Cimarron Health Plan www. cimarronhealthplan. com 2002
A Health Maintenance Organization
Serving: All counties in the State of New Mexico
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.

This plan has 1 year accreditation from NCQA. See the 2002 Guide
for more information on accreditation.

Enrollment codes for this Plan:
PX1 Self Only PX2 Self and Family

For changes in benefits
see page 7.

RI 73-251 1
1 Page 2 3
2002 Cimarron Health Plan 2 Table of Contents
Introduction ............ ............ ............. ........... ............ ............ ............ ............ ............ .............. ........... 4
Plain Language ............ ............ ............. ........... ............ ............ ............ ............ ............ ............ .......... 4
Inspector General Advisory ....... .............. ............ .............. ............ .............. ............. ............. .............. ........... 4
Section 1 — Facts about this HMO plan . ........... ............ ............ ............ ............ ............ ............ .......... 6
How we pay providers ....... ........... ............ .......... ............ ........... ............ ............ .......... 6
Who provides my healthcare? ....... ............ ............ ............ ............ ............ ............ .......... 6
Your Rights ........ ............. ........... ............ ............ ............ ............ ............ ............ .......... 6
Service Area ......... ............. ........... ............ ............ ............ ............ ............ ............ .......... 6
Section 2 — How we change for 2002.... ........... ............ ............ ............ ............ ............ ............ .......... 7
Program-wide changes........ ........... ............ ............ ............ ............ ............ ............ .......... 7
Changes to this Plan............ ........... ............ ............ ............ ............ ............ ............ .......... 7
Section 3 — How you get care .. ............. ........... ............ ............ ............ ............ ............ ............ .......... 8
Identification cards ............. ........... ............ ............ ............ ............ ............ ............ .......... 8
Where you get covered care ........... ............ ............ ............ ............ ............ ............ .......... 8
Plan providers ............. ........... ............ ............ ............ ............ ............ ............ .......... 8
Plan facilities. ............. ........... ............ ............ ............ ............ ............ ............ .......... 8
What you must do to get covered care ..... ........... ............ ............ ............ ............ ............ ............ .......... 8
Primary care .. ............. ........... ............ ............ ............ ............ ............ ............ .......... 8
Specialty care ............. ........... ............ ............ ............ ............ ............ ............ .......... 8
Hospital care.. ............. ........... ............ ............ ............ ............ ............ ............ .......... 9
Circumstances beyond our control . ............ ............ ............ ............ ............ ............ ........ 10
Services requiring our prior approval .......... ............ ............ ............ ............ ............ ........ 10
Section 4 — Your costs for covered services ...... ............ ............ ............ ............ ............ ............ ........ 11
Copayments... ............. ........... ............ ............ ............ ............ ............ ............ ........ 11
Deductible ..... ............. ........... ............ ............ ............ ............ ............ ............ ...... 11
Coinsurance... ............. ........... ............ ............ ............ ............ ............ ............ ........ 11
Your out-of-pocket maximum........ ............ ............ ............ ............ ............ ............ ........ 11
Section 5 — Benefits .... ............ ............. ........... ............ ............ ............ ............ ............ ............ ........ 12
Overview.. ............ ............. ........... ............ ............ ............ ............ ............ ............ ........ 12
(a) Medical services and supplies provided by physicians and other health care
professionals ............ ........... ............ ............ ............ ............ ............ ............ ........ 13
(b) Surgical and anesthesia services and supplies provided by physicians
and other health care professionals... ............ ............ ............ ............ ............ ........ 21
(c) Services provided by a hospital or other facility, and ambulance services ....... ........ 25
(d) Emergency services/ accidents ......... ............ ............ ............ ............ ............ ........ 28
(e) Mental health and substance abuse benefits .. ............ ............ ............ ............ ........ 30
(f) Prescription drug benefits ... ............ ............ ............ ............ ............ ............ ........ 32

