Pages 1--47 Dean Health Plan, Inc.

Enrollment Codes for this Plan: WD1 Self Only
WD2 Self and Family

Dean Health Plan, Inc. http:// www. deancare. com 2002
A Health Maintenance Organization

This Plan has Excellent Accreditation from
the NCQA. See the 2002 Guide
for more information on NCQA.

United States Office of Personnel Management
Retirement and Insurance Service
http:// www. opm. gov/ insure

Authorized for distribution by the:

RI 73-189 1
1 Page 2 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . .12
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . .19
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . .22
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Section 6. General exclusions --things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
When you have…
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

2002 Dean Health Plan, Inc. 1 Introduction/ Plain Language

Table of Contents 2
2 Page 3 4
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . .39
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Long Term Care Insuance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back cover

2002 Dean Health Plan, Inc. 2 Introduction/ Plain Language

Table of Contents 3
3 Page 4 5
Dean Health Plan, Inc.
1277 Deming Way
Madison, WI 53717

This brochure describes the benefits of Dean Health Plan under our contract CS1996 with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of
this brochure.

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
changes are summarized on page 45. Rates are shown at the end of this brochure.

2002 Dean Health Plan, Inc. 3 Introduction/ Plain Language

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

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us 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.

Plain Language 4
4 Page 5 6
2002 Dean Health Plan, Inc. 4 Introduction/ Plain Language
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 information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800-279-1301 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.

Inspector General Advisory 5
5 Page 6 7
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.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing
any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure.
These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

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.

Dean Health Plan Inc. is a for-profit HMO, and has been in business since 1983. If you want more information
about us, call 800-279-1301, or write to Dean Health Plan, Attention Customer Service, 1277 Deming Way,
Madison, WI 53717. You may also contact us by fax at 608-827-4152 or visit our website at www. deancare. com.

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: Columbia, Crawford, Dane, Dodge, Fond Du Lac, Grant Green Lake, Iowa, Jefferson, Juneau,
Lafayette, Marquette, Richland, Rock, Sauk and Walworth Counties in Wisconsin.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your depend-ents
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.

2002 Dean Health Plan, Inc. 5 Section 1

Section 1: Facts about this HMO plan 6
6 Page 7 8
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, got 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 speech therapy benefits by removing the requirement that services must be required to restore
functional speech. (Section 5( a))

Changes to this Plan
Your share of the non-Postal premium will increase by 7.3% for Self Only or -5.8% for Self and Family
.
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))

We now cover certain intestinal transplants. (Section 5( b))
You pay $10 for generic drugs and $15 for brand name drugs under the prescription drug benefit.
Smoking cessation is now covered up to $100 for smoking cessation program per member per lifetime, including
the drug Zyban with a 2 month supply.

2002 Dean Health Plan, Inc. 6 Section 2

Section 2: How we change for 2002 7
7 Page 8 9
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until
you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800-279-1301

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

Plan providers Plan providers are physicians and other health care professionals in our service
area that we contract with to provide covered services to our members. We
credential Plan providers according to NCQA and Dean Health Plan standards.

We list Plan providers in the provider directory, which we update periodically.
Provider updates are also included in the quarterly mailing to all members in the
Notablesnewsletter.

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.

What you must do It depends on the type of care you need. First, you and each family member must to get covered care choose a primary care physician. This decision is important since your primary
care physician provides or arranges for most of your health care. When you
enroll, you (and your family members) must chose a primary care physician.
Each member of your family may select a different primary care physician. Your
primary care physician must be a doctor who practices a general scope of medi-cine.
A physician who specializes in only one area of medicine would not be able
to treat all of your basic health care needs.

Primary care The following types of physicians can be a primary care physician for you:
Family Practice doctors treat people of all ages. They focus on family health
problems. General Practice doctors treat people of all ages. Pediatric doctors treat
children and adolescents, and generally manage their health. Internal Medicine
doctors treat adult men and women. Obstetrics and Gynecology doctors manage a
woman's care during pregnancy and childbirth. They also treat conditions unique
to females. 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.

2002 Dean Health Plan, Inc. 7 Section 3

Section 3: How you get care 8
8 Page 9 10
Specialty care Your primary care physician will arrange your referral to a specialist for needed
care. You may also seek services from other Plan providers, including specialists,
located at the same clinic as your primary care physician, without a referral.
Written referrals are not required for the following types of services when
provided by a Dean Health Plan Provider: MRI (Magnetic Resonance Imaging),
Diagnostic tests & respiratory therapy, Home Health, Oral Surgery for covered
procedures, Routine vision care, and Chiropractic care.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a treatment
plan that allows you to see your specialist for a certain number of visits without
additional referrals. Your primary care physician will use our criteria when
creating your treatment plan

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 800-279-1301. If you are new to
the FEHB Program, we will arrange for you to receive care.

2002 Dean Health Plan, Inc. 8 Section 3 9
9 Page 10 11
If you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances Under certain extraordinary circumstances, such as natural disasters, we may our beyond our control 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. For prior approval 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 prior authorization. Your physician
must obtain prior authorization before sending you to a hospital, referring you
to a non-plan provider or facility, or recommending follow-up care.

We will provide benefits for covered services only when the services are
medically necessary to prevent, diagnose, or treat your illness or condition.

