearest emergency facility as appropriate. It is your responsibility or that of a family member to contact your

PCP prior to receiving non-emergency care, unless it was not reasonably possible to do so. 35.
35 Page 36 37
2003 GHI HMO 36 Section 5( d)
Your membership card instructs physicians and hospitals outside the GHI HMO Service Area to send all claims for services rendered directly to GHI HMO. However, if the emergency care you receive is relatively
minor in cost, you may be asked to pay for services rendered. In these cases, keep all receipts and bills (indicating the provider's name, date of service, procedures performed, amount charged and amount paid) and
present them along with an explanation to GHI HMO's Customer Service department for review and appropriate reimbursement. GHI HMO, Customer Service, 120 Wood Road, PO Box 4332, Kingston, NY
12401.
If you were admitted to the hospital from the Emergency Room the $35 copay is waived. Follow-up care after an emergency must be provided with a participating GHI HMO provider. Care provided by a non-participating

provider will not be covered for follow-up visits.

What is an accidental injury? An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal bites, and poisonings. We do cover dental care for
accidental injury to sound natural teeth only.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient at a hospital, including doctors' services

Note: copay waived if admitted to the hospital.

$10 per office visit
$35 copay
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area

Emergency care at a doctor's office
Emergency care at an urgent care center

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

Note: copay waived if admitted to the hospital

$10 per office visit
$35 copay

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

All charges

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance unless medically necessary and approved
by GHI HMO's Medical Director
All charges 36.
36 Page 37 38
2003 GHI HMO 37 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

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

brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible

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

coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits

All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan
includes 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, nurse, or clinical
social workers.

Medication Management

$10 per office visit

Mental health and substance abuse benefits -continued on next page 37.
37 Page 38 39
2003 GHI HMO 38 Section 5( e)
Mental health and substance abuse benefits (Continued) You Pay
Diagnostic test
Lab work
Nothing if you receive these services during your office

visit otherwise, $10 per office visit

X-rays $10 per office visit

Services provided by a hospital or other facility
Services in approved alternative care settings such as: -partial hospitalization

-residential treatment -full-day hospitalization
-facility based intensive outpatient treatment

Nothing

Not covered in the network: The same exclusions contained in this brochure that apply to other benefits apply to these mental health and
substance abuse benefits, unless the services are included in a treatment plan that we approve.

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

Network mental health and substance abuse benefits --Continued on next page. 38.
38 Page 39 40
2003 GHI HMO 39 Section 5( e)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all of our network authorization processes.
Merit Behavioral Health Care an affiliate of Magellan Behavioral Health has been contracted to manage your behavioral health benefits. In order
to access your benefits, please call the Merit Behavioral Health Care toll free number at 1-800-836-2256. You will be connected to a customer
service representative who will be able to assist you in identifying a behavioral health care provider in your area or to verify if your current
provider is a participating provider in the Behavioral Health network.
If participating, the customer service representative will verify benefits/ eligibility and an authorization for treatment will be sent out to
your provider. They will continue to follow their contractual obligations and submit treatment plan reports for continued authorization. The
treatment reports will be reviewed by a New York State licensed clinician to determine if the treatment you are receiving meets medical
necessity criteria for the level of care and the intensity of treatment you are receiving.

If non-participating, the customer service representative will either offer you a provider participating in the network that specializes in your area
of need or will offer to forward a treatment report to you. You will be responsible for your provider completing the forms in their entirety and
returning them to the address provided. The treatment reports will be reviewed by a New York State licensed clinician to determine if the
treatment you are receiving meets medical necessity criteria for the level of care and the intensity of treatment you are receiving.

Treatment will not be interrupted if the licensed clinician reviewer finds your treatment to be needed and appropriately provided. At that point,
your non-participating provider will be required to sign an ad hoc agreement, which will allow you to continue in treatment. Your non-participating
provider will be required to accept contracted rates. They will be required to follow all the same contract requirements as a
participating provider.
Inpatient and alternative levels of care, which are more intense, than routine outpatient therapy must be called in by using the same toll free
number. New York State licensed staff is available 24 hours a day, 7 days a week, 365 days a year.

Participating provider directories can be obtained by calling the Customer Service department at GHI HMO at 1-877-244-4466 or view
the directory on our website at www. ghihmo. com.

How to submit claims There are no claim forms. You must work through participating providers. In the event you are in the transitional period, you must notify the Plan and
have the provider contact the Plan. If you have mistakenly received a bill for covered services or your provider needs to contact GHI HMO, please
contact customer service at 1-877-244-4466. Mail billing statements to GHI HMO, Attn: Claims, PO BOX 4332, Kingston, NY 12402.