Table of Contents Page 2
2 Page 3 4
2002 Cimarron Health Plan 3 Table of Contents
(g) Special features........ ........... ............ ............ ............ ............ ............ ............ ........ 35
Prenatal Program .......... ... ......................... ............ ............ ............ ............ ........ 35
Child Safety Program ... ... ......................... ............ ............ ............ ............ ........ 35
24-hour nurse line ........ ... ......................... ............ ............ ............ ............ ........ 35
(h) Dental benefits................. ... ......................... ............ ............ ............ ............ ........ 36
(i) Non-FEHB benefits available to Plan members......... ............ ............ ............ ........ 37
Section 6 — General exclusions – things we don't cover............. ............ ............ ............ ............ ........ 38
Section 7 — Filing a claim for covered services ......................... ............ ............ ............ ............ ........ 39
Section 8 — The disputed claims process........... ............ ............ ............ ............ ............ ............ ........ 40
Section 9 — Coordinating benefits with other coverage . ............ ............ ............ ............ ............ ........ 42
When you have ....
Other health coverage . ........... ............ ............ ............ ............ ............ ............ ........ 42
Original Medicare ....... ........... ............ ............ ............ ............ ............ ............ ........ 42
Medicare managed care plan... ............ ............ ............ ............ ............ ............ ........ 44
TRICARE/ Workers' Compensation/ Medicaid......... ............ ............ ............ ............ ........ 45
Other Government agencies ........... ............ ............ ............ ............ ............ ............ ........ 45
When others are responsible for injuries ..... ............ ............ ............ ............ ............ ........ 45
Section 10— Definitions of terms we use in this brochure ............ ............ ............ ............ ............ ........ 46
Section 11— FEHB facts ........... ............. ........... ............ ............ ............ ............ ............ ............ ........ 47
Coverage information ......... ........... ............ ............ ............ ............ ............ ............ ........ 47
No pre-existing condition limitation .... ............ ............ ............ ............ ............ ........ 47
Where you get information about enrolling in the FEHB Program ......... ............ ........ 47
Types of coverage available for you and your family.... ............ ............ ............ ........ 47
When benefits and premiums start ....... ............ ............ ............ ............ ............ ........ 47
Your medical and claims records are confidential ......... ............ ............ ............ ........ 48
When you retire........... ........... ............ ............ ............ ............ ............ ............ ........ 48
When you lose benefits....... ........... ............ ............ ............ ............ ............ ............ ........ 48
When FEHB coverage ends .... ............ ............ ............ ............ ............ ............ ........ 48
Spouse equity coverage........... ............ ............ ............ ............ ............ ............ ........ 48
Temporary Continuation of Coverage (TCC) ... ............ ............ ............ ............ ........ 48
Converting to individual coverage ....... ............ ............ ............ ............ ............ ........ 49
Getting a Certificate of Group Health Plan Coverage.... ............ ............ ............ ........ 49
Section 12 — Long term care insurance is coming later in 2002 .. ............ ............ ............ ............ ........ 50
Index... ............. ............ ............ ............. ........... ............ ............ ............ ............ ............ ............ ........ 51
Summary of benefits ..... ............ ............. ........... ............ ............ ............ ............ ............ ............ ........ 52
Rates.............. ........ ..... ............. ............ ............ ............ ............ ............ ............ ............ ............ ....... Back cover

Table of Contents continued Page 3
3 Page 4 5

2002 Cimarron Health Plan 4 Introduction Plain Language Inspector General Advisory
Introduction
Cimarron Health Plan P. O. Box 3887
Albuquerque, NM 87190
This brochure describes the benefits of Cimarron Health Plan under our contract (CS 2062) 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 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Cimarron Health Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at

the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC, 20415-3650.

Inspector General Advisory
Stop health care fraud Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any 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 800-473-0391, or
(505) 342-4680, and explain the situation.

Inspector General Advisory continued on next page. 4
4 Page 5 6
2002 Cimarron Health Plan 5 Inspector General Advisory (continued)
Inspector General Advisory continued
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. 5
5 Page 6 7

2002 Cimarron Health Plan 6 Section 1
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.

Who provides my health care?
Cimarron Health Plan is an individual practice plan that provides care to members through an extensive list of private practice doctors and other providers located conveniently throughout the entire State of New Mexico. The doctor panel consists of
over 2,400 primary care doctors and over 1,200 specialists.

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

Find out about care management, which includes medical practice guidelines, disease management programs and how we determine if procedures are experimental or investigational.

If you want more information about us, call 800/ 473-0391, or write to Cimarron Health Plan, P. O. Box 3887, Albuquerque, NM 87190. You may also contact us by fax at 505/ 798-4558 or visit our website at www. cimarronhealthplan. 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 the entire State of New Mexico.

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 also reimburse routine care received at Student Health Care Centers at the out-of-
area colleges or universities that your covered dependent children attend, less the office visit copayment. We will not pay for any other health care services out of our service area unless the services have prior plan approval.

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

Section 1. Facts about this HMO Plan 6
6 Page 7 8
2002 Cimarron Health Plan 7 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that
does not change benefits.

Program-wide changes
We increased 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 42% for Self Only or 41. 6% for Self and Family.
We now cover certain intestinal transplants. (Section 5( b))
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We cover six smoking cessation classes. You pay $10 per session. Smoking cessation drugs are covered under the prescription drug benefit up to a maximum of $500 per member per lifetime. Mental health counseling is covered under
Mental health benefits subject to a $10 per visit member copayment.
Fluoride treatment now limited to members under 18.
Under the Preventive dental benefit, we now cover: -Space maintainers
-Emergency treatment for pain relief 7
7 Page 8 9
2002 Cimarron Health Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from
a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health

benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 473-0391 or
(505) 342-4680.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential
Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

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

What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care
physician provides or arranges for most of your health care. Call Customer Service at (800) 473-0391 or (505) 342-4680 to choose or change your primary care

physician.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or will give you a
referral to see a specialist.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care

physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However,
women may see their OB-Gyn physicians for female-related conditions without a referral. Services of providers who are not Plan contracted providers are covered
only when approved in advance by the Plan.

How you get care continued on next page. 8
8 Page 9 10
2002 Cimarron Health Plan 9 Section 3
Section 3. How you get care continued
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with the Plan to develop
a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria
when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

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

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

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

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist
until the end of your postpartum care, even if it is beyond the 90 days. Hospital Care
Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing
or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at (800) 473-0391 or (505) 342-4680. If you are

new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
How you get care continued on next page

. 9
9 Page 10 11
2002 Cimarron Health Plan 10 Section 3
Section 3. How you get care continued
Circumstances beyond our control
These provisions apply only to the benefits of the hospitalized person.
Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make
all reasonable efforts to provide you with the necessary care.

