Pages 1--52 from Coventry Healthcare of Kansas, Inc.

Serving: Wichita, Salina and Central Kansas Areas
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements

Enrollment codes for this Plan:
7W1 Self Only
7W2 Self and Family

RI-73-275

2002
For changes
in benefits
see page 8. 1
1 Page 2 3
2002 Coventry Health Care of Kansas, Inc. 2 Table of Contents
Table of Contents
Introduction .................................................................................................................................................................. 4
Plain Language.............................................................................................................................................................. 4
Inspector General Advisory .......................................................................................................................................... 5
Section 1. Facts about this HMO plan ........................................................................................................................ 6
How we pay providers ................................................................................................................................ 6
Who provides my health care?.................................................................................................................... 6
Your Rights.................................................................................................................................................. 7
Service Area ................................................................................................................................................ 7
Section 2. How we change for 2002 ............................................................................................................................ 8
Program-wide changes ................................................................................................................................ 8
Changes to this Plan .................................................................................................................................... 8
Section 3. How you get care …………... .................................................................................................................... 9
Identification cards ...................................................................................................................................... 9
Where you get covered care........................................................................................................................ 9
Plan providers ........................................................................................................................................ 9
Plan facilities.......................................................................................................................................... 9
What you must do to get covered care........................................................................................................ 9

Primary care .......................................................................................................................................... 9
Specialty care ...................................................................................................................................... 10
Hospital care ........................................................................................................................................ 11
Circumstances beyond our control............................................................................................................ 11
Services requiring our prior approval ...................................................................................................... 11
Section 4. Your costs for covered services ................................................................................................................ 12
Copayments.......................................................................................................................................... 12
Deductible ............................................................................................................................................ 12
Coinsurance.......................................................................................................................................... 12
Your out-of-pocket maximum .................................................................................................................. 12
Section 5. Benefits………………………………………………………….............................................................. 13
Overview .................................................................................................................................................. 13
(a) Medical services and supplies provided by physicians and other health care professionals.............. 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals .......... 21
(c) Services provided by a hospital or other facility, and ambulance services ........................................ 24
(d) Emergency services/ accidents ............................................................................................................ 27
(e) Mental health and substance abuse benefits........................................................................................ 29
(f) Prescription drug benefits .................................................................................................................... 31
(g) Special features .................................................................................................................................... 33 2
2 Page 3 4
2002 Coventry Health Care of Kansas, Inc. 3 Table of Contents
Flexible benefits option
High risk pregnancies
(h) Dental benefits .................................................................................................................................... 34
(j) Non-FEHB benefits available to Plan members.................................................................................. 35
Section 6. General exclusions — things we don't cover .......................................................................................... 36
Section 7. Filing a claim for covered services .......................................................................................................... 37
Section 8. The disputed claims process...................................................................................................................... 38
Section 9. Coordinating benefits with other coverage .............................................................................................. 40
When you have…
Other health coverage .......................................................................................................................... 40
Original Medicare ................................................................................................................................ 40
Medicare managed care plan .............................................................................................................. 42
TRICARE/ Workers Compensation/ Medicaid .......................................................................................... 43
Other Government agencies ...................................................................................................................... 43
When others are responsible for injuries .................................................................................................. 43
Section 10. Definitions of terms we use in this brochure ........................................................................................ 44
Section 11. FEHB facts.............................................................................................................................................. 45
Coverage information................................................................................................................................ 45
No pre-existing condition limitation.................................................................................................... 45
Where you get information about enrolling in the FEHB Program.................................................... 45
Types of coverage available for you and your family ........................................................................ 45
When benefits and premiums start ...................................................................................................... 46
Your medical and claims records are confidential .............................................................................. 46
When you retire .................................................................................................................................. 46
When you lose benefits ............................................................................................................................ 46

When FEHB coverage ends ................................................................................................................ 46
Spouse equity coverage ...................................................................................................................... 46
Temporary Continuation of Coverage (TCC)...................................................................................... 46
Converting to individual coverage ...................................................................................................... 47
Getting a Certificate of Group Health Plan Coverage ........................................................................ 47
Index............................................................................................................................................................................ 49
Summary of benefits .................................................................................................................................................. 51
Rates.............................................................................................................................................................. Back cover 3
3 Page 4 5
2002 Coventry Health Care of Kansas, Inc. 4 Introduction/ Plain Language
Introduction
Coventry Health Care of Kansas, Inc.
8301 E. 21st North, Suite 300
Wichita, Kansas 67206

This brochure describes the benefits of Coventry Health Care of Kansas, Inc. under our contract (CS 2108) 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 exclu-sions
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 xx. 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 Coventry Health Care of Kansas, Inc.