Limitation We may limit your benefits if you do not obtain a treatment plan. 39.
39 Page 40 41
2003 GHI HMO 40 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about your prescription drug benefits:
GHI HMO covers your prescription medications, as described in the chart beginning on the next page.
All prescription drug benefits are subject to the definitions, limitations and exclusions in this brochure. In addition, these benefits are payable only when
determined by GHI HMO that they are medically necessary.
We have no calendar year deductible
Please refer to Section 4, Your costs for covered services, for valuable information about cost sharing, as well as the special sections for members who
are 65 years of age or over. In addition, Section 9 details how you can coordinate your prescription drug benefits with other coverage, including
Medicare.

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Your prescription drug benefits consist of the following important features:
Who is authorized to write your prescription. A licensed physician is the only individual authorized to write your prescription.

Where you can fill your prescription. Your prescription can be obtained through a large network of retail pharmacies that participate in the Express Scripts PERxCare Retail Pharmacy Program. This
network consists of over 51,000 pharmacies nationwide.
For your short-term prescription needs, such as an antibiotic to treat an infection, you may fill your prescription at any network participating retail pharmacy that is convenient to you. A network participating
pharmacy will accept your prescription ID card and charge you the appropriate co-payment when you fill a prescription covered by your plan.

For your long-term prescription needs, such as you might need to treat High Blood Pressure or High Cholesterol, it is more advantageous to fill your prescription by mail, through the Express Scripts Mail
Service Pharmacy.
GHI HMO, through Express Scripts, uses a formulary. The formulary is a list of preferred, clinically effective prescription drugs that are also cost-effective. Express Scripts acts on behalf of GHI HMO to
provide affordable access to clinically sound, high quality pharmacy benefits for you. The formulary is developed using an evaluation process. The process begins with an assessment of the drug's clinical
effectiveness by an independent panel of physicians and pharmacists, also known as the Pharmacy and Therapeutics Committee. If the panel determines the drug is clinically effective, the drug is further
evaluated on an economic basis.
These are the dispensing limitations to your prescription drug benefits. Prescription drugs can be obtained through any retail pharmacy that participates in the Express Scripts
PERxCare Retail Pharmacy Network, or through the Express Scripts Mail Service Pharmacy.
Retail Network Pharmacy Service You can get up to a 30-day supply of medication

You pay a $10 copay for generic drugs You pay a $20 copay for plan preferred brand-name drugs (drugs that are listed on the Express
Scripts National Preferred Formulary)
You pay a $30 copay for non-preferred brand-name drugs (drugs that are not listed on the Express Scripts National Preferred Formulary) 40.
40 Page 41 42
2003 GHI HMO 41 Section 5( f)
Express Scripts Mail Service Pharmacy You can get up to a 90-day supply of medication
You pay a $20 copay for generic drugs
You pay a $40 copay for plan preferred brand-name drugs (drugs that are listed on the Express Scripts National Preferred Formulary)

You pay a $50 copay for non-preferred brand-name drugs (drugs that are not listed on the Express Scripts National Preferred Formulary)

Required Mail Service:
-Please note that your prescription drug coverage also includes a required mail service program. Therefore, you will be allowed two refills per maintenance prescription at any local network

participating retail pharmacy. All future refills must be obtained through the Express Scripts Mail Service Pharmacy.

-When a new maintenance medication is prescribed, you should request 2 prescriptions from your physician. The initial, for a 30-day supply can be filled at a network participating retail
pharmacy, and the second, for up to a 90-day supply, plus appropriate refills for up to one year, is to be sent to the Express Scripts Mail Service Pharmacy.

-For all existing maintenance medications at a network participating retail pharmacy, you are required to obtain new prescriptions from your physician and mail them to the Express Scripts
Mail Service Pharmacy. By filling your prescriptions through the Express Scripts Mail Service Pharmacy, you will pay just one copayment for each prescription or refill.

Why use a generic drug?
-Generic drugs may have unfamiliar names, but they are safe and effective. -Generic drugs contains the same active ingredients, in the same dosage form as their brand name
counterparts, and are manufactured according to the same strict federal regulations.
-Generic drugs may differ in color, size, or shape, but the FDA requires that they have the same strength, purity, and quality as the brand-name alternatives.

-Prescriptions filled with generic drugs often have lower co-payments. Therefore, you may be able to get the same health benefits at a lower cost. You should ask your physician or pharmacist whether a
generic version of your medication is available. By using a generic drug, you may be able to receive the same high-quality medication but reduce your expenses.