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

We call this review and approval process "prior authorization". Your physician must obtain a prior authorization for services such as hospitalization and outpatient surgery
and procedures, testing such as CT Scans and MRI's, and nuclear medicine. Your physician will request these services directly from the Plan. If care must be extended,
your physician will request additional visits or procedures from the Plan. 10
10 Page 11 12
2002 Cimarron Health Plan 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

Copayment A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you visit an emergency room, you pay a $50 copayment.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for those services. Copayments do not count toward any deductible. We do not have deductibles.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. Example: In our Plan, you pay 50% of our allowance for infertility services and 20%
for durable medical equipment.

Your out-of-pocket maximum for coinsurance and
copayments
After your out-of-pocket expenses total $5,665 per member in any calendar year, you do not have to pay any more for covered services. However, copayments for the
following services do not count toward your out-of-pocket maximum, and you must continue to pay copayments for these services:

Dental Services Prescription Drugs
Substance Abuse Rehabilitation
Be sure to keep accurate records of your out-of-pocket expenses, since you are responsible for informing us when you reach the maximum. 11
11 Page 12 13

2002 Cimarron Health Plan 12 Section 5
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) 473-0391 or (505) 342-4680, or at our website at www. cimarronhealthplan. com.

(a) Medical services and supplies provided by physicians and other health care professionals ............. .............. .......... 13-20
Diagnostic and treatment services 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........... .............. .......... 21-24
Surgical procedures Oral and maxillofacial surgery Reconstructive surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services............. ............. ............. .............. .......... 25-27
Inpatient hospital Extended care benefits/ skilled nursing care Outpatient hospital or ambulatory facility benefits

surgical center Hospice care
Ambulance (d) Emergency services/ accidents ........ .............. .............. ............ .............. ............. ............. ............. .............. .......... 28-29

Medical emergency Ambulance (e) Mental health and substance abuse benefits .. .............. ............ .............. ............. ............. ............. .............. .......... 30-31

(f) Prescription drug benefits............... .............. .............. ............ .............. ............. ............. ............. .............. .......... 32-34
(g) Special features............................... .............. .............. ............ .............. ............. ............. ............. .............. .......... 35
Prenatal care Child Safety Program

24-hour Nurse Line
(h) Dental benefits............................... .............. .............. ............ .............. ............. ............. ............. .............. .......... 36
(i) Non-FEHB benefits available to Plan members............ ............ .............. ............. ............. ............. .............. .......... 37
Summary of benefits.............................. .............. .............. ............ .............. ............. ............. ............. .............. .......... 52

Section 5. Benefits ... OVERVIEW (See page 7 for how our benefits changed this year and page 52 for a benefits summary.) 12
12 Page 13 14
2002 Cimarron Health Plan 13 Section 5( a)
Medical services and supplies continued on next page.

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

I M
P O
R T
A N
T

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

Professional services of physicians
In an urgent care center $25 per office visit

During a hospital stay Nothing
In a skilled nursing facility Nothing
Office medical consultations $10 per office visit
Second surgical opinion $10 per office visit

At home $20 per visit
Lab, X-ray and other diagnostic tests

Tests, such as:
Blood tests Urinalysis
Non-routine pap tests Pathology
X-rays Non-routine Mammograms
CAT Scans/ MRI Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per office
visit 13
13 Page 14 15
2002 Cimarron Health Plan 14 Section 5( a)
Maternity care continued on next page.

Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol — once every three years Colorectal Cancer Screening, including

Fecal occult blood test Sigmoidoscopy screening — every 5 years starting at age 50
Prostate Specific Antigen (PSA test) — every five years starting at age 50 Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment above.

Routine mammogram — covered for women age 35 and older, as follows: From age 35 through 39, one during this five-year period
From age 40 through 64, one every calendar year At age 65 and older, one every two consecutive calendar years

$10 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster — once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

Well-child care charges for routine examinations, immunizations and care (under age 22)
Examinations, such as: Eye exams through age 17 to determine the need for vision correction
Ear exams through age 17 to determine the need for hearing correction Examinations done on the day of immunizations (under age 22)

$10 per office visit

Maternity care
Complete maternity (obstetrical) care, such as: Prenatal care

Delivery
$10 per office visit 14
14 Page 15 16
2002 Cimarron Health Plan 15 Section 5( a)
Infertility services continued on next page.

Maternity care continued You pay
Postnatal care
Note: Here are some things to keep in mind:
You need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

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

$10 per visit

Not covered: Routine sonograms to determine fetal age, size or sex. All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization $10 per office visit; nothing per hospital procedure

Surgically implanted contraceptives (such as Norplant) 50% of charges
Injectable contraceptive drugs (such as Depo Provera) $10 per office visit

Intrauterine devices (IUDs) 50% of charges
Diaphrams 50% of charges

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

Not covered: Reversal of voluntary sterilization All charges

Infertility services
Diagnosis and treatment of infertility, such as:
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.

50% of charges 15
15 Page 16 17
2002 Cimarron Health Plan 16 Section 5( a)
Medical services and supplies continued on next page.