2002 Dean Health Plan, Inc. 9 Section 3 10
10 Page 11 12
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, 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 per
admission.

Coinsurance Coinsurance is the percentage that you must pay for specific services.
Example: In our Plan, you pay 50% of actual charges for diagnosis and treatment
of infertility services, and 20% of charges for orthopedic services, prosthetic
devices, lenses following cataract removal, and durable medical equipment.

Your out-of-pocket maximum We do not have an out-of-pocket maximum. `

2002 Dean Health Plan, Inc. 10 Section 4

Section 4: Your costs for covered services 11
11 Page 12 13
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 800-279-1301 or at our website at www. deancare. com.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . .12-18
Diagnostic and treatment servicess Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and occupational therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . .19-21
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . .22-23
Inpatient hospital Extended care benefits/ skilled nursing care facility benefits
Outpatient hospital or Hospice care
ambulatory surgical center Ambulance

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24-25
Medical emergency Ambulance
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27-28
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Dean on Call
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

2002 Dean Health Plan, Inc. 11 Section 5

Section 5: Benefits – OVERVIEW
Please see page 6 for how our benefits changed this year and page 45 for a benefits summary 12
12 Page 13 14
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.
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.

2002 Dean Health Plan, Inc. 12 Section 5 (a)

Section 5 (a): Medical services and supplies provided by physicians and other health care professionals
I M
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I M
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Benefit Description You pay

Diagnostic and treatment services
Professional services of physicians $10 per office visit
In physician's office

Professional services of physicians $10 per office visit
1) In an urgent care center
2) Office medical consultations
3) Second surgical opinion

Tests, such as: Nothing
Blood tests Non-routine Mammograms
Urinalysis CAT Scans/ MRI
Non-routine pap tests Ultrasound
Pathology Electrocardiogram and EEG
X-rays

Routine screenings, such as annual physical: $10 per office visit
Total Blood Cholesterol
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening – every five years starting at age 50

Prostate Specific Antigen (PSA test) – $10 per office visit
one annually for men age 40 and older

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

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

Lab, X-ray and other diagnostic tests
Preventive care, adult 13
13 Page 14 15
Routine immunizations, limited to: $10 per office visit
Tetanus-diphtheria (Td) booster –
once every 10 years, ages19 and over (except as provided for
under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over

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

Childhood immunizations recommended by the $10 per office visit
American Academy of Pediatrics

Well-child care charges for routine examinations, Nothing
immunizations and care (through age 17)

Examinations, such as: $10 per office visit
-Eye exams through age 17 to determine the need for
vision correction.
-Ear exams through age 17 to determine the need for
hearing correction
-Exams done on the day of immunizations (under age 22)

Complete maternity (obstetrical) care, such as: Nothing
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 13 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.
We pay hospitalization and surgeon services (delivery) the
same as for illness and injury. See Hospital benefits (Section 5c)
and Surgery benefits (Section 5b).

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

2002 Dean Health Plan, Inc. 13 Section 5 (a)

Preventive care, adult (continued) You Pay
Preventive care, children

Maternity care 14
14 Page 15 16
2002 Dean Health Plan, Inc. 14 Section 5 (a)
Family planning You Pay
Family planning care such as: $10 per office visit
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

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

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

Diagnosis and treatment of infertility, such as: 50% of actual charges
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs

NOTE: We cover injectable fertility drugs under medical benefits
and oral fertility drugs under the prescription drug benefit.
Coverage for infertility services is limited to one diagnostic
treatment per member per lifetime.

Not covered: All charges
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer, gamete (GIFT) and zygote (ZIFT)
-zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg

Testing and treatment $10 per office visit
Allergy injection

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

Infertility services
Allergy care 15
15 Page 16 17
2002 Dean Health Plan, Inc. 15 Section 5 (a)
Treatment therapies You Pay
Chemotherapy and radiation therapy $10 per office visit
NOTE: High dose chemotherapy in association with
autologous bone marrow transplants are limited to those
transplants listed under Organ/ Tissue Transplants on page 21.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy
Growth hormone therapy (GHT)
NOTE: Growth hormone is covered under the prescription
drug benefit.
NOTE: We will only cover GHT when your primary care
provider prior authorizes the treatment

Inpatient or outpatient basis for up to two months per Nothing
condition if significant improvement can be expected within
two months for the services of each of the following:
qualified physical therapists; and
occupational therapists.
NOTE: We only cover therapy to restore bodily function when
there has been a total or partial loss of bodily function due to
illness or injury. 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 infarctio. Phase II treatment must
begin within 90 days of surgery.

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

Inpatient or outpatient basis for up to two months per condition Nothing
when medically necessary.

Hearing exam $10 for associated office visit
Hearing testing for children through age 17
(see Preventive Care, children)
Hearing Aid – limited to one in any 36 month period. All costs over $500
This includes ear molds and hearing aid dispensing fees
NOTE: Infants and children under the age of 18 with bilateral
hearing loss are eligible for bilateral hearing aids.

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

Physical and occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies) 16
16 Page 17 18
2002 Dean Health Plan, Inc. 16 Section 5 (a)
In addition to the medical and surgical benefits provided for $10 per office visit
the diagnosis and treatment of diseases of the eye, annual eye
refractions (which include the written lens prescription for
eyeglasses)

One pair of eyeglasses or contact lenses to correct an $10 per office visit
impairment directly caused by accidental ocular injury or
intraocular surgery (such as for cataracts)

Eye exam to determine the need for vision correction $10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17, examinations All charges
for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Routine foot care when you are under active treatment for a $10 per office visit
metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe inserts.