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 this structure of this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. 4
4 Page 5 6
2002 Coventry Health Care of Kansas, Inc. 5 Inspector General Adivisory
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/ 664-9251
and explain the situation.
If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone
who uses an ID card if the person tries to obtain services for someone who is
not an eligible family member, or is no longer enrolled in the Plan and tries
to obtain benefits. Your agency may also take administrative action against
you. 5
5 Page 6 7
2002 Coventry Health Care of Kansas, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

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, hospi-tal,
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 healthcare
Coventry Health Care provides you with a comprehensive benefit package that covers many kinds of health services for
a fixed payroll deduction and minimal copayments. As a participant of Coventry Health Care, you will select a personal
doctor for yourself and each member of your family. Depending on where you live, you will be able to choose from a
directory of more than 320 primary care doctors whose offices are located throughout the Plan's service areas.

The first and most important decision each member must make is the selection of a primary care doctor. Your primary
care doctor will be the manager and coordinator of your health care. If you require additional care, your primary care
doctor, with your input, will select the specialist or hospital that best fits your needs. It is the responsibility of your pri-mary
care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization.

The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with
their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated
on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department
at 1-800-664-9251 or 316-634-1222. You can also find out if your doctor participates by calling these numbers. The list
is also on our website. Visit www. chcwichita. com to utilize our doctor search option. Our doctor search on the web is
updated monthly.

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify
that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in the Plan,
services (except for emergency benefits) are provided through the Plan's delivery system; the continued availability
and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Should you decide to enroll, you will be asked to complete a primary care doctor selection and send it to the Plan, indicat-ing
the name of the primary care doctor( s) selected for you and each member of your family. Members may change their
doctor selection by notifying the Plan 30 days in advance. 6
6 Page 7 8
2002 Coventry Health Care of Kansas, Inc. 7 Section 1
Facts about this HMO plan (continued)
Your Rights

OPM requires that 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.

State Insurance Department requirements for external quality review
Years in existence
Profit status

If you want more information about us, call 800/ 664-9251, or write to Coventry Health Care of Kansas Inc., 8301 East
21 st North, Suite 300, Wichita, Kansas 67206. You may also contact us by fax at 316/ 634-1266 or visit our website at
www. chcwichita. com.

Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is:
Butler, Harvey, McPherson, Pratt, Saline, Sedgwick, and Sumner Counties.

You may also enroll with us if you live or work in the following places: Cowley, Dickinson, Greenwood, Harper,
Kingman, Lincoln, Marion, Ottawa and Reno counties.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-
service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do
not have to wait until Open Season to change plans. Contact your employing or retirement office. 7
7 Page 8 9
2002 Coventry Health Care of Kansas, Inc. 8 Section 2
Section 2. How we change for 2002
Do not rely on these changes descriptions; this page is not an official statement of benefits. For that go to Section 5
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 22.5% for Self Only or 35.8% for Self and Family.
We no longer limit total blood cholesterol test to certain age groups. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
Our Mail Order prescription drug benefit is now limited to two copayment tiers. Our Retail Pharmacy prescription drug benefit continues to have three copayment tiers.

Pratt County, Kansas is now in our service area. 8
8 Page 9 10
2002 Coventry Health Care of Kansas, Inc. 9 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 800-664-9251.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We
credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically.
The list is also on our website. Visit www. chcwichita. com to utilize our doctor
search option. Our doctor search on the web is updated monthly.

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 www. chcwichita. com.

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. The
Plan's provider directory lists primary care doctors (generally family practi-tioners,
pediatricians, and internists), with their locations and phone numbers,
and notes whether or not the doctor is accepting new patients. Directories
are updated on a regular basis and are available at the time of enrollment or
upon request by calling the Customer Service Department at 1-800-664-9251
or 316-634-1222. You can also find out if your doctor participates by calling
these numbers.

If you are interested in receiving care from a specific provider who is listed
in the directory, call the provider to verify that he or she still participates with
the Plan and is accepting new patients.

Primary care Your primary care physician will generally be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health
care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physi-cian
leaves the Plan, call us. We will help you select a new one. 9
9 Page 10 11
2002 Coventry Health Care of Kansas, Inc. 10 Section 3
How you get care (continued)
Specialty care Your primary care physician will refer you to a specialist for needed care. You must receive a referral from your primary care doctor before seeing or
obtaining special services, with the following exceptions:, (1) Female members
may visit a participating gynecologist without a referral from their primary
care doctor; (2) All members may visit the Plan's mental health providers for
mental conditions and substance benefits without a referral from their primary
care doctor (See "Mental Conditions /Substance Abuse Benefits").

Referral to a participating specialist is given at the primary care doctor's dis-cretion;
if specialists or consultants are required beyond those participating in
the Plan, the primary care doctor will make arrangements for appropriate
referrals.