Infertility services continued You pay
Not covered:
Assisted reproductive technology (ART) procedures, such as: in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT Zygote transfer

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

All charges

Allergy care
Testing and treatment $10 per office visit
Allergy injection $3 per visit and $10 office visit copay, if applicable

Allergy serum Nothing
Treatment therapies

Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow
transplants are limited to those transplants listed under Organ/ Tissue Transplants on page 23.

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 medical benefits.
Note: We will only cover GHT when we preauthorize treatment. Your attending physician must call the Plan for preauthorization. We will ask

your physician to submit information that establishes that the GHT is medically necessary. We must authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date the treatment is authorized. If your physician does not ask or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and supplies.

$10 per office visit

Not covered: All treatment therapies not shown as covered by the Plan All charges 16
16 Page 17 18
2002 Cimarron Health Plan 17 Section 5( a)
Medical services and supplies continued on next page.

Physical and occupational therapies You pay
60 consecutive days per condition for the services of each of the following:
qualified physical therapists; and $10 per office visit
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.
$10 per outpatient visit

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 36 sessions per cardiac event. Nothing per visit during inpatient admission
Not covered: Long-term rehabilitative therapy
Exercise programs
All charges

Speech therapy
Up to 60 consecutive days per condition. Services may be extended if significant improvement is noted. $10 per visit

Not covered: All services beyond 60 days if significant improvement ceases. All charges

Hearing services (testing, treatment, and supplies)
Initial hearing evaluation Hearing screening for children through age 17 (see Preventive care,

children)
$10 per office visit

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

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by intraocular surgery (such as for cataracts). We limit coverage to

$300 per surgery for eyeglasses or contact lenses.
Eye exam to determine the need for vision correction for children through age 17. Note: See preventive care, children for eye exams for children.

$10 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges 17
17 Page 18 19
2002 Cimarron Health Plan 18 Section 5( a)
Medical services and supplies continued on next page.

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

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

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as
stated above.
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by

open cutting surgery).

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes.
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 treatment of temporo-mandibular joint (TMJ) pain caused by dysfunction syndrome, if trauma related.

Medically necessary podiatric appliances for prevention of feet complications associated with diabetes, including therapeutic molded or
depth-inlay shoes, functional orthotics, custom molded inserts, replacement inserts, preventive devices and shoe modification for
prevention and treatment.

20% of charges when you obtain prior authorization from the Plan

Not covered:
Orthopedic and corrective shoes Arch supports

Foot orthotics Heel pads and heel cups
Lumbosacral supports Corsets, trusses, elastic stockings, support hose, and other supportive
devices.

All charges 18
18 Page 19 20
2002 Cimarron Health Plan 19 Section 5( a)
Medical services and supplies continued on next page.

Durable medical equipment (DME) You pay
Rental or purchase, at our option (rental price not to exceed purchase price), including repair and adjustment, of durable medical equipment prescribed by
your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

walkers hospital beds
standard wheelchairs crutches
blood glucose monitors insulin pumps
oxygen
Note: Durable medical equipment must be prior authorized by the Plan

20% of allowable charges

Not covered: Motorized wheel chairs. All charges
Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home health aide
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered: Nursing care requested by, or for the convenience of, the patient or the
patient's family; Homecare primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges

Chiropractic
Medically necessary and appropriate services directly related to the relief of neuromusculoskeletal pain, limited to 20 visits per calendar year. 50% of charges

Not covered: All other chiropractic care All charges 19
19 Page 20 21
2002 Cimarron Health Plan 20 Section 5( a)
Alternative treatments You pay
Acupuncture — by a contracted Plan provider for: treatment of piercing specific peripheral nerves with needles to relieve the discomfort of painful

disorders or for therapeutic purposes; limited to 20 visits per calendar year.
50% of charges

Not covered:
Naturopathic services Hypnotherapy

Biofeedback.

All charges

Educational classes and programs
Coverage is limited to:
Smoking cessation
classes $10 per session of 6 classes

prescription drugs limited to $500 per member per lifetime (See Prescription drug benefits, Section 5 (f). $8 per prescription for a standard course of treatment (generally 12 weeks), limited to

once per year
mental health counseling (See Mental health and substance abuse benefits, Section 5( e) $10 per visit

Weight control, stress management, workplace ergonomics are routinely offered at plan offices or at the worksite at client request. No charge

Prenatal education class and child safety class with free infant car seat is available to all member mothers who deliver children while enrolled in the
Plan.
No charge

Bike safety class available to all member children ages 4-18. No charge ($ 5 for bike helmet)
Diabetes self-management $10 per office visit 20
20 Page 21 22
2002 Cimarron Health Plan 21 Section 5( b)
Surgical and anesthesia services continued on next page.

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read section 9 about coordinating benefits with other coverage,
including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility
charge (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 or call us
at (800) 473-0391 to identify which surgeries require precertification.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Operative procedures
Treatment of fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery
Surgical treatment of morbid obesity — a condition in which an individual weighs 100 pounds or 100% over his
or her normal weight according to current underwriting standards; eligible members must be 18 or over.
Insertion of internal prosthetic devices. See 5( a) -Orthopedic and prosthetic devices for device coverage
information. Voluntary sterilization
Treatment of burns.
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we
pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing per inpatient or outpatient
hospital admission 21
21 Page 22 23
2002 Cimarron Health Plan 22 Section 5( b)
Oral and maxillofacial surgery continued on next page.

