Page Navigation Panel Document Outline

Document Outline

Pages 1--85 from Untitled


Page 1 2
For changes in benefits
see page 5.

A fee-for-service plan with a preferred provider organization

Sponsored and administered by: The Association
Who may enroll in this Plan: Members of the Association
Annuitants (retirees) who are members of the Association may enroll in this Plan

Enrollment codes for this Plan:
421 -Self Only
422 -Self and Family

A PLAN FOR THE FUTURE
Association Benefit Plan 2002

Mutual of Omaha Insurance Company, the underwriter for Association Benefit Plan, has received accreditation
from URAC (also known as the American Accreditation Healthcare Commission) for Health Utilization Man-agement
Standards. See the 2002 Guide for more infor-mation on accreditation. 1
1 Page 2 3
2002 Associate Benefit Plan 1 Table of Contents
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Section 1. Facts about this fee-for-service plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Identification card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Covered providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Covered facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What you must do to get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How to Get Approval for. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Your hospital stay (precertification) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Other services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Differences between our allowance and the bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
When government facilities bill us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
If we overpay you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
When you are age 65 or over and you do not have Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
When you have Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
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 . . . . . . . . 30
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . 35
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
(e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Flexible benefits option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
24-hour nurse line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
High risk pregnancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2
2 Page 3 4
2002 Associate Benefit Plan 2 Table of Contents
Centers of excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Service overseas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
(h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Section 6. General exclusions things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
TRICARE/ Workers Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
When other Government agencies are responsible for your care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Your medical and claims records are confidential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Long Term Care is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 3
3 Page 4 5
2002 Association Benefit Plan 3
Introduction
Association Benefit Plan
PO Box 668587
Charlotte, NC 28266-8587

This brochure describes the benefits of the Association Benefit Plan under the Government Employees Health Association's
contract (CS 1065) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. The Plan is underwritten by Mutual of Omaha Insurance Company. This brochure is the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and
Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that
were available before January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and are sum-marized
on page 74. Rates are shown at the end of this brochure.

Plain Language

Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or
family member; "we" means Association Benefit Plan.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is
the Office of Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help
you compare plans.

If you have any 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.

INSPECTOR GENERAL ADVISORY
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any infor-mation,
do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-634-0069
and explain the situation.

If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300

The United States Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, NW, Room 6400 Washington, DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card if the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain
benefits. Your agency may also take administrative action against you.
Introduction/ Plain Language 4
4 Page 5 6
2002 Association Benefit Plan 4 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care
providers.

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow.
The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures
carefully.

We also have Preferred Provider Organizations (PPO):
Our fee-for-service plan offers services through a PPO. When you reside in the PPO network area and use our PPO
providers, you will receive covered services at reduced cost. If you reside in Washington, DC, or in one of the
states listed below, contact us at 1-800-634-0069 for information concerning your PPO. You can also go to the
Mutual of Omaha website, www. mutualofomaha. com, for PPO information. Do not call OPM for our provider
directory. Also, when you phone for an appointment, please verify that your physician is still a PPO provider.

The Out-of-network benefits are the standard benefits of this plan. PPO benefits apply only when you reside in the
PPO network area and use a PPO provider. You must present your PPO identification (ID) card confirming
your PPO participation to be eligible for PPO benefits. Provider networks may be more extensive in some areas
than others. We cannot guarantee the availability of every specialty in all areas. If no PPO provider is available, or
you do not use a PPO provider, the standard non-PPO benefits apply. When you use a PPO hospital, keep in mind
that the professionals who provide services to you in the hospital, such as radiologists, emergency room physi-cians,
anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid as
non-PPO providers.

The PPO Network Area consists of Washington, D. C. and selected counties and cities in the following states:

If you reside in the PPO network area and no PPO provider is available, or if you do not use a PPO provider, non-PPO
benefits apply.