When you receive a referral from your primary care doctor, you must return
to the primary care doctor after the consultation. All follow-up care must be
provided or arranged by the primary care doctor. On referrals, the primary
care doctor will give specific instructions to the consultant as to what services
are authorized. If the consultant suggests additional services or visits, you
must first check with your primary care doctor. Do not go to the specialist
unless your primary care doctor has arranged for and the Plan has issued an
authorization for the referral in advance.

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 specialist 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 before-hand).

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 partici-pate
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 10
10 Page 11 12
2002 Coventry Health Care of Kansas, Inc. 11 Section 3
How you get care (continued)
– reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to
your specialist based on the above circumstances, you can continue to see
your specialist until the end of your postpartum care, even if it is beyond the
90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800-664-9251 or
316-634-1222. 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 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefits of the hospitalized
person.

Circumstances beyond
our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that

case, we will make all reasonable efforts to provide you with the necessary
care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most 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, for example, prior authorization from the Plan for outpatient
surgeries or inpatient hospitalization. You may call customer service at
1-800-664-9251 to find out if a specific procedure treatment requires prior
authorization. 11
11 Page 12 13
2002 Coventry Health Care of Kansas, Inc. 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment
of $10 per office visit and when you go in the hospital, you pay nothing.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. We have no
deductible.

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 covered durable medical equipment.

Your Catastophic Protection
out-of-pocket maximum for
coinsurance and copayments After your copayments and coinsurance total $ 1,000 per person or $ 3,000 per family enrollment in any calendar year, you do not have to pay any more

for covered services. However, copayments for prescription drugs do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for prescription drugs.

Be sure to keep accurate records of your copayments since you are responsible
for informing us when you reach the maximum. 12
12 Page 13 14
2002 Coventry Health Care of Kansas, Inc. 13 Section 5 (Overview)
Section 5. Benefits --OVERVIEW (See page 8 for how our benefits changed this year and page 51 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 800-664-9251 or at our website at www. chcwichita. com.

(a) Medical services and supplies provided by physicians and other health care professionals .............................. 14-20
Diagnostic and treatment services Hearing services (testing, treatment, and
Lab, X-ray, and other diagnostic tests supplies)
Preventive care, adult Vision services (testing, treatment, and
Preventive care, children supplies)
Maternity care Foot care
Family planning Orthopedic and prosthetic devices
Infertility services Durable medical equipment (DME)
Allergy care Home health services
Treatment therapies Chiropractic
Physical and occupational therapies Alternative treatments
Speech therapy Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals .......................... 21-23

Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ........................................................ 24-26

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

(d) Emergency services/ accidents.............................................................................................................................. 27-28

Medical emergency Ambulance

(e) Mental health and substance abuse benefits ........................................................................................................ 29-30
(f) Prescription drug benefits .................................................................................................................................... 31-32
(g) Special features.......................................................................................................................................................... 33
Flexible benefits option High risk pregnancies
(h) Dental benefits .......................................................................................................................................................... 34
(i) Non-FEHB benefits available to Plan members ...................................................................................................... 35
Summary of benefits .......................................................................................................................................................... 51 13
13 Page 14 15
2002 Coventry Health Care of Kansas, Inc. 14 Section 5 (a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

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.

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

Professional services of physicians $10 per office visit
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment

Office medical consultations
Second surgical opinion

At home $25 per office visit
Lab, X-ray and other diagnostic tests
Tests, such as: Nothing if you receive these
Blood tests services during your office visit;
Urinalysis otherwise, $10 per office visit
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
C. A. T. Scans/ MRI
Ultrasound
Electrocardiogram and EEG

I M
P O
R T
A N
T

I M
P O
R T
A N
T 14
14 Page 15 16
2002 Coventry Health Care of Kansas, Inc. 15 Section 5 (a)
Preventive care, adult You pay
Routine screenings, such as: $10 per office visit
Blood lead level – One annually
Total Blood Cholesterol – once every three years, ages 19 through 64
Colorectal Cancer Screening, including
–– Fecal occult blood test
–– Sigmoidoscopy, screening – every five years starting at age 50

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

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

Routine mammogram –covered for women age 35 and older, as follows: $10 per office visit
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

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

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

Well-child care charges for routine examinations, immunizations and $10 per office visit 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) 15
15 Page 16 17
2002 Coventry Health Care of Kansas, Inc. 16 Section 5 (a)
Maternity care You pay
Complete maternity (obstetrical) care, such as: $10 for initial office visit to
Prenatal care confirm pregnancy.
Delivery All other copayments for
Postnatal care
prenatal visits during the course

Note: Here are some things to keep in mind:
of pregnancy are waived.