When you need to file a claim. A direct reimbursement claims form must be filed for prescriptions that you obtained through a non-participating retail pharmacy. Upon filling your prescriptions through non-participating
pharmacies:
-You must pay the full cost of the prescription.
-You must complete a direct reimbursement claims form, and submit it to Express Scripts. This form can be obtained by calling Express Scripts at (877) 534-3682.

-Express Scripts will reimburse you for the amount the medication would have cost your benefit plan at a participating pharmacy, minus the co-payment you would have paid.

Prescription drug benefits begin on the next page. 41.
41 Page 42 43
2003 GHI HMO 42 Section 5( f)
Benefit Description You pay
Covered medications and supplies
The following drug categories are available for dispensing through Express Scripts PERxCare Retail Pharmacy Program. For a complete

formulary listing call 1-877-244-4466 (GHI HMO) or Express Scripts at 1-877-534-3682.

Anti-infectives
Cardiovascular
Endocrine
Gastrointestinal
Psychotherapeutics
NSAIDS (Pain relievers)
Respiratory
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan retail pharmacy will be dispensed for up to a 30-day

supply or 100 unit supply, whichever is less, 240 milligrams of liquid (8 oz.); 60 grams of ointment, creams or topical preparation;
or one commercially prepared unit (i. e. one inhaler, one vial ophthalmic medication or insulin).
Contraceptive drugs and devices
Insulin Disposable needles and syringes for the administration of covered

medications
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded

below.
-Prescription drugs for diet or weight control including anorexic agent
-Drugs utilized for treatment of sexual dysfunction are limited to 6 doses per month
-Prescription drugs not obtained at a GHI HMO participating pharmacy or Mail Order Pharmacy
-Initial prescriptions or refills in excess of a 30 consecutive day supply or one month's cycle of any oral contraceptive drug
(Mail order available for up to a 90 day supply)
-Drugs related to non-covered medical services
-OTC drugs
-Contraceptive devices such as condoms and spermacidal agents

-Drugs not approved by the FDA
-Medications for cosmetic purposes only

Retail Pharmacy: $10 co pay -generic
$20 co pay preferred brand $30 co pay non-preferred brand
(30-day supply)
Mail Order: $20 co pay generic
$40 co pay preferred brand $50 co pay non-preferred brand
(90-day supply for maintenance medications)

Covered medications and supplies --continued on next page

Retail Pharmacy: $10 co pay -generic
$20 co pay preferred brand $30 co pay non-preferred brand
(30-day supply)
Mail Order: $20 co pay generic
$40 co pay preferred brand $50 co pay non-preferred brand
(90-day supply for maintenance medications) 42.
42 Page 43 44
2003 GHI HMO 43 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

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

All Charges 43.
43 Page 44 45
2003 GHI HMO 44 Section 5( g)
Section 5 (g). Special features
Feature Description

Services for deaf and hearing impaired We provide a TDD Line for the deaf and hearing impaired, 1-877-208-7920

Centers of excellence for transplants/ heart
surgery/ etc.

Life Trac National Ancillary providers for organ transplants utilizing 31 Centers of Excellence throughout the United States

PHIP -Personal Health Improvement Program GHI HMO is now offering the Personal Health Improvement Program (PHIP) to our members. PHIP is a behavioral medicine intervention for the following types of patients:
(1) those with stress related illnesses such as headaches, back pain, fatigue, insomnia, and gastrointestinal discomfort.
(2) those learning to deal with a chronic disease such as multiple sclerosis, fibromyalgia and diabetes.
(3) patients whose mood (anxiety, depression, etc.) seems to influence their physical health.
PHIP is based on the mind-body theory that mood and physical health are closely correlated. It helps patients reduce suffering and the
symptoms of chronic illnesses by allowing participants to become aware of how their bodily reactions are related to behavioral patterns, including
coping styles. By making such connections, participants learn to adopt new behaviors that will relieve their pain or discomfort.

The program consists of six weekly two hour classes led by a trained facilitator. The classes consist of a combination of group discussion and
specific exercises designed to help participants become aware of their own reactions to daily life. Participants are provided with a workbook
and home-study questions, as well as an audiotape to guide them through an awareness exercise that they are asked to do daily. 44.
44 Page 45 46
2003 GHI HMO 45 Section 5( h)
Section 5 (h). Dental benefits
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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.

GHI HMO does not provide dental benefits.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do

not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

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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. The services must be provided within 12 months of the injury.
Nothing

Dental benefits
We have no other dental benefits. 45.
45 Page 46 47
2003 GHI HMO 46 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury or condition and we agree, as discussed under Services Requiring our Prior Approval on page 14.