How we pay providers
Our participating providers are generally reimbursed according to an agreed-upon fee schedule and are not offered addi-tional
financial incentives based on care provided or not provided to you. Our standard provider agreements do not con-tain
any contractual provisions that include incentives to restrict a providers ability to communicate with and advise
patients of any appropriate treatment options. In addition, the Plan has no compensation, ownership, or other influential
interests that are likely to affect provider advice or treatment decisions.

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. If you want more information about us, call 1-800-634-0069, or write to Asso-ciation
Benefit Plan, PO Box 668587, Charlotte, NC 28266-8587.

Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware Florida Georgia Idaho Illinois
Indiana Iowa Maryland Massachusetts Michigan Missouri
Nevada New Jersey New Mexico New York North Carolina Ohio
Oregon Pennsylvania South Carolina Tennessee Texas Utah
Virginia Washington West Virginia 5
5 Page 6 7
2002 Association Benefit Plan 5 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5,
Benefits. Also we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8).
The following four states have been added to the list of medically underserved in 2002: Georgia, Montana, North
Dakota, and Texas. Louisana has been removed from the list of medically underserved states in 2002. See page 7.

Changes to this Plan
We now cover intestinal transplants. (Section 5( b)).
We changed speech therapy benefits by removing the requirement that services must be required to restore functional
speech. (Section 5( a)).

We clarified the brochure to better explain that the Out-of-network benefits are the standard benefits of this Plan, that
PPO benefits apply only when you reside in the PPO network area and use a PPO provider, and that when no PPO
provider is available, non-PPO benefits apply.

We expanded our optional hospital and physician Preferred Provider Organization (PPO) network area to include selected
counties and cities in the following states: Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida (North), Georgia,
Illinois, Indiana, Iowa, Massachusetts, Michigan, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina,
Ohio, Oregon, South Carolina, Tennessee, Texas, Utah, Virginia (Roanoke) and West Virginia. (Section 4).

If you reside in the PPO network area and use PPO providers, annual routine preventative care services provided out-side
the physician's office will be paid at 100% of the Plan allowance, not subject to the deductible. (Section 5( a)).

A routine mammogram is now available annually for women 35 years and older. (Section 5( a)).
If you have an accidental injury, we will pay 100% of the Plan allowance, not subject to the deductible, of the first
$500 of your outpatient expenses. Your subsequent outpatient care will be paid under the appropriate benefit and at
your applicable copayment/ coinsurance amount. (Section 5( d)).

If you have an accidental dental injury while enrolled in the Plan, we will pay 80% of the Plan allowance, not subject
to the deductible, until the treatment is completed as long as you remain enrolled in the Plan. (Section 5( h)).

Smoking cessation benefits will be limited to $100 per 12 months and will be paid at your applicable copayment/
coinsurance amount, subject to the calendar year deductible. (Section 5( a)).

Physical, speech, and occupational therapy visits will be limited to total combined 90 visits. We removed speech ther-apy
limitations. (Section 5( a)).

Your calendar year deductible will increase to $300 per person or $600 per family. (Section 4)
Your inpatient hospital copayment will increase to $100 for PPO; and $200 for Non-PPO and Out-of-network facili-ties.
(Section 5( c)).

Your out-of-pocket maximum for PPO and Out-of-network providers will increase to $2,500 and to $3,500 for
Non-PPO providers. (Section 4).

Your share of the premiums will increase by 15.4% for Self Only or 13.2% for Self and Family. 6
6 Page 7 8
2002 Association Benefit Plan 6 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card and a Prescription Drug Card when you enroll. You should carry both cards with you at all times. You
must show your ID card whenever you receive services from a medical or
dental provider, or your Prescription Drug Card to fill a prescription at a
participating Plan pharmacy. Until you receive your ID card, use your copy
of the Health Benefits Election Form, SF-2809, or your health benefits
enrollment confirmation (for annuitants).

If you do not receive your cards within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-634-
0069.

Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay and you pay depends on the type of covered provider or
facility you use. If you reside in the PPO network area and use our pre-ferred
providers, you will pay less.