Surgical procedures continued You pay
Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.

All charges

Reconstructive surgery
Surgery to correct a functional defect Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and -the condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast; -treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices — Note: If you need a mastectomy, you may choose to have the
procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$10 per office visit; nothing per hospital admission

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

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit; nothing for inpatient services 22
22 Page 23 24
2002 Cimarron Health Plan 23 Section 5( b)
Surgical and anesthesia services continued on next page.

Oral and maxillofacial surgery continued You pay
Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
Dental work related to the treatment of TMJ

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single — Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or

non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; aplastic anemia;
Wiskott-Aldrich Syndrome; 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.
All transplants must be prior approved by us.
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

$10 per visit; nothing for inpatient services

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

All charges 23
23 Page 24 25
2002 Cimarron Health Plan 24 Section 5( b)
Anesthesia You pay
Professional services provided in Hospital (inpatient) Nothing

Professional services provided in Hospital outpatient department
Skilled nursing facility Ambulatory surgical center Nothing Nothing Nothing

Office $10 per office visit 24
24 Page 25 26
2002 Cimarron Health Plan 25 Section 5( c)
Inpatient hospital continued on next page.

Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We have no calendar year deductible. Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating the 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 Section 5( a) or (b). YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS.
Please refer to Section 3 to be sure which services require precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as:
ward, semiprivate, or intensive care accommodations; general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room

rate.

Nothing

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

Nothing 25
25 Page 26 27
2002 Cimarron Health Plan 26 Section 5( c)
Services provided by a hospital or other facility continued on next page. .

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

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood or blood plasma, if not donated or replaced Pre-surgical testing
Dressings, splints, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics, including nurse anesthetist service Take home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

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

Nothing

Not covered: Blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
We cover up to 30 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by 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.

Nothing

Not covered: Custodial care All charges 26
26 Page 27 28
2002 Cimarron Health Plan 27 Section 5( c)
Hospice care You Pay
Palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care, and family
counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life
expectancy of approximately six months or less. Maximum benefit is 210 days per member per lifetime (includes 7 days of respite care).

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate $50 ground ambulance per trip
$100 air ambulance per trip 27
27 Page 28 29
2002 Cimarron Health Plan 28 Section 5( d)
Emergency services/ accidents continued on next page.

Section 5 (d). Emergency services/ accidents
I M

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

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

including with Medicare.

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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: For true life or limb threatening emergencies, call 911 and go to the nearest facility. For other emergency situations go to a Plan contracted facility or call the Plan's Healthline (Nurse Advice Line) at (800) 564-
8596.
For non life-threatening, acute situations requiring prompt attention, when your primary care physician is not available, you may call any St. Joseph Healthcare physicians' facility in Albuquerque and request "same day care". Call Customer Service
at (505) 342-4680 or (800) 473-0391 or refer to your provider directory for telephone numbers.
Emergencies outside our service area: Life or limb threatening emergencies or medically necessary urgent care: Go to an emergency facility or doctor's office or call the Plan's Healthline at (800) 564-8596 for assistance. You or a family member
must notify the Plan at (800) 473-0391 within 48 hours, unless it was not reasonably possible to do so.
You must return to your primary care physician for all follow-up care. Do not return to the Emergency Room.

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 $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

Note: Hospital emergency care copay waived if you are admitted to the hospital.
$50 per visit

Not covered: Elective care or non-emergency care All charges 28
28 Page 29 30
2002 Cimarron Health Plan 29 Section 5( d)
Emergency outside our service area You pay
Emergency care at a doctor's office $10 per office visit Emergency care at an urgent care center $25 per visit

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

Note: Hospital emergency care copay waived if you are admitted to the hospital.

$50 per visit

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

All charges

Ambulance
Professional ambulance service when medically appropriate. See 5( c) for non-emergency service. $50 per trip for ground ambulance, $100 per trip for air ambulance

Not covered: Non-emergent ambulance transport unless prior authorized by Plan All charges 29
29 Page 30 31
2002 Cimarron Health Plan 30 Section 5( e)
Mental health and substance abuse services continued on next page

Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits for services 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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

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

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this brochure.

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

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

Professional services, including therapy by providers such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per hospital visit or Nothing if hospital confined

Diagnostic tests Nothing
Services provided by a hospital or other facility Services in approved alternative care settings such as partial

hospitalization, full-day hospitalization, facility-based intensive outpatient treatment.
Nothing Nothing

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

All charges 30
30 Page 31 32
2002 Cimarron Health Plan 31 Section 5( e)
Mental health and substance abuse benefits continued
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
Call Customer Service at (505) 342-4680 or (800) 473-0391.
You will be connected with a Behavioral Health Representative who will triage your care to an appropriate provider.

Limitation We may limit your benefits if you do not obtain a treatment plan. 31
31 Page 32 33

2002 Cimarron Health Plan 32 Section 5( f)
Presciption drug benefits continued on next page.

Section 5 (f). Prescription drug benefits
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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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

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There are important features you should be aware of. These include:
Who can write your prescription? A licensed Plan physician must write the prescription.
Where you can obtain them. You may fill the prescription at a participating pharmacy, by internet, or by mail.
We use a formulary. A formulary is a listing of drugs we customarily use. The drugs and medications have been approved in accordance with guidelines established by the Plan along with consulting physicians and pharmacists. The list
is reviewed periodically and is amended as necessary. We cover non-formulary drugs when prescribed by a plan doctor. Unless your physician indicates "dispense as written" or "no substitutions," your prescription will be filled with an available
generic and/ or formulary drug. If your physician specifies that the prescription must be dispensed as written, you will receive the drug as prescribed, at the applicable copay.