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;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services related to the professional fee for treatment of cavities and extractions, care of gums or bones supporting the teeth, orthodontia, false teeth, odontoma (tumors that are of dental origin and

comprised of hard dental tissue), or any other dental services; or
Services, drugs or supplies you receive without charge while in active military service. 46.
46 Page 47 48
2003 GHI HMO 47 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.
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 & Drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 1-877-244-4466.

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 following 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: GHI HMO Claims Department PO Box 4141
Kingston, NY 12401

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.
If a claim is denied, you will receive notice of the decision, including reasons for the denial and the provisions of the contract on which the
denial was based. If you disagree with the plans decision, you may request reconsideration in accordance with the disputed claims procedure
described on page 48.

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. 47.
47 Page 48 49
2003 GHI HMO 48 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: GHI HMO, 120 Wood Road, Kingston, NY 12401; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

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

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

We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630. 48.
48 Page 49 50
2003 GHI HMO 49 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 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 1-877-244-4466 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/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 49.
49 Page 50 51
2003 GHI HMO Section 9 50
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. 50.
50 Page 51 52
2003 GHI HMO Section 9 51
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 still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized and arranged by your Plan PCP.

Claims process when you have the Original Medicare Plan--You probably will never have to file a claim when you have both our Plan and
the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You will not need to do anything. To find out if you need to do something
about filing your claims, call us at 1-877-244-4466 or visit our website at www. ghihmo. com.

(Primary payer chart begins on next page.) 51.
51 Page 52 53
2003 GHI HMO 52 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 52.
52 Page 53 54
2003 GHI HMO 53 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 of the managed
care plan's network and/ or service area (if you use our Plan providers), but we will not waive any of our copayments or coinsurance. If you
enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed
care plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.

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

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan
cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a one of these programs, eliminating your FEHB premium. (OPM does not contribute to any 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.

If you do not enroll in Medicare Part A or Part B 53.
53 Page 54 55
2003 GHI HMO 54 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar

Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in a 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. You must assist us in receiving our excess payment, for
example, by completing and filing claim forms with other Health Plans and endorsing checks over to us. If you need more information, contact
us for our subrogation procedures. 54.
54 Page 55 56
2003 GHI HMO 55 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 16.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 16.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Any service which can be learned and provided by an average individual who does not have medical training. Examples of Custodial Care
include: a. Assistance in meeting activities of daily living such as feeding,
dressing and personal hygiene; b. Administration of oral medications, routine changing of
dressing, or preparation of special diets; c. Assistance in walking or getting out of bed;
d. Child care necessitated by the incapacity of a parent; or e. Respite Care

Custodial care that last 90 days or more is sometimes know as Long term care.

Experimental or Any drug, device or medical treatment or procedure is experimental or investigational services investigational:
If the drug or device has not been approved by the Food and Drug Administration (FDA)
If reliable evidence, (reports in respected medical and scientific literature) shows that the opinion of experts is that further study is
needed to decide how a drug, device or medical treatments or procedures compares with the standard method of treatment or
diagnosis.

Medical necessity Medically necessary health care services are those necessary to preserve and maintain an Enrollee's health in accordance with acceptable
standards of medical practice and received in an appropriate setting. The GHI HMO Medical Director shall determine whether a particular health
care service rendered to an Enrollee is Medical Necessary for the purpose of determining whether such health care services are covered services
and not for the purpose of practicing medicine or determining a course of treatment, which course is to be determined by the Participating
Physician.

Plan allowance The plan allowance is a fee negotiated between the providers of service and the plan. These agreed upon fees are considered to be
payment in full for services rendered by all participating providers. Your coinsurance (50% for infertility services, and 20% for
durable medical equipment) will be applied to these negotiated fees. 55.
55 Page 56 57
2003 GHI HMO 56 Section 10
Us/ We Us and we refer to GHI HMO
You You refers to the enrollee and each covered family member. 56.
56 Page 57 58
2003 GHI HMO 57 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.

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) 57.
57 Page 58 59
2003 GHI HMO 58 Section 11
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 premiums start this Plan during Open Season, your coverage begins on the first day of
your first pay period that starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other
time during the year, your employing office will tell you the effective date of coverage.

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

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

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

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is
the case even when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB 58.
58 Page 59 60
2003 GHI HMO 59 Section 11
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 of Coverage (TCC) If you leave Federal service, or if you lose coverage because you no
longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.