Covered providers We consider the following to be covered providers when they perform ser-vices within the scope of their license or certification:

Physician: Doctors of medicine or psychiatry (M. D.), osteopathy
(D. O.), dental surgery (D. D. S.), medical dentistry (D. M. D.), podiatric
medicine (D. P. M.), and optometry (O. D.) when acting within the scope
of their licenses or certification.

Qualified Clinical Psychologist: An individual who has earned either a
Doctoral or Masters Clinical Degree in psychology or an allied disci-pline
and who is licensed or certified in the state where services are per-formed.
This presumes a licensed individual has demonstrated to the
satisfaction of state licensing officials that he/ she, by virtue of academic
and clinical experience, is qualified to provide psychological services in
that state.

Nurse Midwife: A person who is certified by the American College of
Nurse Midwives or is licensed or certified as a nurse midwife in states
requiring licensure or certification.

Nurse Practitioner/ Clinical Specialist: A person who 1) has an active
R. N. license in the United States, 2) has a baccalaureate or higher
degree in nursing, and 3) is licensed or certified as a nurse practitioner
or clinical nurse specialist in states requiring licensure or certification.

Clinical Social Worker: A social worker who 1) has a Master's or Doc-toral
degree in social work, 2) has at least two years of clinical social
work practice, and 3) in states requiring licensure, certification or regis-tration,
is licensed, certified, or registered as a social worker where the
services are rendered.

Physician Assistant: A person who is licensed, registered, or certified
in the state where services are performed.

Licensed Professional Counselor or Master's Level Counselor: A
person who is licensed, registered, or certified in the state where ser-vices
are performed 7
7 Page 8 9
2002 Association Benefit Plan 7 Section 3
Section 3. How you get care (continued)
Nursing School Administered Clinic: A clinic that is
1) licensed or certified in the state where the services are performed,
and

2) provides ambulatory care in an outpatient setting primarily in
rural or inner city areas where there is a shortage of physicians.
Services billed for by these clinics are considered outpatient
'office' services rather than facility charges

Christian Science Practitioner: If you choose to visit a Christian Sci-ence
practitioner instead of a physician, the charges are still considered
allowable expenses. To qualify for benefits, you must make this choice
annually. The benefits will then apply to all subsequent expenses
incurred during the year. You can change your mind only at the time of
your first claim each year. The practitioner you choose must be listed as
such in the Christian Science Journal that is current at the time the ser-vice
is provided. Your choice will not apply to, or prevent payment of, a
physician's maternity charges.

Medically underserved areas. We cover any licensed medical practitioner
for any covered service performed within the scope of that license in states
OPM determines are "medically underserved." For 2002, the states are:
Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New
Mexico, North Dakota, South Carolina, South Dakota, Texas, Utah, and
Wyoming.

Covered facilities Covered facilities include:
Hospital

1) An institution that is accredited as a hospital under the hospital
accreditation program of the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO); or

2) Any other institution that is operated pursuant to law, under the
supervision of a staff of doctors and with 24-hours-a-day nursing
service, and that is primarily engaged in providing:

a) General patient care and treatment of sick and injured persons
through medical, diagnostic and major surgical facilities, all of
which facilities must be provided on its premises or under its
control; or

b) specialized inpatient medical care and treatment of sick or
injured persons through medical and diagnostic facilities
(including X-ray and laboratory) on its premises, under its
control, or through a written agreement with a hospital (as
defined above) or with a specialized provider of those
facilities.

In no event shall the term hospital include a convalescent nursing home or
institution or part thereof that:

1) is used principally as a convalescent facility, rest facility, nursing
facility or facility for the aged; 8
8 Page 9 10
2002 Association Benefit Plan 8 Section 3
Section 3. How you get care (continued)
2) furnishes primarily domiciliary or custodial care including
training in the routines of daily living; or

3) is operated as a school.
For inpatient and outpatient treatment of alcohol and drug abuse, the term
hospital also includes a free-standing alcohol and drug abuse treatment
facility approved by the JCAHO.