These are the dispensing limitations. Retail prescriptions will be dispensed for the lesser of a 30-day supply or 100 unit dose, or manufacturer's standard trade package, including inhalers. Maintenance drugs may be ordered by mail order.
You will receive a 90-day supply for two copayments. Be sure to have your doctor specify that the prescription is for a 90-day supply. If you do not have a mail order envelope, contact Customer Service at (800) 473-0391 or (505) 342-4680. You
may also order mail order drugs on the internet at the Website: www. merckmedco. com. If there is no generic equivalent of your drug, you will still be required to pay the name brand copayment. A generic equivalent will be dispensed if it is
available, unless your physician specifically requires a name-brand. If your physician does not require it, but you request a 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 offer a safe and economical way to meet your prescription needs. The generic name of a drug is its chemical name, the name brand is the name under which the manufacturer advertises and sells the
drug. Under Federal law, generic and name-brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you — and us — less than a brand-name prescription.

When you have to file a claim. Under normal circumstances, you should not have to file a claim. If this becomes necessary, for example, if you must purchase a drug because you have not yet received your ID card, call Customer Service
at (800) 473-0391 or (505) 342-4680. 32
32 Page 33 34
2002 Cimarron Health Plan 33 Section 5( f)
Prescription drug benefits continued on next page.

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

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
Full range of FDA-approved drugs, prescriptions, and devices for birth control. Contraceptive drugs (Contraceptive devices, including implanted devices and
implantable drugs such as Norplant are covered under Medical and Surgical Benefits as a Limited benefit.)

Compounded dermatological preparations
Nitroglycerin, Phenobarbital, or Thyroid U. S. P.
Insulin, with a copay charge applied to every two vials
Fertility drugs are covered under Infertility benefits (see page 15)
Intravenous fluids and medications for home use, implants, some injectible drugs, and growth hormones are covered under Medical and Surgical Benefits.

Disposable needles and syringes needed to inject covered prescribed medication.
Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, and acetone test tablets. Glucose
monitors are covered under Durable Medical Equipment (see page 19).
Appetite suppressants when prescribed for morbid obesity
* Prescription drugs to aid in smoking cessation, limited to one standard course of treatment once per year. Benefit is limited to $500 per member per lifetime.

Retail Pharmacy $5 per generic
$8 per name brand drug
Mail Order (Maintenance medications only)
$10 per generic prescription $16 per name brand prescription

$8 per prescription
* Drugs for sexual dysfunction, with prior authorization from the Plan. 50% of covered charges
* Growth hormones 20% of charges

* Here are some things to keep in mind about our prescription drug program:
Certain drugs require your physician to prior authorize them in order to verify medical necessity. These include such drugs as:

Drugs for sexual dysfunction Drugs used for dual purposes such as Wellbutrin
Appetite suppressants Growth hormones 33
33 Page 34 35
2002 Cimarron Health Plan 34 Section 5( f)
Covered medications and supplies continued You pay
Not covered: Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription or over-the-counter medicines or products Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics Drugs to enhance athletic performance
Drugs to aid in dieting, unless for morbid obesity

All charges 34
34 Page 35 36
2002 Cimarron Health Plan 35 Section 5( g)
Section 5 (g). Special features
Feature Description
Prenatal Program Member mothers are encouraged to attend one prenatal class and one infant safety class, after which they will receive a free car seat to encourage infant safety.

Child Safety Program
Parents of children ages 4 through 18 are encouraged to bring them to a bicycle safety class that teaches safe riding. At the
conclusion of the class, children can be properly fitted for and receive a bicycle helmet, for a $5 fee, to encourage child
safety.

24-hour nurse line
For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-564-8596 and talk with a registered

nurse who will discuss treatment options and answer your health questions. 35
35 Page 36 37
2002 Cimarron Health Plan 36 Section 5( h)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We have no calendar year deductible.

We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not
cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

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Accidental injury benefit You pay
We cover services and supplies necessary to promptly restore sound natural teeth. The need for these services must
result from an accidental injury, but is not limited to injuries that occurred during enrollment under this plan.
$10 per office visit

Preventive dental benefit
These preventive and diagnostic services are provided by participating Delta Dental Advantage Plan dentists. This
benefit is limited to two visits per year.
Oral Examination, twice per calendar year.
Prophylaxis (cleaning), twice per calendar year.
X-rays (bitewings, twice per calendar year; and full mouth, once per 5 year period).

Fluoride application (through age 18), twice per calendar year.
Sealants for enrolled dependents through age 15 for permanent molars, once per three year period per molar.
Space maintainers (through age 15).
Emergency treatment for pain relief.