You do not need to precertify your normal delivery; see page 11 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
a Self and Family enrollment.

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

benefits (Section 5b).

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to: $100 per sterilization procedure
Voluntary sterilization $10 for office visit applies to
Surgically implanted contraceptives (implant only; not removal) implanted contraceptive devices.
Intrauterine devices (IUDs – implant only, not removal) Benefit does NOT cover removal
Injectable contraceptive drugs
of devices.

Diaphragms (insertion only)
$10 office visit copay applies to

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

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as: 50% of charges up to a $1,000
Artificial insemination: annual out-of-pocket maximum
–– intravaginal insemination (IVI)
for an individual and $3,000 out of

–– intracervical insemination (ICI)
pocket maximum for family. The

–– intrauterine insemination (IUI)
Plan pays remaining charges. 16
16 Page 17 18
2002 Coventry Health Care of Kansas, Inc. 17 Section 5 (a)
Infertility services (continued) You pay
Not covered: All charges.
Assisted reproductive technology (ART) procedures, such as:
–– in vitro fertilization
–– embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm

Cost of donor egg

Allergy care
Testing and treatment 50% of cost of testing; you pay
$10 copayment for treatment
Allergy injection visits, including allergy serum.

Allergy serum Nothing

Not covered: provocative food testing and sublingual allergy desensitization All charges.
Treatment therapies
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone $25 per office visit for
marrow transplants are limited to those transplants listed under Respiratory Therapy
Organ/ Tissue Transplants on page 22.

Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)( covered under the medical benefit.)
Note: Growth hormone is covered under the prescription drug benefit.
Note: – We will only cover GHT when the treatment is prior authorized
by your Primary Care Physician. It is a good idea to call us at
1-800-664-9251 to confirm that prior authorization has been done before
starting treatment. If we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior authorization in Section 3. 17
17 Page 18 19
2002 Coventry Health Care of Kansas, Inc. 18 Section 5 (a)
Physical and occupational therapies You pay
60 days per condition for the services of each of the following: 20% of charges for each outpatient
–– qualified physical therapists and session.
–– occupational therapists.
Note: We only cover therapy to restore bodily function when there
has been a total or partial loss of bodily function or functional
speech due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 days per

condition.

Not covered: All charges.
Long-term rehabilitative therapy
Exercise programs

Speech therapy
60 days per condition 20% of charges for each outpatient session.

Nothing per visit during covered inpatient admission

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury $10 per office visit
Hearing testing for children through age 17 (see Preventive care,
children)

Not covered: All charges.
all other hearing testing

hearing aids, testing and examinations for them

Vision services (testing, treatment, and supplies)
Eye refraction every two years $10

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

Eye exam to determine the need for vision correction for children $10 per office visit through age 17 (see preventive care)

Not covered: All charges.
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery 18
18 Page 19 20
2002 Coventry Health Care of Kansas, Inc. 19 Section 5 (a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic $10 per office visit
or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric
shoe inserts.

Not covered: All charges.
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)

Orthopedic and prosthetic devices
Orthopedic devices such as braces 20% of charges; limited to a
Artificial limbs and eyes maximum Plan benefit of $1,000
Externally worn breast prostheses and surgical bras, including necessary per member per calendar year. replacements, following a mastectomy. External prosthetic devices,

except those associated with reconstructive surgery after a mastectomy,
are limited to one per member per lifetime.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy.

Note: See 5( b) for coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Not covered: All charges.
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements provided less than 3 years after the last one we covered 19
19 Page 20 21
2002 Coventry Health Care of Kansas, Inc. 20 Section 5 (a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of 20% of charges; $1,000 benefit
durable medical equipment prescribed by your Plan physician, such as per member per calendar year
oxygen and dialysis equipment. Under this benefit, we also cover: limitation.

hospital beds;
wheelchairs;
crutches;
walkers;
insulin pumps; and
blood glucose monitors. Blood glucose monitors are
Note: Call us at 1-800-664-9251 as soon as your Plan physician prescribes covered 100% for those with
this equipment. We will arrange with a contracting health care provider to diabetes.
provide you with the necessary equipment, according to the benefit.

Not covered: Motorized wheel chairs All charges.

Home health services
Home health care ordered by a Plan physician and provided by a Nothing. 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.

Not Covered: All charges
Nursing care requested by, or for the convenience of, the patient or the patient's family;

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

Chiropractic
No benefit All charges.

Alternative treatments
Not covered All charges.

Educational classes and programs
Coverage is limited to: Nothing
Diabetes Self-Management educational classes, as referred by your Plan physician

Prenatal education classes 20
20 Page 21 22
2002 Coventry Health Care of Kansas, Inc. 21 Section 5 (b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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 (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 to be sure
which services require precertification and identify which surgeries require precertification.