Skilled nursing facility: An institution, or that part of an institution that
provides convalescent skilled nursing care 24 hours a day and is
classified as a skilled nursing facility under Medicare.

Birthing Center: A licensed facility that is equipped and operated
solely to provide prenatal care, to perform uncomplicated spontaneous
deliveries and to provide immediate post-partum care.

Hospice: A facility that meets all of the following:
1) primarily provides inpatient hospice care to terminally ill persons;
2) is certified by Medicare as such, or is licensed or accredited as
such by the jurisdiction it is in;

3) is supervised by a staff of M. D. s or D. O. s, at least one of whom
must be on call at all times; and

4) provides 24-hour-a-day nursing services under the direction of an
R. N. and has a full-time administrator; and

5) provides an ongoing quality assurance program.

What you must do to
get covered care
It depends on the kind of care you want to receive. You can go to any
provider you want, but we must approve some care in advance.

Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal
Employees Health Benefits (FEHB) Program and you enroll in another
FEHB plan, or

lose access to your PPO specialist because we terminate our contract
with your specialist for other than cause,

you may be able to continue seeing your specialist and receiving any PPO
benefits 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. 9
9 Page 10 11
2002 Association Benefit Plan 9 Section 3
Section 3. How you get care (continued)
Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan
begins, call our customer service department immediately at
1-800-634-0069.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the benefits of the hospitalized person.
How to Get Approval for
Your hospital stay Precertification is the process by which prior to your inpatient hospi-tal admission we evaluate the medical necessity of your proposed stay

and the number of days required to treat your condition. Unless we are
misled by the information given to us, we won't change our decision on
medical necessity.

In most cases, your physician or hospital will take care of precertifica-tion.
Because you are still responsible for ensuring that we are asked to
precertify your care, you should always ask your physician or hospital
whether they have contacted us.

Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one
contacts us for precertification. If the stay is not medically necessary, we
may not pay any benefits.

How to precertify an
admission:
You, your representative, your physician, or your hospital must call us at
1-800-634-0069 before admission.

If you have an emergency admission due to a condition that you
reasonably believe puts your life in danger or could cause serious
damage to bodily function, you, your representative, the physician, or
the hospital must telephone us within two business days following the
day of the emergency admission, even if you have been discharged from
the hospital.

Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting physician; 10
10 Page 11 12
2002 Association Benefit Plan 10 Section 3
Section 3. How you get care (continued)
Name of hospital or facility; and
Number of planned days of confinement.

We will then tell the physician and/ or hospital the number of approved
inpatient days and we will send written confirmation of our decision to
you, your physician, and the hospital.

Maternity care You do not need to precertify a maternity admission for a routine delivery.
However, if your medical condition requires you to stay more than 48
hours after a vaginal delivery or 96 hours after a cesarean section, then your
physician or the hospital must contact us for precertification of
additional days. Further, if your baby stays after you are discharged, then
your physician or the hospital must contact us for precertification of
additional days for your baby.

If your hospital stay needs to
be extended:
If your hospital stay including for maternity care needs to be extended,
you, your representative, your physician or the hospital must ask us to
approve the additional days.

What happens when you
do not follow the
precertification rules

When we precertified the admission but you remained in the hospital
beyond the number of days we approved and did not get the additional
days precertified, then:

for the part of the admission that was medically necessary, we will
pay inpatient benefits, but

for the part of the admission that was not medically necessary, we
will pay only medical services and supplies otherwise payable on an
outpatient basis and will not pay inpatient benefits.

If no one contacted us, we will decide whether the hospital stay was
medically necessary.

If we determine that the stay was medically necessary, we will pay
the inpatient charges, less the $500 penalty.

If we determine that it was not medically necessary for you to be an
inpatient, we will not pay inpatient hospital benefits. We will only
pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis.

If no one contacted us for specified services such as Hospice Care,
Skilled Nursing Facility Care, Home Health Care, we will disqualify
higher paid benefits.

If we denied the precertification request, we will not pay inpatient hos-pital
benefits. We will only pay for any covered medical supplies and
services that are otherwise payable on an outpatient basis.

Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the United States. 11
11 Page 12 13
2002 Association Benefit Plan 11 Section 3
Section 3. How you get care (continued)
You have another group health insurance policy that is the primary
payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If
you exhaust your Medicare hospital benefits and do not want to use your
Medicare lifetime reserve days, then we will become the primary payer
and you do need precertification.

Other services Some other services require precertification, or prior authorization, such as:
Home health care
Hospice care
Organ/ tissue transplants
Skilled nursing facilities
Psychiatric and substance abuse treatment
Surgery for morbid obesity 12
12 Page 13 14
2002 Association Benefit Plan 12 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services. You will only be responsible for
one copayment per day to a provider or facility.
Example: When you see your PPO physician you pay a copayment of $10
per visit, and when you go in a PPO hospital, you pay a copayment of $100
per admission.

Deductible A deductible is a fixed amount of covered expenses you must incur for cer-tain covered services and supplies before we start paying benefits for them.

Copayments do not count toward any deductible.
The calendar year deductible is $300 per person. Under a family enroll-ment,
the deductible is satisfied for all family members when the com-bined
covered expenses applied to the calendar year deductible for
family members reach $600.

Note: If you change plans during Open Season, you do not have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year,
you must begin a new deductible under your new plan.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible.

Example: You pay 10% of our allowance for an X-ray.
Note: If your provider routinely waives (does not require you to pay) your
copayments, deductibles, or coinsurance, the provider is misstating the fee
and may be violating the law. In this case, when we calculate our share, we
will reduce the provider's fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but
routinely waives your 10% coinsurance, the actual charge is $90. We will
pay $81 (90% of the actual charge of $90).

Differences between our
allowance and the bill
Our "Plan allowance" is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in

different ways, so their allowances vary. For more information about how
we determine our Plan allowance, see the definition of Plan allowance in
Section 10.

Often, the provider's bill is more than a fee-for-service plan's allowance.
Whether or not you have to pay the difference between our allowance and
the bill will depend on the provider you use.

PPO providers agree to limit what they will bill you. Because of that,
when you use a preferred provider, your share of covered charges
consists only of your deductible and coinsurance or copayment. Here is
an example about coinsurance: You see a PPO physician who charges
$150, but our allowance is $100. If you have met your deductible, you
are only responsible for your coinsurance. That is, you pay just 10%
of our $100 allowance ($ 10). Because of the agreement, your PPO phy-sician
will not bill you for the $50 difference between our allowance and
his bill. 13
13 Page 14 15
2002 Association Benefit Plan 13 Section 4
Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. For instance,

When reside in the PPO network area and use a non-PPO
provider, you will pay your deductible and coinsurance plus any
difference between our allowance and charges on the bill. Here is an
example: You see a non-PPO physician who charges $150 and our
allowance is again $100. Because you've met your deductible, you
are responsible for your coinsurance, so you pay 25% of our $100
allowance ($ 25). Plus, because there is no agreement between the
non-PPO physician and us, he can bill you for the $50 difference
between our allowance and his bill.

When you reside outside the PPO network area, you will pay
your deductible and coinsurance plus any difference between our
allowance and charges on the bill. As in the example above, once
you have met your deductible, you are responsible for your coinsur-ance.
You will pay 15% of our allowance ($ 15) and the physician
can bill you for the $50 difference between our allowance and his
bill.

The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician
when you reside in the PPO network area. The table uses our example of a
service for which the physician charges $150 and our allowance is $100.
The table shows the amount you pay if you have met your calendar year
deductible.