Not covered: Cutting, trimming or removal of corns, calluses, or All charges
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)

Artificial limbs and eyes; stump hose 20% of the charges per purchase or rental
Externally worn breast prostheses and surgical bras,
including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following mastectomy.
NOTE: We pay internal prosthetic devices as hospital benefits;
see Section 5( c) for payment information. See 5( b) for coverage
of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

NOTE: Purchases exceeding $200 per month must be authorized
by the plan's Medical Director. Your plan doctor will obtain the
prior authorization.

Vision services (testing, treatment, and supplies) You Pay
Foot care
Orthopedic and prosthetic devices 17
17 Page 18 19
2002 Dean Health Plan, Inc. 17 Section 5 (a)
Not covered: All charges
arch supports
orthopedic and corrective shoes
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

NOTE: Medical supplies and equipment are covered when 20% of the charges per purchase or rental
prescribed by your Plan physician for treatment of a diagnosed
illness or injury. The supplies or equipment must be purchased
from a plan durable medical equipment provider.

NOTE: Purchases exceeding $200 per month or rentals
exceeding $200 per month must be authorized by the plan's
Medical Director. Your Plan doctor will obtain the prior
authorization.

Some examples of medical supplies, durable and disposable
medical equipment are:
Wheelchairs (requires prior authorization by our Health
Services Department)
Hospital beds
Splints, trusses, crutches, orthopedic braces, and appliances
Walkers
Blood glucose monitors
Insulin pumps
TENS unit
Oxygen therapy and other inhalation therapy and related items
for home use must be prior authorized by the Health Services
Department
Rental of a ventilator or other mechanical equipment or
purchase of such equipment at the option of Dean Health Plan

NOTE: Call us at 800-279-1301 as soon as your Plan
physician prescribes this equipment. We will arrange with a
health care provider to rent or sell you durable medical
equipment at discounted rates and will tell you more about
this service when you call.

Not covered: All charges
Repairs and replacement of durable medical equipment/ supplies
unless they are prior authorized by the Health Services
Department
Elastic support stockings (e. g., TEDS, JOBST, etc.)
Shoes or orthotics that are not custom made and can be
purchased over the counter.

Orthopedic and prosthetic devices (continued) You Pay
Durable Medical Equipment (DME) 18
18 Page 19 20
2002 Dean Health Plan, Inc. 18 Section 5 (a)
Not Covered: All charges
Medical supplies and durable medical equipment for comfort,
personal hygiene, and convenience such as, but not limited to:
air conditioners, air cleaners, humidifiers, physical fitness
equipment, physician's equipment, disposable supplies,
alternative communication devices, and self-help devices not
medical in nature.
Home testing and monitoring supplies and related equipment
except those used in connection with the treatment of diabetes.
Equipment, models or devices that have features over and above
that which is medically necessary. Coverage will be limited to
the standard model as determined by Dean Health Plan.
Any durable medical equipment or supplies used for work,
athletic, or job enhancement.

Home health services of nurses and health aides, including Nothing
intravenous fluids and medications, when prescribed by your
Plan doctor, who will periodically review the program for
continuing appropriateness and need.

Not covered: All charges
Nursing care requested by, or for the convenience of, the
patient or the patient's family;
Services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.
Home care primarily for personal assistance that does not
include a medical component and is not diagnostic, therapeutic,
or rehabilitative.

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

Not covered: All charges
Long-term or maintenance therapy
Chiropractic services preformed by a non-plan provider

No benefits All charges
Smoking Cessation $100 per member per lifetime through
Limited coverage available in the following programs: program
Group Counseling Internet Program
Self-Direct Kit Telephonic Program Zybanis covered for a 2-month supply
NOTE: Please call us at 800-279-1301 for details on each of the under this program. You pay a $15 brand
above options. name copay. See prescription drug benefits.

Durable Medical Equipment (continued) You Pay
Home Health Services
Chiropractic
Alternative treatments
Educational classes and programs 19
19 Page 20 21
2002 Dean Health Plan, Inc. 19 Section 5 (b)
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.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional
for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.).

Section 5 (b): Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

I M
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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as Operative procedures Nothing
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
braces and prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns
NOTE: Generally, we pay for internal prosthesis (devices)
according to where the procedure is done. For example, we pay
Hospital benefits for a pacemaker and Surgery benefits for insertion
of the pacemaker.

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot Care 20
20 Page 21 22
2002 Dean Health Plan, Inc. 20 Section 5 (b)
Surgery to correct a functional defect Nothing
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by
such surgery
Surgery to correct a condition that existed at or from birth and
is a significant deviation from the common form or norm.
Examples of congenital anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth marks; webbed fingers;
and webbed toes.
All stages of breast reconstruction surgery following a
mastectomy, such as: surgery to produce a symmetrical
appearance on the other breast; treatment of any physical
complications, such as lymphedemas; breast prostheses and
surgical bras and replacements (see Prosthetic devices)

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

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

Oral surgical procedures, limited to: $10 per office visit
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their
supporting structures.
Diagnostic procedures and medically necessary surgical or
non-surgical treatment for the correction of temporomandibular
disorders (TMD) if all of the following apply:
The condition is caused by congenital, developmental or
acquired deformity, disease or injury
Under the accepted standards of the profession of the health
care provider rendering the service, the procedure or device is
reasonable and appropriate for the diagnosis or treatment of this
condition.
The purpose of the procedure or device is to control or
eliminate infection, pain, disease or dysfunction. This includes
coverage for prescribed intra oral splint therapy devices.
All services must be prior authorized by the Health Services
Department, and provided by a plan provider designated by us
to treat TMD.