Benefit Descriptions You pay
Surgical procedures
A comprehensive range of services, such as: $10 for office visit;
Operative procedures Nothing for hospital visit
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to

current underwriting standards; eligible members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information.

Treatment of burns $100 copayment per procedure
Voluntary sterilization

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

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2002 Coventry Health Care of Kansas, Inc. 22 Section 5 (b)
Reconstructive surgery You pay
Surgery to correct a functional defect $10 per office visit;
Surgery to correct a condition caused by injury or illness if: Nothing for hospital visit.
–– 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, $10 for office visit such as: Nothing for hospital visit.

–– surgery to produce a symmetrical appearance on the other breast;
–– treatment of any physical complications, such as lymphedemas;
–– breast prostheses and surgical bras and replacements (see Prosthetic
devices)

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

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

through change in bodily form, except repair of accidental injury.
Surgeries related to sex transformation.
Oral and maxillofacial surgery

Oral surgical procedures, limited to: $10 per office visit;
Reduction of fractures of the jaws or facial bones; Nothing if performed in the hospital
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.
Treatment of TMJ
Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

TMJ related dental work 22
22 Page 23 24
2002 Coventry Health Care of Kansas, Inc. 23 Section 5 (b)
Organ/ tissue transplants You pay
Limited to: Nothing
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; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

and pancreas
National Transplant Program (NTP) -URN
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

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

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

Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in – You pay nothing.
Hospital (inpatient)

Professional services provided in – $10 per office visit;
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 23
23 Page 24 25
2002 Coventry Health Care of Kansas, Inc. 24 Section 5 (c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

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

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

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

Benefit Descriptions You pay
Inpatient hospital
Room and board, such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

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2002 Coventry Health Care of Kansas, Inc. 25 Section 5 (c)
Inpatient hospital (continued) You pay
Not covered: All charges.
Custodial care
Non-covered facilities, such as nursing homes, extended care facilities, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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.

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
A comprehensive range of benefits with no dollar or day limit when Nothing
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.

Not covered: custodial care All charges 25
25 Page 26 27
2002 Coventry Health Care of Kansas, Inc. 26 Section 5 (c)
Hospice care You pay
Supportive and Palliative care for a terminally ill member is covered in the Nothing
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.

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate $25 per trip
Benefits for transportation by air ambulance are reimbursed at the cost of
ground ambulance transportation. 26
26 Page 27 28
Section 5 (d). Emergency services/ accidents
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.

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor, for
First Help, the Plan's 24-hour advice line at 1-800-622-9528. In extreme emergencies, if you are unable to contact your
doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency
room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a
family member must notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely
notified.

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

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

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it is not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be
better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered
in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.

2002 Coventry Health Care of Kansas, Inc. 27 Section 5 (d)

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2002 Coventry Health Care of Kansas, Inc. 28 Section 5 (d)
Benefit Descriptions 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 office visit
Emergency care as an outpatient or inpatient at a hospital, including $50 per office visit; doctors' services waived if admitted to hospital

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center $25 per office visit
Emergency care as an outpatient or inpatient at a hospital, including $50 per ER visit; waived doctors' services if admitted to hospital

Not covered: All charges.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area .

Ambulance
Professional ambulance service when medically appropriate. $25 per trip
See 5( c) for non-emergency service. 28
28 Page 29 30
2002 Coventry Health Care of Kansas, Inc. 29 Section 5 (e)
Section 5 (e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve,
cost-sharing and limitations for Plan mental health and substance abuse benefits will
be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
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.

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.

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

Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day

hospitalization, facility based intensive outpatient treatment

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

Mental Health and substance abuse benefits -Continued on next page

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Your cost sharing responsibilities are no
greater than for other illness or conditions. 29
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2002 Coventry Health Care of Kansas, Inc. 30 Section 5 (e)
Mental health and substance abuse benefits (continued)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

Call 1-800-752-7242. When you call, be prepared to give your name and
member I. D. number. You will be asked some general questions about why
you are seeking services, and you will be referred to a provider for
treatment.. 30
30 Page 31 32
2002 Coventry Health Care of Kansas, Inc. 31 Section 5 (f)
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Section 5 (f). Prescription drug benefits
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. \

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist must write the prescription

Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication.

We use a formulary. We cover non-formulary drugs prescribed by a Plan doctor. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a
31-day supply or 100-unit dosage, whichever is less. You pay a $5 copay per prescription unit or refill
for formulary generic drugs or an $10 copay for formulary name brand drugs or a $20 copay for
non-formulary prescription drugs requested by the prescribing doctor.