Your catastrophic protection
out-of-pocket maximum
for deductibles, coinsurance,
and copayments

If your out-of-pocket coinsurance expenses exceed your catastrophic limit
in a calendar year, we will pay 100% of the Plan allowance for the
remainder of the year. The calendar year limits are:

PPO providers: $2,500

Non-PPO providers: $3,500
Out-of-network providers: $2,500
Out-of-pocket expenses are:
Your $300/$ 600 calendar year deductible;

EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: 100 We set it at: 100
We pay 90% of our allowance: 90 75% of our allowance: 75
You owe:
Coinsurance
10% of our allowance: 10 25% of our allowance: 25

+Difference up to charge?
No: 0 Yes: 50

TOTAL YOU PAY $10 $75 14
14 Page 15 16
2002 Association Benefit Plan 14 Section 4
The percentage you pay for covered services after you have met your
deductible;

The percentage you pay for surgery, anesthesia and extended medical
care after an accidental injury; and

Your copayment for hospital admissions.
The following cannot be included in your out-of-pocket expenses:
Expenses in excess of the Plan allowance or maximum benefit
limitations;

Non-covered services and supplies;
Prescription drug copayments;
PPO copayments;
Expenses for dental care including the 20% you pay for dental care after
an accidental injury; or

Any amounts you pay if benefits have been reduced because of
noncompliance with our cost containment requirements.

When government facilities
bill us
Facilities of the Department of Veterans Affairs, the Department of
Defense, and the Indian Health Service are entitled to seek reimbursement
from us for certain services and supplies they provide to you or a family
member. They may not seek more than their governing laws allow.

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. If your claim has been paid in error for any reason, we
shall make a diligent effort to recover an overpayment to you from you or,
if to the provider, from the provider. We may reduce subsequent benefit
payments to the member or to a provider on behalf of the member to offset
overpayments.

When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And,
your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had
Medicare. The following chart has more information about the limits.

If you
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former
spouse; and

are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this
applies.) 15
15 Page 16 17
2002 Association Benefit Plan 15 Section 4
When you the have the Original
Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that
Medicare would pay under Medicare A (Hospital insurance) and Medicare
B (Medical insurance), regardless of whether Medicare pays. Note: We pay
our regular benefits for emergency services to an institutional provider,
such as a hospital, that does not participate with Medicare and is not reim-bursed
by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket
costs for services both Medicare Part B and we cover depend on whether
your physician accepts Medicare assignment for the claim.

If your physician accepts Medicare assignment, then you pay nothing
for covered charges.

If your physician does not accept Medicare assignment, then you pay
the difference between our payment combined with Medicare's payment
and the charge.

Then, for your inpatient hospital care,
the law requires us to base our payment on an amount the "equivalent Medicare amount" set by
Medicare's rules for what Medicare would pay, not on the actual charge;

you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this
Plan;

you are not responsible for any charges greater than the equivalent Medicare amount; we will show that
amount on the explanation of benefits; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.
And, for your physician care, the law requires us to base our payment and your coinsurance on

an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
If your physician Then you are responsible for
Participates with Medicare or accepts
Medicare assignment for the claim and
is a member of our PPO network,

your deductibles, coinsurance, copayments; and
any balance up to the Medicare approved amount;

Participates with Medicare and is not in
our PPO network,
your deductibles, coinsurance, copayments, and
any balance up to the Medicare approved amount;

Does not participate with Medicare, your deductibles, coinsurance, copayments, and
any balance up to 115% of the Medicare
approved amount

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are
permitted to collect only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If
you have paid more than allowed, ask for a refund. If you need further assistance, call us. 16
16 Page 17 18
2002 Association Benefit Plan 16 Section 4
Note: The physician who does not accept Medicare assignment may not
bill you for more than 115% of the amount Medicare bases its payment on,
called the "limiting charge." The Medicare Summary Notice (MSN) form
that Medicare will send you will have more information about the limiting
charge. If your physician tries to collect more than allowed by law, ask the
physician to reduce the charges. If your physician tries to collect more than
allowed by law, ask the physician to reduce the charges. If the physician
does not, report the physician to your Medicare carrier who sent you the
MSN form. Call us if you need further assistance

When you have a Medicare
Private Contract
A physician may ask you to sign a private contract agreeing that you can be
billed directly for services Medicare ordinarily covers. Should you sign an
agreement, Medicare will not pay any portion of the charges, and we will
not increase our payment. We will still limit our payment to the amount we
would have paid after Medicare's payment.

