Pages 1--72 from Blue Choice

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An independent licensee of the
Blue Cross and Blue Shield Association http:// www. bcbsmo. com 2002

A Health Maintenance Organization

Serving: St. Louis, Central, Southeast and Southwest Missouri areas
and St. Clair and Madison counties in Illinois

Enrollment in this plan is limited. You must live in our
Geographic service area to enroll. See page 8 for requirements.

Enrollment code:
9G1 Self Only 9G2 Self and Family

RI-73-516

For changes
in benefits
see page 9

This plan has commendable accreditation
from the NCQA. See the 2002 Guide
for more information on accreditation. 1
1 Page 2 3
2002 BlueCHOICE Table of Contents 2
Table of Contents
Introduction…………………………………………………………………. ............................................................ 5
Plain Language………………………………………………………………............................................................ 5
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........................................................................................................................................... 6
Service Area.......................................................................................................................................... 8
Section 2. How we change for 2002………………………………………............................................................... 9
Program-wide changes........................................................................................................................... 9
Changes to this Plan .............................................................................................................................. 9
Section 3. How you get care …………................................................................................................................. 10
Identification cards .............................................................................................................................. 10
Where you get covered care................................................................................................................. 10

Plan providers ............................................................................................................................... 10
Plan facilities................................................................................................................................. 10
What you must do to get covered care.................................................................................................. 10

Primary care.................................................................................................................................. 10
Specialty care ................................................................................................................................ 10
Hospital care ................................................................................................................................. 11
Circumstances beyond our control ....................................................................................................... 12
Services requiring our prior approval ................................................................................................... 12
Section 4. Your costs for covered services............................................................................................................ 13

Copayments................................................................................................................................... 13
Deductible..................................................................................................................................... 13
Coinsurance................................................................................................................................... 13
Your out-of-pocket maximum.............................................................................................................. 13

Section 5. Benefits…………………………………………………………............................................................ 14
Overview............................................................................................................................................. 14
(a) Medical services and supplies provided by physicians and other health care professionals .......... 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 27
(c) Services provided by a hospital or other facility, and ambulance services.................................... 32
(d) Emergency services/ accidents.................................................................................................... 35
(e) Mental health and substance abuse benefits................................................................................ 39
(f) Prescription drug benefits .......................................................................................................... 41 2
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2002 BlueCHOICE Table of Contents 3
(g) Special features.......................................................................................................................... 44
Flexible Benefits Option
Away From Home Care
RightSteps
TakeCharge Asthma Program
TakeCharge Diabetes Program
(h) Dental benefits........................................................................................................................... 46
(i) Non-FEHB benefits available to Plan members .......................................................................... 47
Section 6. General exclusions --things we don't cover ......................................................................................... 48
Section 7. Filing a claim for covered services ....................................................................................................... 49
Section 8. The disputed claims process ................................................................................................................. 51
Section 9. Coordinating benefits with other coverage............................................................................................ 53
When you have…

Other health coverage................................................................................................................... 53
Original Medicare ........................................................................................................................ 53
Medicare managed care plan ........................................................................................................ 55
TRICARE/ Workers' Compensation/ Medicaid...................................................................................... 56
Other Government agencies ................................................................................................................ 56
When others are responsible for injuries ............................................................................................... 56
Section 10. Definitions of terms we use in this brochure ....................................................................................... 57
Section 11. FEHB facts ........................................................................................................................................ 59
Coverage information ......................................................................................................................... 59

No pre-existing condition limitation .............................................................................................. 59
Where you get information about enrolling in the FEHB Program.................................................. 59
Types of coverage available for you and your family ..................................................................... 59
When benefits and premiums start................................................................................................. 60
Your medical and claims records are confidential .......................................................................... 60
When you retire ........................................................................................................................... 60
When you lose benefits ...................................................................................................................... 60

When FEHB coverage ends........................................................................................................... 60
Spouse equity coverage................................................................................................................ 60
Temporary Continuation of Coverage (TCC)................................................................................ 60
Converting to individual coverage................................................................................................ 61
Getting a Certificate of Group Health Plan Coverage.................................................................... 61

Long-term care insurance is coming later in 2002 .................................................................................................. 62 3
3 Page 4 5
2002 BlueCHOICE Table of Contents 4
Department of Defense/ FEHB Demonstration Project ........................................................................................... 63
Index.................................................................................................................................................................... 65
Summary of benefits............................................................................................................................................. 66
Rates ....................................................................................................................................................... Back cover

Blue Cross and Blue Shield of Missouri is the name RightCHOICE Managed Care, Inc. (RIT) uses to do business in most of Missouri. In
Missouri, RIT administers the FEHB program. HMO Missouri, Inc. does business as BlueCHOICE. RIT and HMO Missouri, Inc. are independent
licensees of the Blue Cross and Blue Shield Association. 4
4 Page 5 6
2002 BlueCHOICE 5 Introduction/ Plain Language/ Advisory
Introduction
BlueCHOICE
1831 Chestnut Street
St. Louis, Missouri 63103-2275

This brochure describes the benefits of BlueCHOICE HMO under our contract (CS 2838) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 9. 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 BlueCHOICE.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.

Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 932-4480
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 BlueCHOICE 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 described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, hospitals and other types of providers 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. We reimburse primary care physicians through capitation, which includes the majority of services the
primary care physician renders. We compensate certain services, such as immunizations or cardiac diagnostic testing
in the office as fee for service.

Who provides my health care?
This plan is an individual-practice Plan. All participating doctors practice in their own offices in the community.
Unless it is an emergency, benefits are available only from doctors, hospitals and other health care providers that are
in the BlueCHOICE network. The Plan arranges with doctors and hospitals to provide medical care for both the
prevention of disease and the treatment of serious illness.

You must select a primary care doctor for each covered family member. Approximately 1, 300 primary care
physicians participate in BlueCHOICE. For most care, you must contact your primary care doctor for a referral or
authorization before seeing any other doctor for specialty care or nonemergency hospital services. A wide variety of
specialists are participating Plan doctors. Many are Board certified as indicated in the BlueCHOICE directory. If you
need hospital care, your Plan primary doctor will admit you to a participating hospital where he/ she has admitting
privileges.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB Web site (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.

About the plan and care management: Blue Cross and Blue Shield of Missouri has over 60 years of experience in the health insurance industry. We began as St. Louis Blue Cross in 1936. In 1945, Missouri Medical Service,
commonly known as Blue Shield, began business in the St. Louis area. The two companies merged in 1986, forming
Blue Cross and Blue Shield of Missouri, a not-for-profit health service corporation. In 1994, Blue Cross and Blue
Shield of Missouri formed a new managed care company, Alliance Blue Cross Blue Shield.