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

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

convert);
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is 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 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. 59.
59 Page 60 61
2003 GHI HMO 60 Section 11
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 question. 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. 60.
60 Page 61 62
2003 GHI HMO 61 Long Term Care
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. 61.
61 Page 62 63
2003 GHI HMO 62 Index
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 45 Allergy tests 22
Alternative treatment 27 Allogenetic (donor) bone marrow
transplant 30 Ambulance 34
Anesthesia 31 Autologous bone marrow transplant
23,30 Biopsies 28
Blood and blood plasma 33 Casts 33
Catastrophic protection 63 Changes for 2003 11
Chemotherapy 23 Chiropractic 18,27
Cholesterol tests 19 Claims 39,47,48
Coinsurance 16 Colorectal cancer screening 19
Congenital anomalies 28 Contraceptive devices and drugs 42
Coordination of benefits 50 Copayments 16
Covered services 55 Covered providers 12
Crutches 26 Deductible 16
Definitions 55 Dental care 45
Diabetic Supplies 22 Diagnostic services 18
Disputed claims review 48 Donor expenses (transplants) 30
Dressings 33 Durable medical equipment (DME)
26 Effective date of enrollment 58
Emergency 35 Experimental or
investigational 55 Family planning 21
Fecal occult blood test 19 Foot care 25
General Exclusions 46 Hearing services 24
Home health services 26 Home nursing care 26
Hospice care 34 Hospital 13,32

Immunizations 20 Infertility 22
In hospital physician care 18 Insulin 22
Inpatient Hospital Benefits 32 Laboratory and pathological services
19 Mail Order Prescription
Drugs 41,42 Mammograms 18,19,20
Maternity Benefits 21 Medicaid 54
Medically necessary 14 Medicare 50
Mental Conditions/ Substance Abuse Benefits 37
MRI 19 Newborn care 21
Nursery care 21 Obstetrical care 21
Occupational therapy 24 Office visits 18
Oral and maxillofacial surgery 29 Orthopedic devices 25
Out of Pocket maximum 16 Outpatient facility care 33
Oxygen 26 Pap test 18,19
Physical examination 18 Physical therapy 24
Physician 12 Pre-admission testing 33
Preauthorization 14,39 Preventive care, adult 19
Preventive care, children 20 Prescription drugs 40
Prior approval 14,39 Prostate cancer screening 19
Prosthetic devices 25 Psychologist 37
Radiation therapy 23 Renal dialysis 23
Room and board 32 Second surgical opinion 18
Skilled nursing facility care 34 Speech therapy 24
Sterilization procedures 28 Subrogation 54
Substance abuse 37

Surgery 28
Anesthesia 31
Oral 29
Outpatient 33
Reconstructive 29 Syringes 22

Temporary continuation of coverage 59
Transplants 30 Treatment therapies 23
Vision services 25 Well child care 18,20
Wheelchairs 26 Workers' compensation 54
X-rays 19 62.
62 Page 63 64
2003 GHI HMO 63 Summary of Benefits
Summary of benefits for the GHI HMO 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 primary care; $10 specialist 18

Services provided by a hospital: Inpatient............................................................................................
Outpatient .........................................................................................
Lab
X-Ray

Nothing

$10 copay
32

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

$35 per visit
$35 per visit 35
Mental health and substance abuse treatment...................................... Regular cost sharing 37
Prescription drugs ................................................................................. Retail Pharmacy: $10 co pay -generic
$20 co pay preferred brand $30 co pay non-preferred brand

Mail Order: $20 co pay generic
$40 co pay preferred brand $50 co pay non-preferred brand

40

Dental Care ....................................................................................... Accidental injury to sound natural teeth only. You pay nothing 45
Vision Care ....................................................................................... One refraction annually. You pay $10 copay per office visit 25
Special features:
Services for deaf and hearing impaired Centers of Excellence for transplants/ heart surgeries

PHIP Personal Health Improvement Project

44

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum) ................... Your out-of-pocket expenses for benefits under this Plan are limited
to the stated copayments which are required for few benefits 16 63.
63 Page 64
2003 GHI HMO 64 Rates
2003 Rate Information for
GHI HMO

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

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

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

Bronx/ Brooklyn/ Manhattan/ Nassau/ Queens/ Richmond/ Suffolk/ Westchester
Self Only 6V1 $109.30 $44.86 $236.82 $97.19 $129.03 $25.13

Self and Family 6V2 $249.62 $144.77 $540.84 $313.67 $294.70 $99.69
Albany/ Broome/ Columbia/ Delaware/ Dutchess/ Fulton/ Greene/ Montgomery/ Orange/ Otsego/ Putnam/ Rensselaer/ Rockland/ Saratoga/ Schenectday/ Schoharie/ Sullivan/ Ulster/ Warrren/ Washington

Self Only X41 $105.05 $35.01 $227.60 $75.86 $124.30 $15.76
Self and Family X42 $249.62 $84.05 $540.84 $182.11 $294.70 $38.97 64.

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