Reconstructive surgery You Pay
Oral and maxillofacial surgery 21
21 Page 22 23
2002 Dean Health Plan, Inc. 21 Section 5 (b)
Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)

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

Not covered:
Donor screening tests and donor search expenses except those All charges
performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
Professional services provided in hospital (inpatient)

Professional services provided in hospital Nothing
(outpatient department)
Skilled nursing facility
Ambulatory surgical center
Office

Oral and maxillofacial surgery (continued) You Pay
Organ/ tissue transplants

Anesthesia 22
22 Page 23 24
2002 Dean Health Plan, Inc. 22 Section 5 (c)
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
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).

Section 5 (c): Services provided by a hospital or other facility, and ambulance services
I M
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Benefit Description You pay
Inpatient hospital
Room and board, such as ward, semiprivate, or intensive care Nothing
accommodations;
general nursing care; and
meals and special diets.

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

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

NOTE: Inpatient dental procedures – limited benefit. Hospitalization
for certain procedures is covered when a Plan doctor determines
there is a need for hospitalization for reasons totally unrelated to
the dental procedure; the Plan will cover the hospitalization, but not
the cost of the professional dental services. Conditions for which
hospitalization would be covered include hemophilia and heat
disease; the need for anesthesia, by itself, is not such a condition.
The Plan will not cover the cost of the professional dental services.

I M
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23 Page 24 25
2002 Dean Health Plan, Inc. 23 Section 5 (c)
Not covered: Custodial care, non-covered facilities, such as nursing All charges
homes; schools; personal comfort items, such as telephone,
television, barber services, guest meals and beds; and private
nursing care

Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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

Extended care benefit: The Plan provides a comprehensive Nothing
range of benefits for up to 120 days per benefit period when
full-time skilled nursing care is necessary and confinement in a
skilled nursing facility is medically appropriate as determined
by a Plan doctor and approved by the Plan.
All necessary services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily
provided or arranged by the skilled nursing facility when
prescribed by a Plan doctor.
Hospice Care

See above – Extended care benefit Nothing
Not covered: Independent nursing, homemaker services All charges

Local professional ambulance service when medically appropriate Nothing
(Ground and/ or air)

Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Ambulance

Inpatient hospital (continued) You Pay
Hospice care 24
24 Page 25 26
2002 Dean Health Plan, Inc. 24 Section 5 (d)
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.
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.

Section 5 (d): Emergency services/ accidents I
M P
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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems
are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may
determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable
to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospi-tal
emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the
Plan. Your or a family member should notify the Plan within 48 hours. It is your responsibility to ensure that the Plan
has been timely notified.

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

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan
provider would result in death, disability or significant jeopardy to your condition.

Any follow up care recommended by non-Plan providers must be prior authorized by the Plan, or provided by Plan
providers.

Plan pays reasonable charges for emergency services to the extent the services would have been covered if received
from Plan providers.

You pay a $50 copayment per hospital emergency room visit

I M
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25 Page 26 27
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or
unforeseen illness.
If you need to be hospitalized, the Plan should be notified within 48 hours following your admission, unless it was
not reasonably possible to notify the Plan within that time. If a Plan believes you can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Any follow up care recommended by non-Plan providers must be prior authorized by the plan, or provided by Plan
providers.

Plan pays reasonable charges for emergency care services to the extent the services would have been covered in
received from Plan providers.

You pay a $50 copayment per hospital emergency room visit.

2002 Dean Health Plan, Inc. 25 Section 5 (d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center $10 per office visit
Emergency care as an outpatient or inpatient at a hospital, $50 per hospital emergency room visit
including doctors' services

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

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center $10 per office visit
Emergency care as an outpatient or inpatient at a hospital, $50 per hospital emergency room visit
including doctors' services

Not covered: All charges
Elective care or non-emergency care
Emergency care provided outside the service area if the need for
care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area

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

Emergency outside our service area
Ambulance 26
26 Page 27 28
I M
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2002 Dean Health Plan, Inc. 26 Section 5 (e)

When you get our approval for services and follow a treatment plan we approve cost-sharing and
limitations for 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:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
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.

Section 5 (e): Mental health and substance abuse benefits
I M
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T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan Your cost sharing responsibilities are no
provider and contained in a treatment plan that we approve. The greater than for other illness or conditions.
treatment plan may include services, drugs, and supplies described
elsewhere in this brochure.

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

Professional services, including individual or group therapy $10 per office visit
by providers such as psychiatrists, psychologists, or clinical
social workers
Medication management

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

Pre-authorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization
processes:
If you are seeking care from a mental health or substance abuse provider at the same clinic as your primary care
provider, no referral is needed. Your provider will need to file a treatment plan with us for prior approval for ongoing
treatment.