Effective November 30, 2000, Blue Cross and Blue Shield of Missouri and its for-profit managed care subsidiary,
Alliance Blue Cross Blue Shield, merged into a single, for-profit, publicly traded Delaware corporation. The
insurance-related business that was part of the old Blue Cross and Blue Shield of Missouri has been transferred to and
assumed by Healthy Alliance Life Insurance Co., a wholly owned subsidiary of Blue Cross and Blue Shield of
Missouri, as part of the reorganization.

BlueCHOICE, the for-profit HMO subsidiary of Blue Cross and Blue Shield of Missouri, began operations in 1988.
Blue Cross and Blue Shield of Missouri, BlueCHOICE and Healthy Alliance Life Insurance Co. are independent
licensees of the Blue Cross and Blue Shield Association. 6
6 Page 7 8
2002 BlueCHOICE 7 Section 1
Utilization management services include:
Precertifications of medical/ surgical, mental health, rehabilitation, skilled nursing, outpatient and home health
care
Concurrent review of medical/ surgical, mental health, rehabilitation, skilled nursing, outpatient and home health
care
Retrospective review
Discharge planning
Alternative care planning
Individual case management
Appeal for denial of payment due to lack of medical necessity
Medical review

Our contracts with network providers require them to handle all certifications for BlueCHOICE members. You will
not have to be concerned about managed care procedures as long as your receive care from network providers.

We offer special programs to help members with health conditions such as asthma, diabetes and high-risk pregnancy.
These are voluntary programs to help members manage their particular health condition. These programs are
explained in Section 5( g).

Accreditation status: BlueCHOICE is accredited by the National Committee for Quality Assurance (NCQA). The comprehensive review process evaluates how well a plan manages its benefits. The accreditation process evaluates
more than 60 standards in the following six categories:
quality management and improvement
physician qualifications and evaluation
members' rights and responsibilities
preventive health services
utilization management and
medical records

Networks, providers and facilities: The BlueCHOICE network includes approximately 1,300 primary physicians, 3, 600 specialists and 68 hospitals. Approximately 77 percent of network physicians are Board Certified and 90
percent are accepting new patients. The physician's Board status and whether or not he/ she is accepting new patients
are included in the BlueCHOICE provider directory.

We have established credentialing polices that require us to select and recredential physicians every two years,
based on an evaluation of their experience and training, board certification and staff privileges at network hospitals.
Our program goals are to support the development and maintenance of credentialing and recredentialing standards for
our participating providers, review the qualifications of potential participating providers against established standards,
and to reassess the qualifications and performance of our network providers.

Our credentialing criteria for network hospitals include accreditation by the Joint Committee on Accreditation of
Health Care Organizations (JCAHO), Medicare certification, effective utilization management pricing, geographic
location, scope of services and utilization experience.

If you want more information about us, call 1-800-932-4480. For the hearing impaired (TDD), call 1-800-822-1215. 7
7 Page 8 9
2002 BlueCHOICE 8 Section 1
Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is:
The St. Louis Area, including the Missouri counties of Crawford, Franklin, Gasconade, Jefferson, Lincoln,
Montgomery, Pike, St. Charles, St. Francois, St. Louis (City and County), Ste. Genevieve, Warren and Washington;
the Central Missouri Area counties of Adair, Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper, Howard,
Linn, Macon, Maries, Miller, Moniteau, Monroe, Morgan, Osage, Phelps, Pulaski, Putnam, Randolph, Schuyler and
Sullivan; the Southwest Missouri Area counties of Barry, Barton, Cedar, Christian, Dade, Dallas, Douglas, Greene,
Hickory, Jasper, Laclede, Lawrence, McDonald, Newton, Ozark, Polk, Stone, Taney, Texas, Webster and Wright; and
the Southeast Missouri Area counties of Butler, Carter, Ripley and Wayne.

You may also enroll with us if you live in the Illinois counties of Madison or St. Clair and work in Missouri.
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 moves outside 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. As a BlueCHOICE member, you may have access to physician care through the BlueCard
Traditional network. This nationwide network is made up of 9, 500 hospitals and 744, 000 physicians that
participate with Blue Cross and Blue Shield Plans across the country. Benefits are easy to use – a "suitcase" logo
on members' ID cards will identify them as BlueCard members. To locate a BlueCard provider outside the
BlueCHOICE service area, members simply call the toll-free BlueCard Access number on their ID card (1-800-
810-blue) or visit the BlueCard Hospital and Doctor Finder at www. BCBS. com. Members should contact their
primary care physician just as they would if they were at home. The primary care physician will provide a non-network
referral and coordinate care with the out-of-area provider as appropriate. 8
8 Page 9 10
2002 BlueCHOICE 9 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes

We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan

We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
Your share of the non-Postal premium will increase by 10% for Self Only or 10% for Self and Family.
We clarified the Preventive care, adult benefits by removing the entry for blood lead level testing for adults because it is a test more typically done for children. (Section 5( a))

Coverage has been added for cochlear implants. (Section 5( a))
We are adding up to 20 visits per calendar year for chiropractic care, which will be covered as a combined physical therapy/ chiropractic benefit. (Section 5( a))

Treatment limitations for speech therapy have been removed, which will be covered when medically necessary, up to 20 visits per calendar year.
We added treatment for smoking cessation to our mental health and substance abuse benefits, with no copayment for individual and group counseling. And, we will cover prescribed FDA-approved medication for the treatment
of tobacco use at the regular prescription drug copayments.
The University of Missouri Hospital and Clinic, the Ellis Fischel Cancer Center and 400 affiliated physicians joined the network in July, 2000.

Capital Region Medical Center and its physician group in Jefferson City joined the network in October, 2000.
Missouri Baptist Medical Center in St. Louis is no longer a participating network provider. 9
9 Page 10 11
2002 BlueCHOICE 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800-932-4480.

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

Plan providers Plan providers are primary care physicians, specialists and other health care professionals in our service area that we contract with to provide
covered services to our members. We credential Plan providers
according to national standards.

We list Plan providers in the provider directory, which we update
annually. The BlueCHOICE directory is also on our Web site,
www. bcbsmo. com. The online directory is updated daily.

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 annually. The list is also on
our Web site.

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.