Please see Section 9, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with Medicare. 17
17 Page 18 19
2002 Association Benefit Plan 17 Section 5
Section 5. Benefits OVERVIEW (See page 5 for how our benefits changed this year and page 74 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
1-800-634-0069.

(a) Medical services and supplies provided by physicians and other health care professionals .................................. 18-29

(b) Surgical and anesthesia services provided by physicians and other health care professionals............................... 30-34
(c) Services provided by a hospital or other facility, and ambulance services ............................................................. 35-38

(d) Emergency services/ Accidents................................................................................................................................ 39-40
(e) Mental health and substance abuse benefits ............................................................................................................ 41-45
(f) Prescription drug benefits........................................................................................................................................ 46-48
(g) Special features ....................................................................................................................................................... 49

(h) Dental benefits......................................................................................................................................................... 50-51
(i) Non-FEHB benefits available to Plan members...................................................................................................... 52
SUMMARY OF BENEFITS.......................................................................................................................................... 74

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical, occupational, and speech therapies
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

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

Inpatient hospital
Outpatient hospital or ambulatory surgical
center

Skilled nursing care facility

Hospice care
Ambulance

Medical emergency
Accidental injury
Ambulance

Flexible benefits option
High risk pregnancies
Services Overseas

24-hour nurse line
Centers of excellence 18
18 Page 19 20
2002 Association Benefit Plan 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 you should 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.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year
deductible applies to almost all benefits in this Section. We added -* -to show when
the calendar year deductible does not apply.

The Out-of-network benefits are the standard benefits of this Plan. PPO benefits apply
only when you reside in the PPO network area and use a PPO provider. When no PPO
provider is available, non-PPO benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works, with special sections for members who are age 65 or
over. 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 After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We added asterisks -* -to show
when the calendar year deductible does not apply.

Diagnostic and treatment services
Professional services of physicians
In physician's office
PPO: $10 copayment*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Professional services of physicians

In a hospital or urgent care center
In a skilled nursing facility
Second surgical opinion
At home

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Note: For physical therapy treatment, see Physical, occupational and
speech therapies. 19
19 Page 20 21
2002 Association Benefit Plan 19 Section 5 (a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Sonograms

PPO: Services in physician's office$ 10
copayment*

PPO: Services outside physician's office
10% of the Plan allowance

Note: If your PPO provider uses a non-PPO
lab or radiologist, we will pay non-PPO bene-fits
for any lab and X-ray charges.

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Not covered:
Preventative medical care and services (including periodic checkups
and immunizations such as polio, flu, mumps, and smallpox shots),
except as provided under Preventative care, adult and children,
page 20

Telephone consultations

All charges

Preventive care, adult
One annual routine physical examination per person to include a his-tory
and physical, chest X-ray, urinalysis, blood tests, and EKG (elec-trocardiogram).

One annual cervical cancer screening (pap smear) for women age 18
and older. Note: if you see another physician for your pap smear, the
office visit will be covered.

One annual Prostate Specific Antigen test (PSA prostate cancer
screening) for men age 40 and older.

One annual fecal occult blood test (colorectal cancer screening) for
members age 40 and older.

A sigmoidoscopy once every five years starting at age 50.
One annual routine mammogram (breast cancer screening) for women
age 35 and older:

NOTE: Your physician's bill must clearly state "Routine Physical
Exam". If a medical diagnosis is provided on the bill, those services
will be paid under the medical benefit.

PPO: Services in physician's office$ 10
copayment*

PPO: Services outside physician's office
Nothing*

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-Network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.* 20
20 Page 21 22
2002 Association Benefit Plan 20 Section 5 (a)
Preventative care, adult -Continued You Pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

Pneumococcal vaccine, annually, age 65 and over
Influenza vaccine, annually, regardless of age

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Preventive care, children
Childhood immunizations recommended by the American
Academy of Pediatrics (to age 22)
PPO: Nothing*

Non-PPO: Only the difference between the
Plan allowance and the billed amount*

Out-of-network: Only the difference between
the Plan allowance and the billed amount*

For well-child care charges for routine examinations and care (to
age 2)
PPO: 10% of the Plan allowance.