If you are seeking care outside of your primary care provider or clinic, you must obtain a referral from your primary
care provider before receiving services. On your behalf, your provider must submit referral request (and treatment
plan if applicable) to us for prior approval. We will provide written confirmation to the provider if approval is given
for the services. For information on available plan providers or status of a referral, please contact Customer Service
at 800-279-1301.

Limitations We may limit your benefits if you do not obtain a treatment plan. 27
27 Page 28 29
2002 Dean Health Plan, Inc. 27 Section 5 (f)
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable
only when we determine they are medically necessary.
Certain prescription drugs included in our formulary require prior authorization. The drug prior
authorization process can be initiated by you r Plan physician or your plan pharmacy by filling out a
Drug Prior Authorization Request form. A copy of this request including the determination will then
be mailed back to you, your plan pharmacy, and plan physician. Updates to our drug formulary are
provided in Notables, our quarterly news magazine sent to the member's home. Members may also
obtain a listing by calling our Customer Service Department at 800-279-1301.
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.

Section 5 (f): Prescription drug benefits
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There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or referral doctor must write the prescription
Where you can obtain them. You must fill the prescription at a plan pharmacy or national plan pharmacy.
We use a formulary. Prescription drugs are included in our formulary by our Pharmacy and Therapeutics
Committee to ensure that our members receive safe, effective treatment at a reasonable cost. The committee
is staffed by providers from many different specialties. Drugs recently approved by the Food and Drug
Administration are not automatically included in the formulary, but may be added after the committee determines
therapeutic advantages of the drug and its medically appropriate application. In addition, certain drug products
are excluded when therapeutic alternatives are available. If your physician prescribes a drug that is not on our
formulary, the physician must obtain prior authorization from the plan in order for the prescription to be covered
under plan benefits. In some cases, the physician will need to prescribe an alternative formulary drug if an alterna-tive
is available that is equally effective for the patient for treatment of the specific condition. To order a listing
of the drugs that require prior authorization or are excluded, call our Customer Service Department at 800-279-1301.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a
plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply, whichever is less; 240 milligrams of
liquid (8oz.); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i. e., one
inhaler, one vial opthamolic medication or insulin). You pay a $10 copay per prescription unit or refill for generic
drugs and a $15 copay for name brand drugs when generic substitution is not permissible. When generic substitu-tion
is available, a generic equivalent will be dispensed, unless your physician specifically requires a name brand.
If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not
specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name
brand drug and the generic.
Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and
dosage to the original brand name product. Generic drugs cost you and your plan less money than a name-brand
drug.
When you have to file a claim. If you receive a prescription outside of the area or a situation arises where the
pharmacy cannot process a prescription under the plan, you may submit an itemized receipt to us for reimburse-ment
for all covered prescription drugs. Send the receipt to: Dean Health Plan, 1277 Deming Way, Madison, WI
53717. 28
28 Page 29 30
2002 Dean Health Plan, Inc. 28 Section 5 (f)
Benefit Description You pay
Covered medications and supplies

We cover the following medications and supplies prescribed by $10 per generic prescription
a Plan physician and obtained from a Plan pharmacy: $15 per name brand prescription

Drugs and medicines that by Federal law of the United States NOTE: If there is no generic equivalent
require a physician's prescription for their purchase. available, you will still have to pay the
Oral and injectable contraceptive drugs up to a 30 day supply; brand name copay.
contraceptive diaphragms
Insulin, with a copay charge applied to each vial
Diabetic supplies, including disposable needles and syringes
needed forthe injecting covered prescribed medication, glucose
test tabletsand test tape, Benedict's solution or equivalent and
acetone test tablets; a copay will apply for each item purchased
Infertility drugs and growth hormones; you pay 50% of the cost 50% of cost
of the prescription unit or refill
Intravenous fluids and medication for home use are covered
under Medical and Surgical Benefits
Zyban is covered for a one time 2-month supply under the
brand name prescription drug benefit through the Smoking
Cessation program

NOTE: (Limited Benefits): Drugs to treat sexual dysfunction are You pay a 50% copay up to the doses
limited. Contact the Plan for dose limits limit and all charges above that

Here are some things to keep in mind about our prescription drug
program:
A generic equilivant will be dispensed if it is available, unless
your physician specifically requires a name brand. If you receive
a name brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as
Written for the name brand drug, you have to pay the difference
in cost between the name brand drug and the generic.
We administer a closed formulary. If your physician beleives a
name brand product is necessary or there is no generic available,
your physician may prescribe a name brand drug from a
formulary list. This list of name brand drugs is a preferred list
of drugs that we selected to meet patient needs at a lower cost.
To order a listing of the drugs that require prior authorization or
are excluded, call our Customer Service Department at 800-279-
1301.

Not covered: All charges
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs not approved by the Plan
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
Vitamins, nutritional substances and food supplements that can
be purchased without a prescription
Nonprescription medicines 29
29 Page 30 31
2002 Dean Health Plan, Inc. 29 Section 5 (g &h)
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient. We do not cover the
dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

Section 5 (h): Dental benefits
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Benefit Description You pay
Accidental injury benefit
We cover restorative services and supplies necessary to promptly Nothing
repair (but not replace) sound natural teeth. The need for these
services must result from an accidental injury. Treatment must
begin within 90 days from injury.