Use the directory or Web site to select a physician convenient to you.
Write the physician's office code number in the space provided on your
Provider Selection Card. You'll find the office number listed before each
primary care physician's name. See the Selection Card for instructions.

Primary care Your primary care physician can be a family or general practitioner, internist, pediatrician or geriatrician. Your primary care physician will
provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. You can change your primary care
physician at any time. We will send you a new ID card with your new
doctor's name and phone number on the front.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a network OB/ GYN for any medically necessary
OB/ GYN care without a referral. And you may go to a network eye care
provider for one routine vision exam each calendar year without a
referral. 10
10 Page 11 12
2002 BlueCHOICE 11 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval
beforehand).

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

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

If you have a chronic or disabling condition and lose access to your specialist because we:

__ terminate our contract with your specialist for other than cause; or
__ drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or

__ reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.

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

If you think you have a mental health or substance abuse problem, we
encourage you to see your primary care physician, who will coordinate
your care. Your primary care physician may treat you or recommend that
you call our mental health and substance abuse benefits manager.

If you do not wish to go through your primary care physician for care,
you may call our mental health and substance abuse benefits manager
directly at 1-800-965-2583. A trained professional will evaluate your
needs and authorize your care.

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. 11
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2002 BlueCHOICE 12 Section 3
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-932-4480. 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 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, is
medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification and
recertification. Your physician must obtain precertification before you
can receive certain types of care, such as:

Inpatient hospital care
Outpatient hospital care
Care in a freestanding surgery center or skilled nursing facility
Home health care

Your physician must obtain recertification if your care needs to continue
longer than originally certified.

Your BlueCHOICE primary care physician or specialist will handle all
certification requirements for you. However, if you receive emergency
care at a non-network facility, you will need to contact us for approval.
Please see Section 5( d) for further information. 12
12 Page 13 14
2002 BlueCHOICE 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit.

Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.

Your catastrophic protection out-of-pocket maximum
for copayments After you pay 100% of your annual premium in copayments for one family member, or 100% of your annual premium for two or more family
members, you do not have to make any further payments for certain
services for the rest of the year. This is called a catastrophic limit.
However, copayments for your prescription drugs and dental services do
not count toward these limits and you must continue to make these
payments.

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the limits. 13
13 Page 14 15
2002 BlueCHOICE 14 Section 5
Section 5. Benefits – OVERVIEW
(See page 9 for how our benefits changed this year and pages 66-67 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 1-800-932-4480.

(a) Medical services and supplies provided by physicians and other health care professionals.......................... 15-26

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

Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes & programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ...................... 27-31
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services................................................... 32-34

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

(d) Emergency services/ accidents................................................................................................................... 35-38
Medical emergency Ambulance

(e) Mental health and substance abuse benefits................................. ............................................................... 39-40
(f) Prescription drug benefits.................................................................................................................................. 41-43
(g) Special features.................................................................................................................................................. 44-45

Flexible benefits option
Away From Home Care
RightSteps
TakeCharge Asthma Program
TakeCharge Diabetes Program
(h) Dental benefits........................................................................................................................................... .... 46
(i) Non-FEHB benefits available to Plan members .............................................................................................. 47
Summary of benefits........................................................................................................................................ 66-67 14
14 Page 15 16
2002 BlueCHOICE 15 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

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

Office medical consultations
Second surgical opinion

$10 per office visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility

Nothing

At home $10 per visit
Not covered:
Care that is not medically necessary
Care that is investigational
Care from a non-network provider without prior approval from us

All charges.

Diagnostic and treatment services --Continued on next page 15
15 Page 16 17
2002 BlueCHOICE 16 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine Pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if services are received during your office visit
$10 copay applies to services received at outpatient facilities

Preventive care, adult
Routine screenings, such as:
Total blood cholesterol – once every three years*
Colorectal cancer screening, including __
Fecal occult blood test

$10 per office visit

__ Sigmoidoscopy, screening – every five years starting at age 50*
Chlamydial infection
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older*

Routine Pap test – annual*
*or more frequently if recommended by your BlueCHOICE physician. 16
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2002 BlueCHOICE 17 Section 5( a)
Preventive care, adult (Continued) You pay
Routine mammogram – once per calendar year or more frequently if recommended by a physician $10 per visit

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – ages 19 and over is based on medical necessity

Influenza/ Pneumococcal vaccines

Nothing ($ 10 office visit copay
applies to any other covered
services)

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

Immunizations for travel or occupational reasons.

All charges.

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing ($ 10 office visit copay applies to any other covered
services)

Well-child care charges for routine examinations, immunizations and care (through age 22)

Examinations, such as: __
Eye exams to determine the need for vision correction
__ Ear exams to determine the need for hearing correction

__ Newborn hearing screening, rescreening and initial amplification
__ Examinations done on the day of immunizations

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

Immunizations for travel or occupational reasons.

$10 per office visit 17
17 Page 18 19
2002 BlueCHOICE 18 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 12 for specific details.

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. If you leave in less than
48 hours (or 96 hours after a cesarean delivery), we will cover two
home visits by a registered nurse provided through a network home
health agency.

We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

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

Surgery benefits (Section 5( b)).

$10 (for first office visit only)
Nothing
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

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

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling, voluntary abortions and related care.
All charges. 18
18 Page 19 20
2002 BlueCHOICE 19 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, limited to:
__ in vitro fertilization

__ gamete intrafallopian tube transfer (GIFT)
__ zygote intrafallopian tube transfer
However, we will only cover these treatments if you or your spouse:
(1) have not been able to become pregnant or sustain a pregnancy
through reasonable, less costly and medically appropriate covered
infertility treatment;

(2) have not undergone four completed oocyte retrievals (except if a
live birth follows a completed oocyte retrieval, then we will cover
two more completed oocyte retrievals); and

(3) have the procedures performed at medical facilities that conform to
the American College of Obstetrics and Gynecology guidelines or to
the American Fertility Society's minimum standards for in vitro
fertilization.

Artificial insemination:
__ intravaginal insemination (IVI)

__ intracervical insemination (ICI)
__ intrauterine insemination (IUI)

Oral fertility drugs and injectable fertility drugs

Note: Preauthorization is required for fertility medication.

$10 per office visit
Nothing
We cover fertility drugs under the
prescription drug benefit. Please
refer to Section 5( f).

Not covered
Treatment for infertility following voluntary sterilization
Cost of donor sperm
Cost of donor egg
Any treatment not specified above

All charges.