50% of charges 36
36 Page 37 38
2002 Cimarron Health Plan 37 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

VOLUNTARY BUY-UP DENTAL PLAN You may elect Delta's Buy-Up plan for more coverage. You must enroll in Cimarron's HMO for the 2002 plan year to be
eligible. Your enrollment of "self only" or "self and family" must match in both Cimarron's HMO and Delta's Buy-Up plan. You are responsible for the monthly premium payable by automatic bank draft as authorized by you.
DEDUCTIBLE: $50 deductible per enrolled person, $150 per family each contract term. MAXIMUM: The maximum amount payable by Delta is $1000 per enrolled person each contract term.
The Delta Buy-Up Plan is Delta's Advantage, a PPO plan with its own list of participating providers. Percentages listed are applied to Delta's Advantage maximum allowable fee schedule or billed charges, whichever is less. Dentists who do not
participate in Delta's Advantage network may charge more; the difference is the patient's responsibility.
Diagnostic & Preventive Services — oral exams (twice per year), cleanings (twice per year), x-rays (full-mouth once per five years/ bitewings twice per

calendar year), emergency treatment for relief of pain, topical flouride (twice per year through age 18), space maintainers (through age 15), sealants (for dependent
children through age 15, permanent molars only).

100% of Delta's Advantage Plan fee schedule (no deductible applies)

Restorative Services — amalgam fillings on posterior teeth, composite fillings on anterior teeth, stainless steel crowns. 80% of Delta's Advantage Plan fee schedule (deductible applies)
Basic Services — extractions (simple or surgical), oral surgery, endodontics (root canal and pulp therapy), periodontics (non-surgical and surgical), general
anesthesia (when dentally necessary and administered by a licensed provider for a covered oral surgery procedure).
80% of Delta's Advantage Plan fee schedule (deductible applies)

Major Services — Crowns and Cast Restorations--when teeth cannot be restored with amalgam, composite resin, or plastic restorations. Prosthodontics--procedures
for construction or repair of fixed bridges, partial, or complete dentures. 50% of Delta's Advantage Plan fee schedule (deductible applies)

AVAILABLE AFTER A 12 MONTH WAITING PERIOD FOR NEW ENROLLEES BEGINNING JANUARY 1, 2002
Orthodontic Services — coverage is for adults and children, subject to $1000 lifetime maximum per enrolled person 50% of Delta's Advantage Plan fee schedule (no deductible applies)

AVAILABLE AFTER A 12 MONTH WAITING PERIOD FOR NEW ENROLLEES BEGINNING JANUARY 1, 2002
For a complete listing of Delta's Buy-Up Plan Benefits and Delta's Advantage Providers, call (505) 855-7111 or toll-free at (877) 395-9420. Applications will only be accepted during Federal Open Season for active or retired employees. New hires are eligible after the

probationary period. Disenrollment mid-year precludes any future enrollment in this Voluntary Buy-Up plan. This is only a summary of benefits, please refer to the contract documents for specific information on benefits and eligibility.

VISION BENEFITS (You are NOT required to pay any additional premium for this benefit.)

Your vision exam and eyewear purchase are covered by Cimarron Health Plan through the Vision Service Plan. No referral is necessary, just call the participating provider and schedule your appointment. Your copayment for your eye exam is $10.
(Note: If an exam is done for contact lenses, an additional copayment applies.) You and your covered family members may each have one exam every 12 months.

Eyewear is available in most Plan provider offices. You will receive a 20% discount off the VSP doctor's usual and customary fee for a complete pair of prescription glasses. You can also save 15% off the cost of the contact lens exam
when you receive services from a VSP doctor (this discount does not apply to the contact lenses). Additionally, you are entitled to a $55.00 allowance toward those materials after the discount has been applied.

Remember! This benefit is for routine eye care. Medically necessary diagnostic eye care is available by referral under your FEHB Medical and Surgical Benefits. Refer to the Medical directory for these providers.
For a complete listing of the Vision Service Plan benefits and providers, please call Cimarron Health Plan at (800) 473-0391 or (505) 342-4680. 37
37 Page 38 39
2002 Cimarron Health Plan 38 Section 6
Section 6. General exclusions: things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease,
injury or condition and we agree, as discussed in What Services Require Our Prior Approval on page 10.
We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program 38
38 Page 39 40
2002 Cimarron Health Plan 39 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) 473-0391 or (505) 342-4680.

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: Cimarron Health Plan, Box 3887, Albuquerque, NM 87190

Prescription drugs Call Customer Service at (800) 473-0391 or (505) 342-4680 for a Prescription Drug Reimbursement form.
Submit your claims to: PAID Prescriptions, P. O. Box 2187, Lee's Summit, MO 64063-2187.
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by 90 days following the date you received the service, unless
timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably

possible.
When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 39
39 Page 40 41
2002 Cimarron Health Plan 40 Section 8
Disputed claims process continued on next page.

Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies -including a request for prior authorization:

Step Description
1 Ask us in writing to reconsider our initial decision. Write to us at: Cimarron Health Plan, P. O. Box 3887, Albuquerque, NM 87190. You must:

(a) Write to us within 6 months from the date of our decision; and (b) Send your request to us at: Cimarron Health Plan, P. O. Box 3887, Albuquerque, NM 87190.
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial — go to step 4; or (c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request — go to step 3.
3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was

due. We will base our decision on the information we already have. We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us — if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street NW, Washington, D. C. 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim; Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review 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. 40
40 Page 41 42
2002 Cimarron Health Plan 41 Section 8
Section 8. The disputed claims process continued
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 precertification or prior approval. This is
the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at (505) 342-4680 or 800-473-0391 and we will expedite our review; or

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

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 41
41 Page 42 43
2002 Cimarron Health Plan 42 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We,
like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular
benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:

People 65 years of age and older Some people with disabilities, under 65 years of age
People with End-Stage-Renal Disease (permanent kidney failure requiring dialysis or a transplant).