We have an open formulary. If your physician believes a name brand product is necessary or there is no
generic available, your physician may prescribe a name brand drug from a formulary list. This list of name
brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call 1-800-664-9251. When generic substitution is permissible (i. e., a generic
drug is available and the prescribing doctor does not require the use of a name brand drug), but you request
the name brand drug, you pay the price difference between the average wholesale prices of the generic and
name brand drug as well as the $10 copay per prescription unit or refill.

You can obtain through Mail Order covered "maintenance" prescription drugs use to treat chronic or long-term health conditions such as high blood pressure or diabetes) for a 93-day supply. You pay $10
copay per prescription unit or refill for formulary generic drugs, and $20 copay for formulary name brand
drugs. Non formulary prescription drugs are not covered under the maintenance mail order.

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's formulary is based on effectiveness and cost of drugs. Nonformulary drugs under the retail
pharmacy benefit ill be covered when prescribed by a Plan doctor.

These are the dispensing limitations. Retail Pharmacy-Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31-day supply or 100-unit dosage,
whichever is less. If a 90 day supply is prescribed, you will be able to pick up a 31 day supply at the
pharmacy. The balance of the script will be dispensed on a 31-day basis. Mail Order-Covered Mail Order
"maintenance" prescription drugs use to treat chronic or long-term health conditions such as high blood
pressure or diabetes) for a 93-day day supply.

Prescription drug benefits begin on the next page. 31
31 Page 32 33
2002 Coventry Health Care of Kansas, Inc. 32 Section 5 (f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

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

Not covered.
Insulin
Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution, or equivalent, and acetone test tablets

are each available for the $10 copay.
Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Prior authorization below)
Contraceptive drugs and devices

Not covered: All charges
Drugs available without a prescription or for which a non-prescription equivalent is available.

Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Drugs obtained at a non-plan pharmacy except out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs to aid in smoking cessation, including nicotine patches

Fertility drugs
Appetite suppressants and other drugs to assist in weight control (except for the treatment of morbid obesity when authorized by the

Plan and your primary care physician).

Retail Pharmacy
$ 5 per generic formulary drug
$ 10 per brand name formulary
drug

$20 per non formulary drug
Mail Order (93-day supply)
$10 generic formulary
$20 brand name formulary
Note: our mail order benefit is
limited to the two tiers listed
above.

Note: If there is no generic
equivalent available, you will
still have to pay the brand name
copay. If there is a generic
equivalent and you choose the
brand name drug, you will pay
the brand name copay plus the
difference in the average whole-sale
price between the generic
and the brand name drug. This
applies to both the formulary and
non-formulary drugs. 32
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2002 Coventry Health Care of Kansas, Inc. 33 Section 5 (g)
Section 5 (g). Special Features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may with draw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

High risk pregnancies Members enrolled in our prenatal program who are identified as being in a high risk category will be followed by an RN and placed into case
management. This program offers special services for moms with special
needs. Contact us at 1-800-664-9251 for more information. 33
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2002 Coventry Health Care of Kansas, Inc. 34 Section 5 (h)
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Section 5 (h). Dental benefits
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 non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do

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

coverage, including with Medicare.

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair $10 per office visit
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.

Dental Benefits

We have no other dental benefits. 34
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2002 Coventry Health Care of Kansas, Inc. 35 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.

Vision Discount Program: When you have an office visit with a participating optometrist
who dispenses glasses and non-disposable contact lenses, that eyewear can be purchased
with a 15% discount. Ask your participating optometrist for details. 35
35 Page 36 37
2002 Coventry Health Care of Kansas, Inc. 36 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.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest ;

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 36
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2002 Coventry Health Care of Kansas, Inc. 37 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, coinsurance,
or deductible.

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

Medical, hospital and drug
benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.

Facilities will file on the UB-92 form. For claims questions and assistance,
call us at 1-800-664-9251.

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 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: Coventry Health Care of Kansas
8301 E. 21 st North, Suite 300
Wichita, Kansas 67206

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

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 37
37 Page 38 39
2002 Coventry Health Care of Kansas, Inc. 38 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. Write to us at: Coventry Health Care of Kansas, Inc, 8301 E 21 st North, Suite 300, Wichita, KS 67206

You must:
(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: Coventry Health Care of Kansas, Inc.; 8301 E. 21 st North, Suite 300;
Wichita, KS 67206

(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 III,
P. O. Box 436, Washington, D. C. 20044-0436.

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. 38
38 Page 39 40
2002 Coventry Health Care of Kansas, Inc. 39 Section 8
The disputed claims process (continued)
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 provide a copy of your specific written consent with the
review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline
because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed
services, drugs, or supplies or from the year in which you were denied 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 law
suit, benefits, and payment of benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in
dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions
or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
1-800-664-9251 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 III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 39
39 Page 40 41
2002 Coventry Health Care of Kansas, Inc. 40 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under
coverage 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 a Medicare+ Choice plan that 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 hat 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 your Plan PCP, or precertified as required.