We have no other dental benefits
Dental benefits

Section 5 (g): Special features
24 hour nurse line Dean on Call. For any of your health concerns, 24 hours a day, 7 days a week, you may
call 800-576-8773 and talk with a registered nurse who will discuss treatment options and answer your health
questions. 30
30 Page 31 32
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 What Services Require Our Prior Approval on
page 9.

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;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

2002 Dean Health Plan, Inc. 30 Section 6

Section 6: General exclusions – things we don't cover 31
31 Page 32 33
2002 Dean Health Plan, Inc. 31 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 and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at 800-279-1301
When you must file a claim – such as for out-of-area care – submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills and
receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or
supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary
payer – such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: 1277 Deming Way, Madison, WI 53717
Prescription drugs Send your prescription drug receipts to the address noted above
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service,
unless timely filing was prevented by administrative operations of Government
or legal incapacity, provided the claim was submitted as soon as reasonably
possible.

When we need more Please reply promptly when we ask for additional information. We may delay information processing or deny your claim if you do not respond. 32
32 Page 33 34
2002 Dean Health Plan, Inc. 32 Section 8
Section 8: The disputed claims process
Step Description
1 Ask us in writing to reconsider our initial decision. Write to us at 1277 Deming Way, Madison, WI 53717. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 1277 Deming Way, Madison, WI 53717; 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, DC 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in
this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

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 pre-authorization: 33
33 Page 34 35
2002 Dean Health Plan, Inc. 33 Section 8
Step Description
4 NOTE: If you want OPM to review different claims, 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.
6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which
you received the disputed services, drugs, or supplies or from the year in which you were denied
pre-certification 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 pre-authorization/ prior approval, then call
us at 800-279-1301 and we will expedite our review; or
(b) We denied your initial request for care or pre-authorization/ 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 can call OPM's Health Benefits Contracts Division IV at 202-606-0737 between 8 a. m. and
5 p. m. eastern time. 34
34 Page 35 36
2002 Dean Health Plan, Inc. 34 Section 9
Section 9: Coordinating benefits with other coverage
When you haveother health You must tell us if you are covered or a family member is covered under another coverage 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 reasonable charge.
After the primary plan pays, we will pay either what is left of the reasonable
charge or our regular benefit, whichever is less. We will not pay more than our
reasonable charge. If we are the secondary payer, we may be entitled to receive
payment from your primary plan.

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If
you or your spouse worked for at least 10 years in Medicare-covered employ-ment,
you should be able to qualify for premium-free Part A insurance.
(Someone who was a Federal employee on January 1, 1983 or since automati-cally
qualifies.) Otherwise, if you are age 65 or older, you may be able to buy
it. Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement check

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

The Original The Original Medicare Plan (Original Medicare) is available everywhere in
Medicare Plan the United States. It is the way everyone used to get Medicare benefits and is
(Part A or Part B) 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. 35
35 Page 36 37
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. Tell us if you or a
family member is enrolled in Medicare Part A and B. Medicare will determine
who is responsible for paying for medical services and we will coordinate the
payments. On occasion you may need to file a Medicare claim form.

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.

2002 Dean Health Plan, Inc. 35 Section 9
Primary Payer Chart
A. When either you -or your covered spouse-are age 65 over and you... Then the primary payer is...
Original Medicare This Plan

1) Are you an active employee with the Federal government (including 3
when you or a family member are eligible for Medicare solely because
of a disability),

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

b) The position is not excluded from FEHB 3
(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 3
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, 3( for Part B services) 3( for other services)

6) Are a former Federal employee receiving Workers' Compensation and 3
the Office of Workers' Compensation Programs has determined that (except for claims related
you are unable to return to duty, 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 3
solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are still 3
eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became 3 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 3
b) Are an active employee, or 3
c) Are a former spouse of an annuitant, or 3
d) Are a former spouse of an active employee 3 36
36 Page 37 38
2002 Dean Health Plan, Inc. 36 Section 9
Claims process-when you have the Original Medicare Plan –You probably will never have to file a claim form when you have both our Plan and the Original
Medicare Plan.
When we coordinate benefits as the primary plan, we will process the claims
without consideration of what Medicare may cover. All plan copayments,
deductibles, policy maximums, limitations and exclusions will apply

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
800-279-1301.

We do not waive any costs when you have Medicare.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan – a Medicare
managed care plan. These are health care choices (like HMOs) in some areas of
the country. In most Medicare managed care plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare managed care provide
all the benefits that Original Medicare covers. Some cover extras, like prescrip-tion
drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are
available to you:

This Plan and our Medicare managed care plan: You may not enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan.

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, but we will not waive any of our copayments, coinsurance. If you
enroll in a Medicare managed care plan, tell us. We will need to know whether
you are in the Original Medicare Plan or in a Medicare managed care plan so we
can correctly coordinate benefits with Medicare.

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

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under Medicare Part A or Part B 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. 37
37 Page 38 39
2002 Dean Health Plan, Inc. 37 Section 9
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both
TRICARE and this Plan cover you, we pay first. See your TRICARE Health
Benefits Advisor if you have questions about TRICARE coverage.