Allergy care
Testing and treatment
Allergy injection

$10 per office visit

$3 per visit ($ 10 office visit copay
applies to any other covered
services)

Allergy serum Nothing
Not covered: Provocative food testing and sublingual allergy
desensitization
All charges. 19
19 Page 20 21
2002 BlueCHOICE 20 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High-dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/ Tissue Transplants on page 30.

Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Before administering any GHT treatment, your BlueCHOICE
physician needs to obtain authorization by submitting a written request
to our Provider Services Unit. Please check with your BlueCHOICE
physician before receiving GHT treatment.

We will not cover GHT or related services and supplies unless you have
received prior authorization.

Growth hormone is covered as a medical benefit.

Nothing
$10 per visit outpatient
$10 per visit outpatient

Nothing
Nothing

Not covered:
Therapy that is not listed as covered in this booklet. For example,
massage therapy or exercise conditioning.

All charges. 20
20 Page 21 22
2002 BlueCHOICE 21 Section 5( a)
Physical and occupational therapies You pay
20 visits per calendar year for physical therapy and chiropractic care combined, and

20 visits per calendar year for occupational therapy.
For the services of each of the following:
__ qualified physical therapists and chiropractors, and

__ occupational therapists.

Note: We only cover physical and occupational therapy to restore
bodily function when there has been a total or partial loss of bodily
function due to illness or injury.

Cardiac rehabilitation following, but not limited to, a heart transplant,
bypass surgery or a myocardial infarction, is provided for one
consecutive 12-week program per calendar year

Pulmonary rehabilitation for up to 14 sessions within 12 months and
then one session every 3 months thereafter

Note: See Chiropractic care

$10 per office visit

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
20 visits per calendar year $10 per office visit 21
21 Page 22 23
2002 BlueCHOICE 22 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
Routine hearing exams
Newborn hearing, screening, rescreening and initial amplification

$10 per office visit

Not covered:
Hearing aids, testing and examinations for them, except for newborns All charges.

Vision services (testing, treatment, and supplies)
Routine eye exam (one per calendar year)
Eyeglasses and contact lenses are covered up to $35 per 24-month period. Reduced-cost glasses or contact lenses from selected

providers.

$10 per office visit

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

$10 per office visit

Eye exam to determine the need for vision correction for children (see Preventive care, children)
Annual eye refractions

$10 per office visit

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery, including LASIK procedures

All charges.

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

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

$10 per office visit

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

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

treatment is by open cutting surgery)

All charges. 22
22 Page 23 24
2002 BlueCHOICE 23 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants; and surgically implanted breast implant
following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see
Section 5 (c) for payment information. See 5( b) for coverage of the
surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
orthotic devices used primarily for convenience, comfort or for participation in athletics

corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges. 23
23 Page 24 25
2002 BlueCHOICE 24 Section 5( a)
Durable medical equipment (DME) You pay
We cover the use of standard models of the durable medical equipment
(DME) and medical supplies listed below when medically necessary to
treat certain conditions.

Your primary care physician or network specialist must give you a
prescription for the equipment or supplies. You must obtain the
equipment or supplies from a network DME provider.

We only provide benefits up to our allowed amount for supplies and for
basic models of equipment. If you want other than the basic model, you
must pay your copay and any charges above the allowed amount for the
basic equipment. We determine what is a basic model.

Following is a list of covered equipment and medical supplies. The
copay is shown at right.

Air flotation mattress and alternating pressure pump
Apnea monitor (1)
Bi-directional Positive Airway Pressure (BIPAP) apparatus (1)
Bill phototherapy system (1)
Blood glucose monitor (1)
Bone growth stimulator (electrical) (2)
Canes
Commode (bedside)
Continuous Passive Motion (CPM) Devices
Continuous Positive Airway Pressure (CPAP) apparatus (1)
Replacement CPAP apparatus
Continuous Positive Airway Pressure (CPAP) humidifier
Crutches
Enteral feeding equipment
Enteral feeding supplies
Formulas for treatment of phenylketonuria or any inherited disease
of amino and organic acids, one month supply per copayment
Hospital bed (electric)
Hospital bed (nonelectric)
Incontinence cathethers and irrigation supplies, one month supply
per copayment (1)
Insulin pump (2)
Insulin pump supplies (2)
Intermittent Positive Pressure Breathing Apparatus (IPPB) (1)
Lymphedema pumps/ lymphedema sleeves
Mattress overlays
Medical and post-surgical dressings, irrigation supplies, and
dressing tape, one month supply per copayment
Nebulizer compressor (1)
Neuromuscular Electronic Stimulator (NMES)
Ostomy supplies, all types, one month supply per copayment
Oxygen, one month supply per copayment
Patient lifts
Peak flow meters
Pulmoaids
Spacers for Metered Dose Inhalers (MDI)
Sphygmomanometer for gestational hypertension
Suction catheters, one month supply per copayment (1)
Suction equipment

$10 to $100
$ 10
$ 25
$ 50
$ 25
$ 25
$100
$ 10
$ 10
$ 25
$ 25
$ 25
$ 25
$ 10
$ 25
$ 10
$ 15

$ 50
$ 25
$ 10

$100
$ 25
$ 25
$ 50
$ 25
$ 10

$ 25
$ 25
$ 10
$ 50
$ 25
$ 10
$ 10
$ 10
$ 25
$ 10
$ 25 24
24 Page 25 26
2002 BlueCHOICE 25 Section 5( a)
Transcutaneous Electrical Nerve Stimulator (TENS) Units
Traction devices
Walkers
Wheelchairs (electric)
Wheelchairs (non-electric)
Wheelchair gel pads

The maximum benefit for a medically necessary nonstandard
wheelchair is $2, 000. The regular copay for a manual or electric
wheelchair applies. (2)

ABI Vest, used to treat members with cystic fibrosis, is available for
$200 per month.

(1) Includes initial provision of nonpharmaceutical medically necessary
supplies.

(2) Subject to review by BlueCHOICE. To obtain more information,
you may contact us at 1-800-932-4480.

$ 25
$ 25
$ 10
$ 50
$ 25
$ 10

$ 10

Not covered:
Dialysis equipment (rental or purchase) Equipment or supplies that are not listed as covered

Nonstandard models of equipment

All charges.
Copay plus any charges above the
allowed amount for the basic
equipment.

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide. Your physician will
periodically review the program for appropriateness and need.

Services include oxygen therapy, intravenous therapy and medications.

Nothing

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

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.

All charges. 25
25 Page 26 27
2002 BlueCHOICE 26 Section 5( a)
Chiropractic You pay
20 visits per calendar year for chiropractic care and physical therapy combined

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

Note: See Physical therapy

$10 per office visit

Not covered:
long-term rehabilitative therapy
exercise programs
maintenance care
relaxation therapy

All charges.

Alternative treatments
See Non-FEHB benefits, page 44.
Educational classes and programs
Smoking Cessation

Asthma and diabetes self-management

Please refer to Mental health and
substance abuse benefits in
Section 5( e); for prescription drug
benefits, Section 5( f); and for non-FEHB
benefits, Section 5( i).

Please refer to Special features,
Section 5( g). 26
26 Page 27 28
2002 BlueCHOICE 27 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

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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.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as
Operative procedures Treatment of fractures, including casting

Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over

Insertion of internal prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information.

Nothing, unless services are
received during an office visit,
then the $10 copay applies.

Surgical procedures continued on next page. 27
27 Page 28 29
2002 BlueCHOICE 28 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing, unless services are
received during an office visit,
then the $10 copay applies.

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

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if: __
the condition produced a major effect on the member's
appearance and __

the condition can reasonably be expected to be corrected by such
surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

Nothing, unless services are
received during an office visit,
then the $10 copay applies.

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

Prosthetic devices)

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

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

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

All charges 28
28 Page 29 30
2002 BlueCHOICE 29 Section 5( b)
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures;
Extractions of teeth that interfere with radiation therapy; Treatment of trauma resulting in injuries to the jaw, cheeks, lips,
tongue, roof and floor of the mouth;
Treatment of bony impactions; Surgical correction of anatomical abnormalities for treatment of

temporomandibular disease when approved in advance by
BlueCHOICE; and

Other surgical procedures that do not involve the teeth or their supporting structures.

General anesthesia for certain dental patients, limited to:
Children through age 4 Severely disabled people; and

People with medical or behavioral conditions that require hospitalization or general anesthesia for dental care.

The general anesthesia must be provided in a network hospital, network
freestanding surgery center or dentist's office. A primary care
physician referral is required. The dental procedures themselves are not
covered.

Nothing, unless services are
received during an office visit,
then the $10 copay applies.

Nothing
Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures (such

as the periodontal membrane, gingiva, and alveolar bone)

All charges. 29
29 Page 30 31
2002 BlueCHOICE 30 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ pancreas
Liver
Lung: single –double
Pancreas
Allogeneic bone marrow transplant, if the treatment is part of a National Cancer Institute (NCI) phase III or IV trial, or the

treatment is available elsewhere as part of a NCI phase III or IV
trial. Donor screening tests and donor search expenses are also
covered for allogeneic 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): We are a member of the
Blue Quality Centers for Transplants.

Note: Autologous bone marrow or stem cell transplants after high-dose
chemotherapy to treat breast cancer, and related care, must be received
at St. Louis University Hospital/ SLU Care.

All care for transplants must be coordinated through BlueCHOICE in
writing. The physician should send a letter to the BlueCHOICE
Medical Director requesting precertification.

If you live outside the St. Louis metropolitan area, we may cover up to
$10,000 in reasonable and necessary expenses for transportation,
lodging and meals while you are away from home for the transplant.
This must be approved in advance by Case Management.

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

Nothing

Not covered:
Implants of artificial organs

Transplants not listed as covered
Organ donation expenses unless this program is covering the organ transplantation.

All charges 30
30 Page 31 32
2002 BlueCHOICE 31 Section 5( b)
Anesthesia You pay
Professional services provided in –

Hospital (inpatient)
General anesthesia for certain dental patients, limited to:
Children through age 4 Severely disabled people; and

People with medical or behavioral conditions that require hospitalization or general anesthesia for dental care.

Nothing

Professional services provided in –
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office
Nothing

$10 per office visit 31
31 Page 32 33
2002 BlueCHOICE 32 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

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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, unless it is an emergency, (see Section 5( d)).

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.

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

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

Nothing

Inpatient hospital continued on next page. 32
32 Page 33 34
2002 BlueCHOICE 33 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
Custodial care Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and guest beds
Private nursing care

All charges.

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

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing 33
33 Page 34 35
2002 BlueCHOICE 34 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care/ skilled nursing facility (SNF):

We cover treatment in a network skilled nursing facility for a condition
that otherwise would require hospital confinement.

You may transfer directly from the hospital. If you do not, your
primary care physician must obtain advance approval from
BlueCHOICE.

We will cover the care only as long as it is medically necessary. We
will notify you if we determine SNF care is no longer necessary. Then
we will not cover any SNF charges after the date in the notice.

We cover the following SNF services:
Semiprivate room and board (We will cover a private room if
BlueCHOICE agrees in advance that it is medically necessary. If
not, you are responsible for any difference between the private
room and the semiprivate room.)
General nursing care
Drugs, medications, biologicals, supplies, equipment and services
ordered by the attending network physician with the primary care
physician's prior authorization.

Nothing

Not covered: custodial care All charges
Hospice care
When a terminally ill member's life expectancy has reached six months
or less, the member may benefit from hospice care. This care provides
pain control and emotional support.

Your primary care physician must obtain advance approval from
BlueCHOICE. You must go to a network hospital or receive care from
a network home health agency licensed to provide hospice care. The
hospice provider will write a treatment plan for your signature.
BlueCHOICE and your primary care physician must coordinate your
care.

We also cover inpatient hospice care for short-term pain control.

Nothing

Not covered: Independent nursing, homemaker services; bereavement
services
All charges

Ambulance
Local professional ambulance service when medically appropriate Nothing 34
34 Page 35 36
2002 BlueCHOICE 35 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

What to do in case of emergency:
Emergencies at network hospitals within our service area: If possible, when an unexpected condition arises, call your primary care physician– unless you believe any
delay would be harmful. This applies even if it's after office hours. Your primary care physician will tell
you whether to go to the emergency room. Your primary care physician's number is listed on the front of
your ID card.

If you need additional care after an emergency condition is stabilized, precertification is required. Your
BlueCHOICE physician will handle this for you. We will make a decision about the care within 30 minutes after we receive all the necessary information.

When you need care right away but it is not an emergency, always call your primary care physician. Your
primary care physician may have you come into the office for an urgent appointment. An urgent
appointment is one scheduled with a physician for the same day or during hours not normally used for
appointments.

Emergencies at non-network hospitals (inside or outside our service area):
If possible, when an unexpected condition arises, call your primary care physician unless you believe any
delay would be harmful. This applies even if it's after office hours. Your primary care physician will tell
you whether to go to the emergency room. Your primary care physician's number is listed on the front of
your ID card.

If you receive emergency care before you call your primary care physician, you or a family member should
notify your primary care physician as soon as possible. We encourage you to try to call within 24 hours.
Your primary care physician's number is listed on the front of your ID card.

If you need additional care after an emergency condition is stabilized, precertification is required. We
will make a decision about the care within 30 minutes after we receive all the necessary information.

If you are admitted as an inpatient to a non-network hospital as a result of an emergency, you, your doctor
or a family member should call BlueCHOICE as soon as possible for precertification of the case.
BlueCHOICE will cover your care until you are stabilized. Then you must transfer to a BlueCHOICE
network hospital. The transfer must be coordinated through BlueCHOICE in advance. 35
35 Page 36 37
2002 BlueCHOICE 36 Section 5( d)
BlueCHOICE will not provide benefits for continued care at a non-network hospital after you are stable
enough to transfer.

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

Hospital observation
If you need follow-up care after emergency treatment, call your primary
care physician. If your primary care physician cannot provide the care,
he or she will give you a written referral to a network specialist.

If you are treated in the emergency room and then held for observation,
only one copay will be charged.

If you receive follow-up care without a written referral from your
primary care physician, you must pay all charges.

$10 per office visit
$10 per office visit

$50 at emergency
room( waived if
admitted)

$50 (waived if admitted)

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

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

If you are treated in the emergency room and then held for observation,
only one copay will be charged.

After your condition is stabilized, you, the hospital, a family member or
a friend must call us for approval of continued care.

Benefits are available only until BlueCHOICE determines that your
condition has improved enough for you to travel back to the
BlueCHOICE service area.

If you receive follow-up care without a written referral from your
primary care physician, you must pay all charges.

$10 per office visit
$10 per office visit

$50 at emergency room
(waived if admitted)

$50 (waived if admitted) 37
37 Page 38 39
2002 BlueCHOICE 38 Section 5( d)
Emergency outside our area (continued)
Not covered:

Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

All charges.

Ambulance
Professional ambulance and air ambulance service when medically
appropriate. Transportation by air ambulance must be approved in
advance by BlueCHOICE.

See 5( c) for non-emergency service.

Nothing 38
38 Page 39 40
2002 BlueCHOICE 39 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

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

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

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

Copayments are the same as
for any other illness or
condition.

Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

$10 per office visit

Mental health and substance abuse benefits -Continued on next page 39
39 Page 40 41
2002 BlueCHOICE 40 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests $10 per office visit or test

Individual and group therapy for the treatment of
smoking cessation
Nothing

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

Nothing on inpatient basis;
$10 per visit for outpatient

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
If you think you have a mental health or substance abuse problem, we
encourage you to see your primary care physician. Your primary care
physician may treat you or may recommend that you call our mental
health and substance abuse benefits manager.

If you do not wish to go through your primary care physician for mental
illness or substance abuse care, to receive benefits you must call our
mental health and substance abuse benefits manager before you receive
care. This number is 1-800-965-2583, and is also listed on your ID card.

Network providers will handle all authorizations for you. However, your
benefits allow up to two visits each calendar year to diagnose and assess
a mental health condition, in or out of network, without authorization.

Mental health providers are included in the BlueCHOICE directory.
Limitation We may limit your benefits if you do not obtain a treatment plan. 40
40 Page 41 42
2002 BlueCHOICE 41 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Some prescription drugs are covered only if your physician obtains prior authorization from us. In addition, coverage for some drugs is provided in limited quantities.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

I M
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There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or plan dentist must write the prescription, unless it is an emergency.

Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication. For the same copay, you can also use the Internet to place your
prescription orders at www. express-scripts. com.
Reimbursement for prescriptions purchased out-of-area will be covered up to the allowed amount after a $25 copayment.

Most maintenance drugs are available through mail order. To find out if a certain maintenance drug is available by mail order, call 1-800-655-1936.
We use an incentive-based three-tier formulary. A formulary is a list of preferred drugs chosen for use based upon their effectiveness, safety and cost. Drugs are prescribed by Plan doctors and
dispensed in accordance with BlueCHOICE's drug formulary. Nonpreferred brand-name drugs will
be covered when prescribed by a Plan doctor. The Plan must authorize a nonpreferred brand-name
drug before it may be dispensed. It is the prescribing doctor's responsibility to obtain the Plan's
authorization. You pay a $5 copay per prescription unit or refill for generic drugs; $10 for preferred
brand-name drugs; and $15 for nonpreferred brand-name drugs. When a generic drug is available
but you or your physician request the brand-name drug, you pay the price difference between the
generic and brand-name drug as well as the $5 copay per prescription or refill unless your physician
has obtained prior authorization for the brand-name drug. When the physician has obtained the prior
authorization, you pay only the appropriate brand copay.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply for retail or one

commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin); and are
available at $5 for generic; $10 for preferred brand-name; and $15 for nonpreferred brand-name.

Mail order prescription drugs are dispensed for up to a 90-day supply, and are available at $10 for
generic; $20 for preferred brand-name; and $30 for nonpreferred brand-name.

Why use generic drugs? Generic drugs normally cost considerably less than brand-name drugs. So, the copayment you pay for generic drugs is also lower. The generic name of a drug is its

chemical name. The brand name is the trade name under which the drug is advertised and sold. By
law, generic and brand-name drugs must meet the same standards for safety, purity, strength and
effectiveness. They are dispensed in the same dosage and taken in the same way.

When you have to file a claim. Follow the same procedures for filing a prescription drug claim found in Section 7.

Prescription drug benefits begin on the next page. 41
41 Page 42 43
2002 BlueCHOICE 42 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
and online 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.
Drugs that under state law are dispensed only with a written prescription from a physician or other lawful provider.

Insulin Disposable needles and syringes for the administration of covered
medications, including insulin
Drugs for sexual dysfunction (See Limited Drug Benefits below) FDA-approved prescription drugs and devices for birth control

Diabetic test strips, lancets FDA-approved medications for the treatment of tobacco use

Please note:
Most prescriptions are limited to a 30-day supply each time the prescription is filled.

Refills your doctor authorizes are covered for up to 12 months from the original prescription date. Then a new prescription is required.
Some prescription drugs are covered only if your physician obtains prior authorization from us. In addition, coverage for some drugs is
provided in limited quantities.

Intravenous fluids and medication for home use are provided under home health services at no charge; and some injectable drugs are
covered under Medical and Surgical Benefits.
Limited Drug Benefits Prescription benefits for the treatment of sexual dysfunction will only be
available with prior authorization where sexual dysfunction is secondary
to a medical condition and the medical history and work-up is
documented. You must receive prior authorization before receiving any
prescription for the treatment of sexual dysfunction. If approved, four
prescribed treatments per month will be available and subject to the
nonpreferred brand-name copayment.

Retail (up to a 30-day supply)
$5 generic
$10 preferred brand
$15 nonpreferred brand

Mail order and online (up to a 90-day
supply)
$10 generic
$20 preferred brand
$30 nonpreferred brand

Note: If there is no generic
equivalent available, you will still
have to pay the brand-name copay. 42
42 Page 43 44
2002 BlueCHOICE 43 Section 5( f)
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name-brand drug when a Federally approved generic drug is
available, whether or not your physician has specified Dispense as
Written for the name-brand drug, you have to pay the difference in
cost between the name-brand drug and the generic, unless your
physician has obtained prior authorization for the brand-name drug.

We have an incentive-based, three-tier 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 copy of our Preferred Drug List, please call Client
Services at 1-800-932-4480 or visit our Web site at
www. bsbsmo. com/ member_ services.

Not covered:
Drugs for which there is a nonprescription equivalent available
Drugs obtained at a non-Plan pharmacy (except out-of-area).
Vitamins and nutritional substances that can be purchased without a
prescription
Medical equipment, devices and supplies such as dressings and
antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Test agents and devices
Appetite suppressants and other drugs for weight loss
Nonprescription medicines

All Charges 43
43 Page 44 45
2002 BlueCHOICE 44 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 withdraw 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.

Away From Home Care Through our BlueCard program, BlueCHOICE offers its members
medical care in emergency and urgent situations when traveling
outside the service area.

Also, members who are traveling for an extended time or who are on
an extended work assignment in another city may be eligible to apply
for a Guest Membership in a local Blue Cross and Blue Shield HMO.
The Guest Membership also temporarily covers dependent children
who are away at school or living in another city. For more
information, see Section 1, page 8, or members can call Customer
Service at the number listed on the back of their ID card.

RightSteps This is a voluntary program that strives to help mothers-to-be avoid potential problems during pregnancy. Pregnant women who choose to
participate are asked to complete a questionnaire within 20 weeks of
becoming pregnant. An obstetrical registered nurse will then contact the
member periodically to provide information on pregnancy and childbirth.
We encourage the member to have early, regular prenatal care and to pay
attention to her lifestyle behaviors. Mothers-to-be who participate in the
program will also receive a nationally recognized book on pregnancy,
childbirth and infant care; up to a $40 reimbursement for the cost of a
childbirth or parenting class; and a gift from us after the baby arrives.

TakeCharge Asthma Program Our goal is to help our members who have asthma manage their disease more successfully. Working with the patient's physician, we provide case
management services to severe asthmatics through frequent phone calls,
individual care plans, home health visits (as approved by the patient's
doctor), durable medical equipment benefits and asthma educational
material. Adults and children with mild or moderate asthma receive
asthma educational materials as requested. 44
44 Page 45 46
2002 BlueCHOICE 45 Section 5( g)
Section 5 (g). Special features
TakeCharge Diabetes Program This comprehensive care and disease management program is designed to support the health care needs of people with diabetes. The program
is a complimentary, value-added service offered to members with
diabetes to reinforce the diabetes treatment plan that has been designed
by each member's physician. The member's doctor and other
members of the diabetes management team also receive information
about the program. This program provides newsletters, reminder cards
and other important educational health information to members with
diabetes throughout the year.

Note: Special programs such as
RightSteps , TakeCharge
Asthma Program and
TakeCharge Diabetes
Program are special programs
that are available to members
who have primary health
coverage through BlueCHOICE. 45
45 Page 46 47
2002 BlueCHOICE 46 Section 5( h)
Section 5 (h). Dental benefits
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Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists, which makes hospitalization necessary to safeguard the health

of the patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

I M
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Dental Benefits

Service You pay

The following dental services are covered when
provided by your participating Plan primary dentist:

Office visit for oral examination, limited to two
visits per calendar year

Oral prophylaxis (cleaning) as necessary, limited to
two visits per calendar year

Topical application of fluorides is limited to two
courses of treatment per calendar year, limited to
children under age 18

Oral hygiene instruction
Dietary advice and counseling
Consultations with Primary Dentist

Not Covered: Any procedures or services not listed.

$ 5 per office visit 46
46 Page 47 48
2002 BlueCHOICE 47 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 the FEHB out-of-pocket maximum. Your medical program copay does not apply to these services. You must pay for the services or supplies when you receive

them.

Wellness and Education Programs
Eat Smart: Learn to eat right and control your weight. You'll get $75 if you achieve your weight loss goal through a participating facility.

Breathe Easy: Smoking cessation classes offered in cooperation with local health care providers teach you some helpful tips for kicking the habit. Earn $50 for regular class attendance and for quitting smoking.
Physical Fitness: If you are 18 or older, we will reimburse you 25% (up to $100) for a single membership and 50% of annual dues (up to $200) for a family membership at the health club of your choice.
Self-Help Educational Information: Free literature is available on a variety of subjects, including stress, alcohol, drugs and cholesterol.

Discounted Services
Hearing Aids: Free hearing evaluations and savings on hearing aids are available through Accent Hearing Network providers and HearAmerica providers.

Vision Care: BlueCHOICE members may receive discounts on eye exams, lenses and frames by showing their ID card at a participating vision center. Members also can receive discounts off the regular retail price for all eye care
accessories, including contact lens solutions and non-prescription sunglasses. Members can obtain discounted eye
wear and eye care services through Access Eye Care network, Unity Health Eye Care network or Crown Optical.*

*Savings on LASIK surgery are available to members through Crown Optical. For more information, contact Crown
at 1-800-232-4526.

Alternative Health Programs through American Specialty Health Networks: BlueCHOICE provides access to an alternative health care discount program through American Specialty Health Networks (ASHN). BlueCHOICE
members can pay discounted fees when they see chiropractors, acupuncturists and massage therapists in ASHN's
credentialed network. Members receive ASHN's toll-free telephone number to request provider directories and
program brochures when they enroll.

In addition, members can access ASHN's national network of fitness clubs at the clubs' lowest membership rates.
Additionally, members can try the fitness facilities at no charge for one full week.

Additional discounts are available for everything from educational videos to herbal supplements ordered through the
Internet. Just go to www. bcbsmo. com for additional information.

For more information on any of the special programs described on this page, call Client Services at 1-800-932-4480.
Note: We may receive payments from the providers of these discount programs to cover administrative and related
costs associated with offering the programs and services to members. We do not select or recommend providers for
the discount programs and do not recommend or prescribe the services or treatments provided. We encourage
members to consult with their physician about any of these services or products. 47
47 Page 48 49
2001 BlueCHOICE 48 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 the Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

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

incest.
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 48
48 Page 49 50
2001 BlueCHOICE 49 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.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-800-932-4480.

How to file a claim:
You can obtain claim forms by calling Client Services at 1-800-932-
4480. The back of the claim form has complete filing instructions.

You can use the same claim form to file a claim for all your health care
benefits.

You may submit claims for more than one person in the same envelope.
However, you must submit a separate claim form for each person.
Attach each person's bill to the correct form.

Complete the claim form fully and accurately. You must check "yes" or
"no" for each question. If you do not answer a question, we may have to
return your claim to you. This is also true if you do not provide
additional information required.

When you write in your identification number on the claim form, be sure
to include the first three digits.

We can only accept itemized bills. Each bill must show: the name of the
patient; the name and address of the provider of care; a description of
each service and the date provided; a diagnosis; and the charge for each
service.

Canceled checks and nonitemized bills that show only "balance due" or
"for professional services rendered" are not sufficient.

Include all bills for covered services not previously submitted.
If you have paid the provider, mark each bill "paid."
In some cases, we will pay you directly for covered services. In other
cases, we will pay the provider.

Please keep copies of the completed claim form and itemized bills.
Send your claims to the address shown on the form. 49
49 Page 50 51
2001 BlueCHOICE 50 Section 7
Prescription drugs
Major chains and independent pharmacies belong to your pharmacy
network. At these pharmacies, if you show your BlueCHOICE ID card,
you should only be responsible for paying your share of the cost. The
pharmacy should file your claim, and we will pay the pharmacy directly.

At a Non-Network Pharmacy: If you go to a non-network pharmacy in an urgent or emergency situation outside the BlueCHOICE service area, you
are responsible for paying for your prescription at the time of service and
then filing a claim. Your program will not provide benefits if you use a non-network
pharmacy within the BlueCHOICE service area.

You can obtain a Prescription Drug Claim Form by calling Client Services at
1-800-932-4480.

You can file up to three prescriptions on each form. Please do not use a
regular health benefits claim form to file your prescription drug claim. If
you do, your claim may be denied.

Please fill out a separate claim form for each person and pharmacy.
Be sure to provide all the information requested for each prescription.
You may need to have the pharmacy complete the form or get the
information from the pharmacy.

Then you or the pharmacist should fill out the pharmacy's name, address
and National Association of Board of Pharmacy (NABP) number.

On the completed form, tape your original itemized prescription drug
receipt( s). Please do not send cash register receipts, canceled checks,
bottle labels, copies of the original prescription drug receipts, or your
own itemization of charges.

The receipt( s) must show: the prescription number, the patient's name,
the name of the drug, the quantity and unit dose, and the strength of the
drug.

Sign the claim form. Then mail it and your receipt( s) to the address
shown on the form.

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. 50
50 Page 51 52
2001 BlueCHOICE 51 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
Ask us in writing to reconsider our initial decision. You must:

(a) Write to us within six months from the date of our decision; and
(b) Send your request to us at: BlueCHOICE Grievance Unit
P. O. Box 66828
St. Louis, MO 63166-6828
(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.

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.

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.
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 2,
1900 E Street, NW, Washington, DC 20415-3620.

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. 51
51 Page 52 53
2001 BlueCHOICE 52 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 include a copy of your specific written consent with the
review request.

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

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

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file
the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs or supplies or from the year 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 its disputed claim
decision. This information will become part of the court record.

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

NOTE: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
1-800-932-4480 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 it can give your claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division 2 at 202/ 606-3818 between 8 a. m. and 5 p. m. Eastern time. 52
52 Page 53 54
2001 BlueCHOICE 53 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group
health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We, like other
insurers, determine which coverage is primary according to the National Association of
Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary
plan pays, we will pay what is left of our allowance, up to our regular benefit. All
programs together will not pay more than 100% of allowable expenses. The allowable
expense is the maximum amount that a plan will pay for covered services. 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 The Original Medicare Plan (Original Medicare) is a Medicare+ Choice (Part A or Part B) 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 that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are
not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP and you will
still be responsible for the Plan's copayments.

(Primary payer chart begins on next page.) 53
53 Page 54 55
2001 BlueCHOICE 54 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is… A. When either you— or your covered spouse— are age 65 or over and …

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

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

b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

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

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

(for other
services)

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

(except for claims
related to Workers'
Compensation.)

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

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,

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

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant
b) Are an active employee, or

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

Filing a claim When this Plan is primary and you have a claim for covered services that you must file yourself, please follow the claim filing instruction in
Section 7.

Once you receive an Explanation of Benefits (EOB) from us, then file a
claim for your Medicare benefits. (For information on filing a Medicare
claim, contact your Social Security office.) When Original Medicare is
primary you must submit your claims to Medicare first. The federal
government requires most health care providers and suppliers to file your 54
54 Page 55 56
2001 BlueCHOICE 55 Section 9
Medicare claims for you. So in most cases, you shouldn't need to file a
claim to obtain your Medicare benefits.

Also, in most cases, you shouldn't need to file to receive the benefits of
this program. If the services or supplies are covered by Medicare, the
Medicare carrier will usually forward your medical claim to us. Then we
will provide the benefits of this program automatically in most cases.

You should not submit a claim for benefits of this program if your
Medicare EOB states, in part: "This information is being sent to your
private insurer." This note means that the Medicare carrier is submitting
your claim to us. Then we can provide the benefits of this program. If
this note is on your Medicare EOB, please do not submit a claim to us.
Also, please let your providers of care know that they should not submit
your claim to us. When we receive duplicate claims, this increases costs.

Your Medicare EOB may not indicate that your claim has been referred
to supplemental claims processing. In that case, you should file your
own claim.

To file your own claim To file, send us a copy of your Medicare EOB. Include a completed claim form and copies of your itemized bills. Send the information to
the address shown on the claim form.

You should also file a claim if you receive services or supplies that are
not covered by Medicare but a