We will waive some copayments, coinsurance, and deductibles, as follows: When
Original Medicare is the primary payor, we will waive your out of pocket costs
including copayments and coinsurance. 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.

(Primary payer chart begins on next page.) 40
40 Page 41 42
2002 Coventry Health Care of Kansas, Inc. 41 Section 9
The following chart illustrates whether 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 re-employed 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 (for other
services) services)

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

c) Are a former spouse of an annuitant, or
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. 41
41 Page 42 43
2002 Coventry Health Care of Kansas, Inc. 42 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 1-800-664-9251 or visit us at www. chcwic. cvty. com.

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
your out-of-pocket costs including copayments and coinsurance. 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.

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 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 we will waive your out-of pocket costs like copayments
and coinsurance, up to our allowed amount. 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 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. For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open
season unless you involuntarily lose coverage or move out of the Medicare
managed care plan's service area.

If you do not enroll in 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. 42
42 Page 43 44
2002 Coventry Health Care of Kansas, Inc. 43 Section 9
Coordinating benefits with other coverage (continued)
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 disease 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 benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, or Federal
are responsible for your care Government agency directly or indirectly pays for them.

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

the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 43
43 Page 44 45
2002 Coventry Health Care of Kansas, Inc. 44 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Non-medical services that do not attempt to cure, are provided during periods when the medical condition of a patient is not changing, and do not require
the continual services of medical personnel.

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 deductible.

Experimental or
investigational services Any treatment, procedure, facility, equipment, drug or drug usage, device, or supply that is not accepted as standard medical practice by Coventy Health

Care or the general medical community, or does not have federal government
agency approval for its use or application.

Medical necessity Any service or supply for the prevention, diagnosis, or treatment that is (1) consistent with illness, injury or condition of the Member; (2) in accordance
with the approved and generally accepted medical or surgical practice
prevailing in the geographical locality where, and at the time when, the
service or supply is ordered. Determination of "generally accepted practice"
is the discretion of the Medical Director or Medical Director's designee.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. We base our allowance on the allowed
covered charges Providers in the network accept from the Plan. Allowances,
which are generally lower than a provider's billed charges, serve as
maximum allowed amounts in computing coinsurances. Providers in the
network accept the Plan allowance as payment in full for all covered
services.

Us/ We Us and we refer to Coventry Health Care of Kansas
You You refers to the enrollee and each covered family member. 44
44 Page 45 46
2002 Coventry Health Care of Kansas, Inc. 45 Section 11
Section 11. FEHB Facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office can
about enrolling in the answer your questions, and give you a Guide to Federal Employees Health
FEHB Program Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement
office authorizes coverage for. Under certain circumstances, you may also
continue coverage for a disabled child 22 years of age or older who is
incapable of self-support.

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

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 45
45 Page 46 47
2002 Coventry Health Care of Kansas, Inc. 46 Section 11
FEHB Facts (continued)
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay

period that starts on or after January 1. Annuitants' coverage and premiums
begin on January 1. If you joined at any other time during the year, your

employing office will tell you the effective date of coverage.

Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential 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 If you are divorced from a Federal employee or annuitant, you may not coverage 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 Federal
ex-spouse's employing or retirement office to get RI 70-5, the Guide to
Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, or other information about your coverage choices.

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. 46
46 Page 47 48
2002 Coventry Health Care of Kansas, Inc. 47 Section 11
FEHB Facts (continued)
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5,
the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, from your
employing or retirement office or from www. opm. gov/ insure. It explains
what you have to do to enroll.

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

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

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

Getting a Certificate of
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 tp the "TCC and HIPAA" frequently asked
question. It These highlightss 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. 47
47 Page 48 49
2002 Coventry Health Care of Kansas, Inc. 48 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:

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.

Welcome to the club! 76% of Americans believe they will never need long term care, but the
facts are that about half 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 planing.

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.

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 the their state's pover-ty 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.

Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc.

What is long term care
(LTC) insurance?

I'm healthy. I won't need
long term care. Or, will I?

Is long term care expensive?
But won't my FEHB plan,
Medicare or Medicaid cover
my long term care?

When will I get more information
on how to apply for this new
insurance coverage?