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

When others are responsible When you receive money to compensate you for medical or hospital care for for injuries injuries or illness caused by another person, you must reimburse us for any
expenses we paid. However, we will cover the cost of treatment that exceeds
the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 38
38 Page 39 40
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 38.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care The type of care given when the basic goal is to help a person in the activities of daily life. This includes help in walking; getting in and out of bed, bathing,
dressing, eating, using the toilet, preparing special diets, taking medications
properly; and 24 hour supervision for potentially unsafe behavior. Such care
is custodial when it does not require continued attention by trained medical
personnel. Such care is custodial even if provided by registered nurses, licensed
practical nurses, or other trained medical personnel.

Experimental or We regularly evaluate new medical devices, new techniques, and new uses for investigational services older existing procedures. This process is both proactive and reactive. Health care
experts in the Dean organization, including physicians, and specialty providers,
review and evaluate all pertinent information. If new technology is approved,
procedures and policies are revised or established to implement this decision.

Medical necessity The services or supplies provided by a hospital, or plan provider (or a non-plan provider if there is an authorized referral requested or in an emergency or urgent
care situation) that are required to identify or treat a member's illness or injury
and which, as determined by the Health Services Department, are: (a) consistent
with the illness or injury; (b) in accordance with generally accepted standards of
acceptable medical practice; (c) not solely for the convenience of a member,
hospital, plan provider, or other provider; and (d) the most appropriate supply or
level of service that can be safely provided to the member.

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

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

2002 Dean Health Plan, Inc. 38 Section 10 39
39 Page 40 41
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get informationSee www. opm. gov/ insure. Also, your employing or retirement office can answer about enrolling in the FEHB your questions, and give you a Guide to Federal Employees Health Benefits
Program Plans, brochures for other plans, and other materials you need to make an informed decision about:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave
without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your for you and your family 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 immedi-ately
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.

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

2002 Dean Health Plan, Inc. 39 Section 11

Section 11: FEHB facts 40
40 Page 41 42
2002 Dean Health Plan, Inc. 40 Section 11
Your medical and claims We will keep your medical and claims information confidential. Only the records are confidential following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the
Office of Workers' Compensation Programs (OWCP), when coordinating
benefit payments and subrogating claims;

Law enforcement officials when investigating and/ or prosecuting alleged civil
or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.

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 You will receive an additional 31 days of coverage, for no additional premium,
coverage ends 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 continue
coverage to get benefits under your former spouse's enrollment. But, you may be eligible
for your own FEHB coverage under the spouse equity law. 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.

Temporary Contination Enrolling in TCC. If you leave Federal service, or if you lose coverage because Coverage (TCC)
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. 41
41 Page 42 43
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.

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

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

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Group Health Plan Coverage Federal law that offers limited Federal protections for health coverage availability
and continuity to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan Coverage
that indicates how long you have been enrolled with us. You can use this certifi-cate
when getting health insurance or other health care coverage. Your new plan
must reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as you
enroll within 63 days of losing coverage under this Plan. If you have been
enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans.

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

2002 Dean Health Plan, Inc. 41 Section 11 42
42 Page 43 44
Long Term Care Insurance is coming later in 2002
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance

The Office of Personnel Management (OPM) will sponsor a high-quality long-term care insurance program effective
in October 2002. As a part of its educational effort, OPM asks you to consider these questions:

What is long-term care (LTC) It's insurance to help pay for long term care services you may need if you insurance? can't take care of yourself because of an extended illness or injury, or an
age-related disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care,
care in an assisted living facility, care in your home, adult day care, hospice
care, and more. LTC insurance supplement care provided by family members,
reducing the burden you place on them.

I'm healthy. I won't need Welcome to the club! Long-term care. Or, will I? 76% of Americans believe they will never need long-term care, but the facts
are that about half of them will. And it's just not the old folks. About 40% of
people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long-term care, but everyone should have a plan
just incase. Many people now consider long-term care insurance to be vital to
their financial and retirement planning.

Is long-term care expensive? Yes, it can be very expensive. A year in a nursing home can exceed $50,000.00. Home care for only three 8-hour shifts a week can exceed
$20,000.00 a year. And that's before inflation!
Long-term care can protect your savings. Long-term care Insurance can
protect your savings.

But won't my FEHB plan, Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your Medicare orMedicaid cover FEHB brochure. Health plans don't cover custodial care or a stay in an assisted
mylong term care? living facility or a continuing need for home health aide to help you get in and out of bed and with other activities of daily living. Limited stays in skilled
nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty guide-lines,
but has restrictions on covered services and where they can be received.
Long-term care insurance can provide choices of care and preserve your
independence.

When will I get more Employees will get more information from their agencies during the LTC open information on how to apply enrollment period in the late summer/ early fall of 2002.
for this new insurance coverage? Retirees will receive information at home.

How can I find out more Our toll-free teleservice center will begin in mid-2002. In the meantime, you about the Program NOW? can learn more about the program on our web site at www. opm. gov/ insure/ ltc.