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount.

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Maternity care
Complete maternity (obstetrical) care such as:
Prenatal care
Amniocentesis
Inpatient delivery
Initial, routine examination of your newborn infant covered under
your family enrollment

Circumcision of your newborn infant
Postnatal care

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount*

Note: Here are some things to keep in mind
You do not have to precertify your normal delivery; see page 9 for
other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will cover an
extended stay, if medically necessary, but you, your representative,
your physician or your hospital must precertify. 21
21 Page 22 23
2002 Association Benefit Plan 21 Section 5 (a)
Maternity care-Continued You Pay
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 if we cover the
infant under a Self and Family enrollment.

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

If your baby stays in the hospital after your discharge and is
covered under yourself and Family enrollment, you must pay a
separate hospital admission. See Section 5( c), Hospital benefits.

Bassinet or nursery charges on which you and your baby are
confined are considered your maternity expenses, not your baby's.

Sonograms and other related tests that are not included in your
routine prenatal or postnatal care are covered in Lab, X-ray, and
other diagnostic tests, page 19.

Outpatient maternity (obstetrical care) for covered hospital and
physician services at the time of delivery, including the initial, routine
examination of your newborn infant covered under your family
enrollment, when:

Delivery is on an outpatient basis;
Delivery is at a licensed birthing center; or
Inpatient delivery results in a hospital confinement of one day
(overnight) or less and no more than one day's room and board
charge applies

PPO: Nothing*
Non-PPO: Only the difference between the
Plan allowance and the billed amount*

Out-of-network: Only the difference between
the Plan allowance and the billed amount*

Note: If you or your newborn child is transferred from a birthing
center to a hospital due to medical complications, the birth center
expenses will be paid as inpatient care.

If you and your child leave the hospital against medical advice, this
outpatient benefit is not payable.

Not covered:

Routine sonograms to determine fetal age, size or sex; or procedures,
services, drugs and 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 or rape or incest

All charges 22
22 Page 23 24
2002 Association Benefit Plan 22 Section 5 (a)
Family planning You Pay
A broad range of voluntary family planning services, limited to:
Voluntary sterilization (such as Norplant)
Surgically implanted contraceptives
Intrauterine devices (IUDs)

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount*

Injection of contraceptive drugs (such as Depo-Provera)

Note: We cover oral contraceptive drugs in Section 5( f), Prescrip-tion
drug benefits.

Note: We cover contraceptive drugs in Section 5( f).

PPO: $10 copay*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility including prescription drugs, up
to $5,000 per person per lifetime, except as shown in Not covered.
PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount 23
23 Page 24 25
2002 Association Benefit Plan 23 Section 5 (a)
Infertility services-Continued You Pay
Not covered:
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination

in vitro fertilization
embryo transfer and GIFT
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Services and supplies related to ART procedures.
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Allergy testing, injections and treatment

Note: We cover allergy serum in Section 5( f), Prescription drug
benefits

PPO services in physician's office: $10
copayment*

PPO services outside physician's office: 10%
of the Plan allowance

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered: Provocative food testing, end point titration techniques,
hair analysis, and sublingual allergy desensitization
All charges 24
24 Page 25 26
2002 Association Benefit Plan 24 Section 5 (a)
Treatment therapies You Pay
Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed in Section 5( b),
Organ/ tissue transplants.

Note: We cover chemotherapy drugs in Section 5( f).
Dialysis Hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy Home IV and antibiotic
therapy

Respiratory and inhalation therapies
Growth hormone therapy (GHT)
Note: We only cover GHT when you obtain prior approval. Call
1-800-634-0069 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See services
requiring our prior approval in Section 3.

Note: Growth hormone is covered under the prescription drug benefit.

PPO services in physician's office: $10
copayment*

PPO services outside physician's office: <