How can I find out more about the
program NOW? 48
48 Page 49 50
2002 Coventry Health Care of Kansas, Inc. 49 Index
Index
General Exclusions ........................ 36
Hearing services ............................ 18
Home health services .................... 20
Hospice care .................................. 26
Home nursing care ........................ 20
Hospital.......................................... 24
Immunizations .............................. 15
Infertility ........................................ 16
Inhospital physician care .............. 14
Inpatient Hospital Benefits ............ 24
Insulin ............................................ 32
Laboratory and pathological
services ...................................... 14
Machine diagnostic tests................ 14
Magnetic Resonance Imagings
(MRIs)........................................ 14
Mail Order Prescription Drugs ...... 32
Mammograms................................ 15
Maternity Benefits ........................ 16
Medicaid ........................................ 43
Medically necessary ...................... 44
Medicare ........................................ 40
Members .......................................... 9
Mental Conditions/ Substance Abuse
Benefits ...................................... 28
Neurological testing ...................... 25
Newborn care ................................ 14
Non-FEHB Benefits ...................... 35
Nurse
Licensed Practical Nurse............ 14
Nurse Anesthetist........................ 24
Nurse Midwife............................ 16
Nurse Practitioner ...................... 14
Psychiatric Nurse........................ 29
Registered Nurse ........................ 21
Nursery charges ............................ 16
Obstetrical care ............................ 16
Occupational therapy .................... 18
Ocular injury.................................. 18
Office visits.................................... 14
Oral and maxillofacial surgery ...... 22
Orthopedic devices ........................ 19
Ostomy and catheter supplies........ 20
Out-of-pocket expenses ................ 12
Outpatient facility care .................. 25
Oxygen .......................................... 20

Pap test .......................................... 15
Physical examination .................... 15
Physical therapy ............................ 18
Physician ................................ 9 or 14
Pre-admission testing .................... 25
Precertification .............................. 11
Preventive care, adult .................... 15
Preventive care, children .............. 15
Prescription drugs .......................... 31
Preventive services ........................ 15
Prior approval ................................ 11
Prostate cancer screening .............. 15
Prosthetic devices .......................... 19
Psychologist .................................. 29
Psychotherapy................................ 29
Radiation therapy .......................... 17
Rehabilitation therapies ................ 18
Renal dialysis ................................ 24
Room and board ............................ 24
Second surgical opinion ................ 14
Skilled nursing facility care .......... 25
Speech therapy .............................. 18
Splints ............................................ 24
Sterilization procedures ................ 21
Subrogation.................................... 45
Substance abuse ............................ 29
Surgery .......................................... 21
Anesthesia .............................. 23 Oral.......................................... 22

Outpatient................................ 25 Reconstructive ........................ 22
Syringes ........................................ 32
Temporary continuation of
coverage .................................... 46
Transplants .................................... 23
Treatment therapies ...................... 17
Vision services .............................. 18
Well child care .............................. 15
Wheelchairs .................................. 20
Workers' compensation ................ 43
X-rays ............................................ 14

Accidental injury .......................... 27
Allergy tests .................................. 17
Alternative treatment .................... 20
Allogenetic (donor) bone marrow
transplant .................................... 23
Ambulance .................................... 26
Anesthesia...................................... 23
Autologous bone marrow
transplant .................................... 23
Biopsies ........................................ 21
Birthing centers.............................. 16
Blood and blood plasma ................ 24
Breast cancer screening ................ 15
Casts .............................................. 24
Catastrophic protection.................. 12
Changes for 2002 ............................ 8
Chemotherapy................................ 17
Childbirth ...................................... 16
Chiropractic .................................. 20
Cholesterol tests ............................ 15
Circumcision.................................. 16
Claims............................................ 37
Coinsurance .................................. 12
Colorectal cancer screening .......... 15
Congenital anomalies .................... 21
Contraceptive devices and drugs .. 32
Coordination of benefits ................ 40
Covered charges ............................ 44
Covered providers............................ 9
Crutches ........................................ 20
Deductible...................................... 12
Definitions .................................... 44
Dental care .................................... 34
Diagnostic services ........................ 14
Disputed claims review ................ 38
Donor expenses (transplants) ........ 23
Dressings ...................................... 24
Durable medical equipment
(DME) ........................................ 20
Educational classes and programs 20
Effective date of enrollment ............ 9
Emergency .................................... 27
Experimental or investigational .... 36
Eyeglasses...................................... 18
Family planning ............................ 16
Fecal occult blood test .................. 15 49
49 Page 50 51
NOTES:
2002 Coventry Health Care of Kansas, Inc. 50 Notes 50
50 Page 51 52
2002 Coventry Health Care of Kansas, Inc. 51 Summary
Summary of benefits for Coventry Health Care of Kansas -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;

If you want to enroll or change your enrollment in this for more detail, look inside. Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ........................ Office visit copay: $10 primary 14 care; $10 specialist

Services provided by a hospital:
Inpatient .................................................................................................... Nothing 24
Outpatient.................................................................................................. 25

Emergency benefits: $25 per Urgent Care visit
In-area ...................................