2002 Dean Health Plan, Inc. 42 Long Term Care Insurance 43
43 Page 44 45
2002 Dean Health Plan, Inc. 43 Index
Index
A Accidental injury . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Allergy tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Alternative treatment . . . . . . . . . . . . . . . . . . . . . . . .18
Allogeneic (donor) bone marrow transplant . . . . . . .21
Ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Autologous bone marrow transplant . . . . . . . . . . . .21

B Biopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Birthing centers . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Blood and blood plasma . . . . . . . . . . . . . . . . . . . . .21
Breast cancer screening . . . . . . . . . . . . . . . . . . . . . .12

C Casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Changes for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Cholesterol tests . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Colorectal cancer screening . . . . . . . . . . . . . . . . . . .12
Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . .12
Contraceptive devices and drugs . . . . . . . . . . . . . . .27
Coordination of benefits . . . . . . . . . . . . . . . . . . . . .35
Covered charges . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Covered providers . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Crutches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

D Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Dental care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Diagnostic services . . . . . . . . . . . . . . . . . . . . . . . . .12
Disputed claims review . . . . . . . . . . . . . . . . . . . . . .32
Donor expenses (transplants) . . . . . . . . . . . . . . . . .21
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Durable medical equipment (DME) . . . . . . . . . . . . .16

E Educational classes and programs . . . . . . . . . . . . . .18
Effective date of enrollment . . . . . . . . . . . . . . . . . .39
Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Experimental or investigational . . . . . . . . . . . . . . . .38
Eyeglasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

F Family planning . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Fecal occult blood test . . . . . . . . . . . . . . . . . . . . . . .12
G General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . .30

H Hearing services . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Home health services . . . . . . . . . . . . . . . . . . . . . . .18
Hospice care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Home nursing care . . . . . . . . . . . . . . . . . . . . . . . . .18
Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

I Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Inhospital physician care . . . . . . . . . . . . . . . . . . . . .22
Inpatient Hospital Benefits . . . . . . . . . . . . . . . . . . .22
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

L Laboratory and pathological services . . . . . . . . . . . .12

M Machine diagnostic tests . . . . . . . . . . . . . . . . . . . . .12
Magnetic Resonance Imagings (MRIs) . . . . . . . . . .12
Mammograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Maternity Benefits . . . . . . . . . . . . . . . . . . . . . . . . . .13
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Medically necessary . . . . . . . . . . . . . . . . . . . . . . . .38
Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Mental Conditions/ Substance Abuse Benefits . . . . .26

Do not rely on this page. It is for your convenience and may not show all pages where terms appear. 44
44 Page 45 46
2002 Dean Health Plan, Inc. 44 Index
N Newborn care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
O Obstetrical care . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Occupational therapy . . . . . . . . . . . . . . . . . . . . . . . .15
Ocular injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Office visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Oral and maxillofacial surgery . . . . . . . . . . . . . . . .20
Orthopedic devices . . . . . . . . . . . . . . . . . . . . . . . . .16
Ostomy and catheter supplies . . . . . . . . . . . . . . . . .17
Out-of-pocket expenses . . . . . . . . . . . . . . . . . . . . . .10
Outpatient facility care . . . . . . . . . . . . . . . . . . . . . .23
Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

P Pap test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Physical examination . . . . . . . . . . . . . . . . . . . . . . . .12
Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Precertification . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Preventive care, adult . . . . . . . . . . . . . . . . . . . . . . .12
Preventive care, children . . . . . . . . . . . . . . . . . . . . .13
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . .27
Preventive services . . . . . . . . . . . . . . . . . . . . . . . . .12
Prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Prostate cancer screening . . . . . . . . . . . . . . . . . . . .12
Prosthetic devices . . . . . . . . . . . . . . . . . . . . . . . . . .16
Psychologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

R Radiation therapy . . . . . . . . . . . . . . . . . . . . . . . . . .15
Renal dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Room and board . . . . . . . . . . . . . . . . . . . . . . . . . . .22

S Skilled nursing facility care . . . . . . . . . . . . . . . . . . .23
Smoking cessation . . . . . . . . . . . . . . . . . . . . . . . . . .18
Speech therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Splints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Sterilization procedures . . . . . . . . . . . . . . . . . . . . . .14
Subrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Oral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Reconstructive . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Syringes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

T Temporary continuation of coverage . . . . . . . . . . . .40
Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Treatment therapies . . . . . . . . . . . . . . . . . . . . . . . . .15

V Vision services . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

W Well child care . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Wheelchairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Workers' compensation . . . . . . . . . . . . . . . . . . . . . .37

X X-rays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 45
45 Page 46 47
2002 Dean Health Plan, Inc. 45 Summary of Benefits
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: Office visit copay:
Diagnostic and treatment services provided in the office $10 copayment per office visit 12

Services provided by a hospital:
Inpatient Nothing 22

Outpatient $10 for office visit or a house call by a 23
doctor (except for well child care through
age 17 and maternity visits)

Emergency benefits:
In-area $50 per hospital emergency room visit 24

Out-of-area $50 per hospital emergency room visit 24
Mental health and substance abuse treatment $10 copayment for each visit 26
Prescription drugs: 27
Generic prescription drugs $10 per prescription or refill

Brand name prescription drugs $15 per prescription or refill
Dental Care:
Accidental injury Nothing 29

Vision Care:
One refraction annually $10 per office visit 16

Summary of benefits for Dean Health Plan, Inc. 2002 46
46 Page 47
2002 Rate Information for
Dean Health Plan

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

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

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

South Central Wisconsin
High Option Self Only WD1 $88.76 $29.59 $192.32 $64.11 $105.04 $13.31
High Option Self & Family WD2 $223.41 $96.15 $484.06 $208.32 $263.75 $48.04 47

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