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

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

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

most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan
pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue
to be authorized by the Plan PCP, or prior authorized as required.
We will waive most copayments, coinsurance, and deductibles. We will coordinate benefits with Medicare as we coordinate benefits with any other Plan.

(Primary payer chart begins on next page.) 42
42 Page 43 44
2002 Cimarron Health Plan 43 Section 9
Coordinating benefits with other coverage continued on next page.

The following chart illustrates whether The Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart A. When either you— or your covered spouse— are age 65 or over and… Then the primary payer is…

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

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

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

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

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

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

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

b) Are an active employee
c) Are a former spouse of an annuitant
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 43
43 Page 44 45

2002 Cimarron Health Plan 44 Section 9
Coordinating benefits with other coverage continued on next page.

Section 9. Coordinating benefits with other coverage continued
Claims process when you have the Original Medicare Plan — You probably will never have to file a claim form when you have both our Plan and the Original
Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will 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) 473-0391 or
(505) 342-4680.
We waive some costs when you have the Original Medicare Plan — When Original Medicare is the primary payer, we will waive some out-of-pocket costs, as
follows:
Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare Part B, we will waive copayments
and coinsurance for Medicare covered medical services when plan procedures are followed.

= 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 plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs.
To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan does not offer a Medicare managed care 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 and you have utilized our Plan providers and followed our Plan procedures,
and we will waive deductibles and copayments. 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 and 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. 44
44 Page 45 46
2002 Cimarron Health Plan 45 Section 9
Section 9. Coordinating benefits with other coverage continued
If you do not enroll in Medicare Part A or Part B If you do not have one or both Parts of Medicare, you can still be covered under the
FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it.

TRICARE 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 agencies are responsible for

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

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

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 45
45 Page 46 47
2002 Cimarron Health Plan 46 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care or service that is designed primarily to assist in meeting the needs of an individual. This type of care is administered to the individual, whether or not totally disabled. This

care is given as assistance in daily living. These activities may include bathing, dressing, feeding, special diet preparations, walking assistance, and getting in and out of

bed. It also provides for the supervision over medication that can normally be self-administered.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. We have no
deductibles.
Experimental or Investigational services The Plan's experimental/ investigational determination process is based upon authoritative information obtained from medical literature, medical specialist opinion,
and evidence from State and Federal government agencies and research organizations including FDA.

Medical necessity Care, services, or supplies that meet all of the following criteria, as determined by the Plan Medical Director:
(a) Is consistent with symptoms, diagnosis, treatment, and is non-Experimental or under investigation;

(b) Is appropriate in keeping with standards of good medical practice;
(c) Is not solely for the convenience of the Member, Primary Care Physician, or
(d) Is the appropriate level of service which 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. Plans determine their allowances in different ways. We determine our
allowance as follows:

The contracted amount that has been negotiated between the physician and the Plan.
Note: Contracted Plan providers accept the plan allowance as payment in full.
Us/ We Us and we refer to Cimarron Health Plan.
You You refers to the enrollee and each covered family member. 46
46 Page 47 48

2002 Cimarron Health Plan 47 Section 11
FEHB facts continued on next page.

Section 11. FEHB facts
No pre-existing condition limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get information about
enrolling in the FEHB Program

See www. opm. gov/ insure. Also, your employing or retirement office can answer your questions, and give you a Guide to Federal Employees Health Benefits Plan, 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 for you and your
family

Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment

31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your spouse until you marry.

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

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

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

of coverage. 47
47 Page 48 49

2002 Cimarron Health Plan 48 Section 11
FEHB facts continued on next page.

Section 11. FEHB facts continued
Your medical and claims records are confidential We will keep your medical and claims information confidential. Only the 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 coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue 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 continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).

For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child
and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage

and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll. 48
48 Page 49 50

2002 Cimarron Health Plan 49 Section 11
Section 11. FEHB facts continued
Converting to individual coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends. (If you canceled your coverage or did not pay your premium, you cannot convert);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a

waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of Group Health Plan Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability
and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates

how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or
eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of
losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a
certificate from those plans.
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 HIPPA" 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. 49
49 Page 50 51

2002 Cimarron Health Plan 50 Section 12— Long Term Care Insurance
Section 12. Long Term Care Insurance
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 part of its educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance? It's insurance to help pay for long term care services you may need if you 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. It can supplement care provided by family members, reducing the
burden you place on them.

I'm healthy. I won't need long term care. Or, will I? Welcome to the club! 76% of Americans believe they will never need long term care, but the facts are
that about half of them will. And it's not just 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 in case. 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. Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before inflation! Long term care can easily exhaust your savings. Long term care insurance can
protect your savings.
But won't my FEHB plan, Medicare or Medicaid cover my long term

care?
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don't cover custodial care or a stay in an assisted
living facility or a continuing need for a 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 guidelines, 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 information on how to apply for this new
insurance coverage?
Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall