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Alliance Health Benefit Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Alliance Health Benefit Plan
Privacy Practices
Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Facts about this fee-for-service plan
How we change for 2003
How you get care
Identification cards
Where you get covered care
- Covered providers
- Covered facilities
What you must do to get covered care
Transitional care
Hospital care
How to Get Approval for
- Your hospital stay
- Other services
Your costs for covered services
- Copayments
- Deductible
- Coinsurance
- Differences
out-of-pocket maximum
When government facilities bill us
If we overpay you
When you are age 65 or over and you do not have Medicare
When you have Medicare
Benefits
Overview
Medical services and supplies
Surgical and anesthesia
Services provided by a hospital
Emergency services/accidents
Mental health
Substance Abuse
Prescription drugs
Special features
Dental benefits
Non-FEHB benefits
- CIGNA Dental Health Plan
- AFLAC
General exclusions
Things we dont cover
Filing a claim
The disputed claims process
Coordinating benefits
- When you have other coverage
- Original Medicare
- Medicare managed care
- TRICARE
- CHAMPVA
- Workers Compensation
- Medicaid
- Other agencies
- Others are responsible
Definitions
FEHB facts
Coverage Information
- No pre-existing condition
- Enrolling information
- Coverage available
- Childrens Equity Act
- When benefits start
- When premiums start
- When you retire
When you lose benefits
- When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
- Spouse equity coverage
- Temporary Continuation
- Converting to individual coverage
- Certificate of coverage
Long Term Care
Index
Summary of benefits
Rates

Pages 1--65 from Untitled

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

Alliance Health Benefit Plan
http:// www. ahbp. com 2003
A fee-for-service plan with a preferred provider organization

Sponsored and administered by: The National Alliance of Postal and Federal Employees.
Who may enroll in this Plan: All eligible civilian employees and annuitants who become members or associate members of the National Alliance of Postal
and Federal Employees (NAPFE).
To become a member or associate member: At installations and subdivisions where there is a NAPFE local, you may join as a regular or associate member. If there is no local, or
you are an annuitant, you will automatically become an associate member of the NAPFE upon enrollment in the Alliance Health Benefit Plan.

Annuitants (retirees) may enroll in this plan.
Membership dues: $5.00 per month. Members will have the option of paying dues on an annual or semi-annual basis. Dues paid on an annual basis on or before March first of the plan year will receive
a 10% discount. NAPFE will bill new associate members for annual dues when it receives notice of enrollment. NAPFE will also bill continuing associate members for the annual membership.

Enrollment codes for this Plan:
1R1 Self Only 1R2 Self and Family

RI 71-003

For
changes in
benefits,
see page 7. 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for
our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal
medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover
your personal medical information that was given to you or your personal representative, any information that you
authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a
disputed claim. 3.
3 Page 4 5

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a
P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree
to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call
202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice within 60 days of the change. The privacy
practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 Alliance Health Benefit Plan 2 Table of Contents 5.
5 Page 6 7

2003 Alliance Health Benefit Plan 3 Table of Contents 6.
6 Page 7 8

Introduction
This brochure describes the benefits of the Alliance Health Benefit Plan under our contract CS 1164 with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by the Alliance Health
Benefit Plan. The address for the Alliance Health Benefit Plan administrative office is:

The Alliance Health Benefit Plan
1628 11 th Street NW
Washington, DC 20001

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 7. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language 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 the Alliance Health Benefit Plan.

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

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

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor,
other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider 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 1/ 800-321-0347 and explain the situation.
If we do not resolve the issue:

2003 Alliance Health Benefit Plan 4 Introduction/ Plain Language/ Advisory 7.
7 Page 8 9
CALL -THE HEALTH CARE FRAUD HOTLINE
202-418-3300
OR WRITE TO: The United States Office of Personnel Management

Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415.

2003 Alliance Health Benefit Plan 5 Introduction/ Plain Language/ Advisory
Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support)

If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM
if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB
benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the
Plan. 8.
8 Page 9 10

Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.
We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and
extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We also have a Preferred Provider Organization (PPO):
Our fee-for-service plan offers services through a PPO. When you use our PPO providers, you will receive covered services at
reduced cost. The Alliance Health Benefit Plan is solely responsible for the selection of PPO providers in your area. Contact us for
the names of PPO providers and to verify their continued participation. You can also go to our web page, which you can reach
through the FEHB web site, www. opm. gov/ insure. Contact the Alliance Health Benefit Plan to request a PPO directory.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider
networks may be more extensive in some areas than others. We cannot guarantee the availability of every speciality in all areas. If no
PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply.

How we pay providers
This Plan has a Preferred Provider Organization (PPO). This is a group of doctors, hospitals and other providers who have contracted
to provide medical services at reduced cost. This PPO operates in 50 states, and the District of Columbia. Each time you need
medical care you have the choice to use a health care provider who participates in the network or one who doesn't.

When you use a PPO hospital, your benefits increase from 70% after the $250 inpatient deductible to 90% after the $150 inpatient
deductible. When you use a PPO doctor, your surgery benefits increase to 90% after a $200 deductible and your office visit benefits
increase to paid in full after a $15 copayment. Non-PPO benefits for both are 70% after a $400 deductible. Precertification is
required as explained on pages 9 and 10 for all inpatient hospitalizations. It is your responsibility to complete this prior notification;
however, your PPO doctor may initiate precertification and will file your claims for you. Note: PPO benefits are not payable when
the Alliance Health Benefit Plan is not the primary payer.

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

Network providers must meet specific criteria including location, medical specialty, professional skill and proper credentials
Years in existence
Profit status
If you want more information about us, call 1/ 800-321-0347 or for calls in the Washington, DC metropolitan area (202) 939-6325, or
write to Alliance Health Benefit Plan, 1628 11 th Street NW, Washington, DC 20001. You may also contact us by fax at 202-939-6389
or visit our website at http:// www. ahbp. com.

2003 Alliance Health Benefit Plan 6 Section 1 9.
9 Page 10 11
Section 2. How we change for 2003
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
A notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB
Program enrollment.

Program information on Medicare is revised.
The Medically Underserved section is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-postal premium will increase by 20.4% for Self Only or 21.5% for Self and Family.
The Plan will now use PHCS as its PPO Network instead of the First Health Network.
Your share of the calendar year PPO deductible has increased to $200 per individual, $600 per family and your share of the
calendar year Non-PPO deductible has increased to $400 per individual, $1200 per family.

Your share of the catastrophic protection out-of-pocket maximum for PPO has increased to $3,000 per individual/ per family and
your share of the catastrophic protection out-of-pocket maximum for Non-PPO has increased to $4,000 per individual/ per family.

Your share of the emergency room co-payment has increased to $50 per visit.
Your share of the retail prescription drug benefit, after the combined annual $200 deductible, has increased to 10% for the initial
fill of a generic prescription and 15% for the initial fill of a brand name prescription and 50% coinsurance for each refill. Your
share of the mail order prescription drug benefit has also increased to 20% for generic prescriptions and 25% for brand name
medications.

Your share of the Plan allowance for Non-PPO benefits will be based on the 80 th percentile. Previously the Plan allowance was
based on the 90 th percentile.

The Plan has eliminated the $100 PPO calendar year deductible, the $300 Non-PPO calendar year deductible, the $150 PPO per
admission inpatient hospital copayment, and the $250 Non-PPO per admission inpatient hospital copayment from counting toward
the catastrophic protection out-of-pocket maximum.

The Plan has added the Blood Cholesterol screening (a fasting lipoprotein profile) once every 5 years for adults age 20 and over.
The Plan has added a screening colonoscopy once every 10 years at age 50.
The Plan has clarified that in network mental health professional services, preventive care (routine screenings) for adults, and
home health nursing services are not subject to the calendar year deductible.

The Plan has clarified that the 45 annual visits are combined for physical and occupational therapy services.

2003 Alliance Health Benefit Plan 7 Section 2 10.
10 Page 11 12

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/ 800-321-0347, or write to us at
1628 11 th Street NW, Washington, DC, 20001. You may also request replacement cards
through our website: http:// www. ahbp. com.

Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay and you pay depends on the type of covered provider or facility you use. If you
use our preferred providers, you will pay less.
Covered providers We consider the following to be covered providers when they perform services within
the scope of their license or certification:

(1) a licensed doctor of medicine (M. D.), or a licensed doctor of osteopathy (D. O.), and
a licensed podiatrist practicing within the scope of their license.

(2) other covered providers include: a Chiropractor, Dentist, Optometrist, Clinical
Psychologist, Clinical Social Worker, Nurse Midwife, Nurse Practitioner/ Clinical
Specialist, Nurse Anesthetist or Nursing School Administered Clinic. Charges for
Christian Science Nurses and Christian Science Practitioners who are listed in the
Christian Science Journal will be covered under this Plan the same as other medical
providers.

Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in states OPM determines

are "medically underserved." For 2003, the states are: Alabama, Idaho, Kentucky,
Lousiana, Maine, Mississippi, Missouri, Montana, New Mexico, North Dakota, South
Carolina, South Dakota, Texas, Utah, West Virginia, and Wyoming.

Covered facilities Covered facilities include:
Birthing Center: A free standing facility licensed or certified by the State in which
it functions, or Plan approved, which offers comprehensive maternity care in a
home-like atmosphere.

Hospice: A facility which provides short periods of stay for a terminally ill person in
a home-like setting for either direct care or respite. This facility may either be free-standing
or affiliated with a hospital. It must operate as an integral part of the
hospice care program.

Hospital: An institution licensed by the State or conforming to the standards of, and
accredited by, the Joint Commission on Accreditation of Health Care Organizations
(JCAHO) providing inpatient diagnostic and therapeutic facilities for surgical and
medical diagnosis, treatment and care of injured and sick persons by or under the
supervision of a staff of licensed doctors of medicine (M. D.), or licensed doctors of
osteopathy (D. O.). The hospital must provide continuous 24-hour-a-day professional
registered nursing (R. N.) services and may not be an Extended Care Facility (other
than an approved ECF); nursing home; a place for rest; an institution for exceptional
children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary
institution having the primary purpose of furnishing food, shelter, training, or non-medical
personal services. This definition includes college infirmaries and Veterans
Administration Hospitals. This also includes Christian Science Nursing facilities that
are approved by the Commission for the Accreditation of Christian Science Nursing
Organizations/ Facilities, Inc.

2003 Alliance Health Benefit Plan 8 Section 3 11.
11 Page 12 13
What you must do to get It depends on the kind of care you want to receive. You can go to any provider you covered care want, but we must approve some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your PPO specialist because we drop out of the Federal Employees
Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or

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

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

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

Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service
department immediately at 1/ 800-321-0347.
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 benefits of the hospitalized person.

How to Get Approval for
Your hospital stay Precertification is the process by which prior to your inpatient hospital admission we evaluate the medical necessity of your proposed stay and the number of days required to

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

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

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

How to precertify an admission: You, your representative, your doctor, or your hospital must call us at 1/ 800-321-0347
at least 48 hours before admission.

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

Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;

2003 Alliance Health Benefit Plan 9 Section 3 12.
12 Page 13 14
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting doctor;
Name of hospital or facility; and
Number of planned days of confinement.
We will then tell the doctor and/ or hospital the number of approved inpatient days and
we will send written confirmation of our decision to you, your doctor, and the hospital.

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

2003 Alliance Health Benefit Plan 10 Section 3
If your hospital stay
needs to be extended
If your hospital stay including for maternity care needs to be extended, you, your
representative, your doctor or the hospital must ask us to approve the additional days.

What happens when you
do not follow the
precertification rules:

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

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

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

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

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

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

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

Exceptions: You do not need precertification in these cases:

You are admitted to a hospital outside the United States.
You have another group health insurance policy that is the primary payer for the
hospital stay.

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

Other services Some services require a referral, precertification, or prior authorization.
Right-sided heart catheterization.
Mental Health and Substance Abuse services and admissions
Growth Hormone Therapy 13.
13 Page 14 15
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your PPO physician you pay a copayment of $15 per visit and
when you go in a PPO hospital, you pay $150 per admission.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count
toward any deductible.
The calendar year deductible is $200 per person for PPO benefits and $400 per
person for Non-PPO benefits. Under a family enrollment, the deductible is satisfied for
all family members when the combined covered expenses applied to the calendar year
deductible for family members reach $600 for PPO benefits and $1,200 for Non-PPO
benefits.

We also have separate deductibles for:
There is a combined annual $200 deductible per person for mail order and/ or
retail prescription drugs.

There is a Non-PPO $500 deductible per person, per confinement for inpatient
care for mental conditions.

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

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

Example: You pay 30% of our allowance for non-PPO physician office visits.
10% for PPO inpatient hospital room/ board, and other hospital charges;
30% for non-PPO inpatient hospital room/ board, and other hospital charges;
10% for PPO inpatient and outpatient surgical benefits, maternity benefits, and other
medical benefits;

30% for non-PPO inpatient and outpatient surgical benefits, maternity benefits, and
other medical benefits;

10% for PPO inpatient hospital charges for treatment of mental conditions;
30% for non-PPO inpatient hospital charges for treatment of mental conditions;
10% for PPO doctors' visits for (inpatient) mental conditions;
30% for non-PPO doctors' visits (inpatient and outpatient) for mental conditions;
10% for PPO inpatient hospital charges for treatment of substance abuse;

2003 Alliance Health Benefit Plan 11 Section 4 14.
14 Page 15 16
30% for non-PPO inpatient hospital charges for treatment of substance abuse;
50% for non-PPO inpatient and outpatient professional charges for treatment of
substance abuse;

20% for skilled nursing facility
Note: If your provider routinely waives (does not require you to pay) your copayments,
deductibles, or coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the provider's fee by the
amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives
your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual
charge of $70).

2003 Alliance Health Benefit Plan 12 Section 4
Differences between our allowance and
the bill
Our "Plan allowance" is the amount we use to calculate our payment for covered
services. Fee-for-service plans arrive at their allowances in different ways, so their
allowances vary. For more information about how we determine our Plan allowance, see
the definition of Plan allowance in Section 10.

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

PPO providers agree to limit what they will bill you. Because of that, when you use
a preferred provider, your share of covered charges consists only of your deductible
and coinsurance or copayment. Here is an example about coinsurance: You see a PPO
physician who charges $150, but our allowance is $100. If you have met your
deductible, you are only responsible for your coinsurance. That is, you just pay 10%
of our $100 allowance ($ 10). Because of the agreement, your PPO physician will not
bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit what they will
bill you. When you use a non-PPO provider, you will pay your deductible and
coinsurance plus any difference between our allowance and charges on the bill.
Here is an example: You see a non-PPO physician who charges $150 and our
allowance is again $100. Because you've met your deductible, you are responsible
for your coinsurance, so you pay 30% of the $100 allowance ($ 30). Plus, because
there is no agreement between the non-PPO physician and us, he can bill you for the
$50 difference between our allowance and his bill.

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

EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: 100 We set it at: 100
We pay 90% of our allowance: 90 70% of our allowance: 70
You owe: Coinsurance 10% of our allowance: 10 30% of our allowance: 30
+Difference up to charge? No: 0 Yes: 50
TOTAL YOU PAY $10 $80 15.
15 Page 16 17

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

2003 Alliance Health Benefit Plan 13 Section 4

For those services with coinsurance, the Plan pays 100% of the plan allowance for the
remainder of the calendar year after the calendar year deductible is met when out-of-pocket
expenses for coinsurance in that calendar year exceed $3,000 under the PPO
benefit. The Plan pays 100% of the plan allowance, if out-of-pocket expenses for the
coinsurance in that calendar year exceed $4,000 under the non-PPO benefit. Any
expenses incurred through PPO or non-PPO benefits are applied toward both
catastrophic limits.

Out-of-pocket expenses for the purposes of this benefit are:
The 10% you pay for PPO hospital, surgical, maternity and other medical benefits;
The 30% you pay for non-PPO hospital, surgical, maternity and other medical
benefits.

The following cannot be counted toward out-of-pocket expenses:
Deductibles
Copayments
Expenses in excess of the plan allowance or maximum benefit limitations;
Expenses for dental care;
Any amounts you pay because benefits have been reduced for non-compliance with
the Plan's cost containment requirements (see pages 9 and 10)

Expenses for prescription drugs purchased through retail or mail order program; and
Expenses for skilled nursing facility confinements.
Carryover If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses

that would have applied to that plan's catastrophic protection benefit during the prior
year will be covered by your old plan if they are for care you got in January before the
effective date of your coverage in this Plan. If you have already met the covered out-of-pocket
maximum expense level in full, your old plan's catastrophic protection benefit
will continue to apply until the effective date. If you have not met this expense in full,
your old plan will first apply your covered out-of-pocket expenses until the prior year's
catastrophic level is reached and then apply the catastrophic protection benefit to
covered out-of-pocket expenses incurred from that point until the effective date. The old
plan will pay these covered expenses according to this year's benefits; benefit changes
are effective on January 1.

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

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. 16.
16 Page 17 18
When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And, your
physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. The
following chart has more information about the limits.

If you..
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

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

you are responsible for your applicable deductibles, coinsurance or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on
the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.

And, for your physician care, the law requires us to base our payment and your coinsurance on...
an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.

If your Physician.... Then you are responsible for...

2003 Alliance Health Benefit Plan 14 Section 4
Participates with Medicare or accepts
Medicare assignment for the claim and is
a member of our PPO network,

your deductibles, coinsurance, and copayments;

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

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

approved amount

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

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or
hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us. 17.
17 Page 18 19
When you have the Original Medicare Plan (Part A, Part B, or both)
2003 Alliance Health Benefit Plan 15 Section 4

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

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

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

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

Note: The physician who does not accept Medicare assignment may
not bill you for more than 115% of the amount Medicare bases its
payments on, called the " limiting charge." The Medicare Summary
Notice (MSN) that Medicare will send you will have more information
about the limiting charge. If your physician tries to collect more than
allowed by law, ask the physician to reduce the charges. If the
physician does not, report the physician to your Medicare carrier who
sent you the MSN form. Call us if you need further assistance.

Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with

Medicare. 18.
18 Page 19 20

Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and pages 59-60 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
claim forms, claims filing advice, or more information about our benefits, contact us at 1/ 800-321-0347 or at our website at
www. ahbp. com.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . .17-24
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 therapy
Speech therapy

2003 Alliance Health Benefit Plan 16 Section 5

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . .25-29
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30-32
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ Skilled nursing care facility benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33-34
Accidental injury
Medical emergency
Ambulance

I M
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Section 5 (a). Medical services and supplies provided by physicians and other health care professionals

2003 Alliance Health Benefit Plan 17 Section 5( a)
Here are some important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductibles are: PPO $200 per person ($ 600 per family); Non-PPO $400
per person ($ 1,200 per family). Calendar year deductibles apply to almost all benefits in this
Section. We added "( No deductible)" to show when a calendar year deductible does not
apply.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about
how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.

Benefit Description You Pay
After the calendar year deductible...

NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply

Diagnostic and treatment services
Professional services of physicians
In physician's office
Second surgical opinion

PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial examination of newborn child covered under a family enrollment
At home

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount 20.
20 Page 21 22
Routine physical one annually every two years
Note: The maximum PPO benefit is $150

Lab, X-ray and other diagnostic tests You pay
Tests, such as
Blood tests
Urinalysis
Non-routine pap smears
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiograms and EEG

2003 Alliance Health Benefit Plan 18 Section 5( a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

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

Preventive care, adults
Routine screenings, limited to:
Blood Cholesterol Screening (a fasting lipoprotein profile) once
every 5 years for adults age 20 and over

Chlamydial Infection Screening
Colorectal Cancer Screening, including
Fecal occult blood test annually for members age 40 and older
Sigmoidoscopy, screening one every five years starting at age 50
Colonoscopy once every 10 years at age 50

PPO: (No deductible) Nothing after office visit
copayment

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Routine Prostate Specific Antigen (PSA) test one annually for men
age 40 and older
PPO: (No deductible) Nothing after office visit
copayment

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Routine pap test one annually for women age 18 and older PPO: (No deductible) Nothing after office visit
copayment

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

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

PPO: (No deductible) Nothing after office visit
copayment

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

PPO: $15 copayment (No deductible)

Non-PPO: All charges
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19
and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not Covered:
Preventive medical care and services, including;
Periodic checkups
associated X-ray and lab test
immunizations such as polio, flu, mumps and smallpox, except as shown
under preventive care, adults and preventive care, children

All charges 21.
21 Page 22 23

2003 Alliance Health Benefit Plan 19 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of
Pediatrics for children under age 22
PPO: Nothing (No deductible)

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

For well-child care charges for routine examinations, immunizations
and care (to age 6) limited to 12 well care visits.

Sickle Cell Screening for newborns for sickle cell anemia
Blood lead level screening

PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Examinations, limited to:
Examinations for amblyopia and strabismus-limited to one
screening (ages 2 through 6)

Examinations done on the day of the immunizations (ages 3
through age 22)

PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Maternity care
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 10 for
other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will cover an extended stay
if medically necessary, but you, your representative, your doctor, or
your hospital must precertify.

We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment if we cover the infant under
a Self and Family enrollment.

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

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover contraceptive drugs in Section 5( f).

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered: Reversal of voluntary surgical sterilization, genetic counseling. All charges 22.
22 Page 23 24

Infertility services You pay
Diagnosis and treatment of infertility, except as shown in
Not covered.

(Including fertility drugs)

2003 Alliance Health Benefit Plan 20 Section 5( a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination
in vitro fertilization
embryo transfer and GIFT
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Services and supplies related to ART procedures.
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment, including materials (such as allergy serum) PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Allergy injections PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered: provocative food testing and sublingual allergy desensitization. All charges

Treatment therapies
Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed on page 27.

Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV) Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We only cover GHT when we preauthorize the treatment. Call
1/ 800-321-0347 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will only cover
GHT services from the date you submit the information. If you do not ask
or if we determine GHT is not medically necessary, we will not cover the
GHT or related services and supplies. See Services requiring our prior
approval in Section 3.

Respiratory and inhalation therapies

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 23.
23 Page 24 25
Physical and occupational therapies You pay
Physical and Occupational therapy;
Up to 45 combined visits for physical and occupational therapy per
calendar year for the services provided by a:

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

1) orders the care;
2) identifies the specific professional skills the patient requires and the
medically necessity for skilled services; and

3) indicates the length of time the service is needed.

2003 Alliance Health Benefit Plan 21 Section 5( a)

PPO: 10% of the Plan allowance and all cost
after 45 visits.

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount and all cost after 45 visits.

Not covered: All charges
Exercise programs
Chelation therapy, except for acute arsenic, gold, lead, or mercury poisoning.
Massage therapy

Speech therapy
Speech therapy:
Up to 45 visits per calendar year for the services provided by a:
Speech therapist

Not covered: All charges
Eyeglasses or contact lenses and examinations for them
Eye exercise and orthoptics
Radial keratotomy and other refractive surgery

PPO: 10% of the Plan allowance and all cost
after 45 visits.

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount and all cost after 45 visits.

Hearing services (testing, treatment, and supplies)
Testing only when necessitated by accidental injury PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Not covered: All charges
hearing testing, except for accidental injury
hearing aids, testing and examinations for them

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

Note: See Preventive care, children for eye exams for children

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 24.
24 Page 25 26
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes.

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

2003 Alliance Health Benefit Plan 22 Section 5( a)

PPO: $15 copayment and/ or 10% of the Plan
allowance

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

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

Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability, imbalance or subluxation of the foot (unless the treatment is
by open cutting surgery)

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes; 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 implants following
mastectomy.

Note: Internal prosthetic devices are paid as hospital benefits; See
Section 5 (c) for payment information. Insertion of the device is paid as
surgery, see Section 5 (b).

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not Covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges

Durable medical equipment (DME)
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician who is
treating your illness or injury);

2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an illness or
injury.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Durable medical equipment (DME) continued on next page 25.
25 Page 26 27
We cover rental or purchase, at our option, including repair and adjustment,
of durable medical equipment, such as oxygen and dialysis equipment.
Under this benefit, we also cover:

Hospital beds;
Wheelchairs, to include medically necessary motorized wheelchairs;
Iron lungs;
Certain types of traction equipment;
Oxygen and rental of equipment for its administration;
Crutches; and
Walkers.

Note: Call us at 1/ 800-321-0347 as soon as your physician prescribes this
equipment. We arrange with a health care provider to rent or sell you
durable medical equipment at discounted rates and will tell you more about
this service when you call.

2003 Alliance Health Benefit Plan 23 Section 5( a)

Durable medical equipment (DME) (continued) You pay
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered: All charges
exercise equipment
whirlpool baths
sun-lamps
heating pads
air conditioners
humidifiers, dehumidifiers, and purifiers

Home health services
Nursing services:
240 units annually up to $15 per unit when rendered by a:
Registered Nurse (R. N.), a licensed practical nurse (L. P. N.) , or a
Christian Science Nurse who is listed in the Christian Science Journal

Note: One private duty nursing unit consists of up to one hour of private
duty nursing care.

PPO: (No deductible) all charges after $15 per
unit with the maximum of 240 units

Non-PPO: (No deductible) all charges after
$15 per unit with the maximum of 240 units

Home health services continued on next page
Home health care services:
60 home health visits per calendar year up to a maximum plan payment
of $40 per visit when:

A home health care visit consists of:
Less than an 8-hour shift of nursing care; or
One therapy session; or
One social worker visit; or
Less than an 8-hour shift by a home health aide.
Covered home health care services are:
Nursing care provided on a part-time basis (less than an 8-hour shift)
by:

a) a registered nurse (RN); or
b) a licensed practical nurse (LPN); or
c) a Christian science nurse
Physical, occupational or speech therapy provided by a licensed
therapist;

Services of a licensed social worker (but not more than 2 visits);

PPO: (No deductible) all charges after we pay
$40 per visit

Non-PPO: (No deductible) all charges after we
pay $40 per visit 26.
26 Page 27 28

Home health aide services provided on a part-time basis (less than
an 8-hour shift) that;

a) are performed by a home health aide under the supervision of a
registered nurse (RN); and

b) consist mainly of medical care and therapy provided solely for the
care of the patient.

Note: The home health care services must be furnished:
by a home health care agency (or by visiting nurses where services of a
home health care agency are not available);

in accordance with a home health care plan, see definition on page 52;
and

in the patient's home

2003 Alliance Health Benefit Plan 24 Section 5( a)

Home health services (continued) You pay
PPO: (No deductible) all charges after we pay
$40 per visit

Non-PPO: (No deductible) all charges after we
pay $40 per visit

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

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

Chiropractic
Chiropractor The Plan pays a maximum of $225 per person annually for
outpatient services for:

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

Note: No other services of a chiropractor are covered under any other
provision of this Plan.

PPO: 10% of the Plan allowance and all cost
after $225.

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount and all cost after the $225

Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for:
anesthesia when used as an anesthesic agent for covered surgery.
PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Educational classes and programs
Coverage is limited to:
Cardiac rehabilitation program Outpatient visits must consist of
outpatient cardiac rehabilitative exercise, education, and counseling
when:

patient has been diagnosed as having angina pectoris (chest pain); or
patient has been hospitalized for a diagnosed myocardial infarction
(heart attack); or

coronary surgery.
Note: Services must be provided by an approved hospital-based or
hospital-coordinated cardiac rehabilitation program.

PPO: 30% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and the
billed amount

Smoking Cessation Up to $100 for one smoking cessation program
per member per lifetime, including all related expenses such as drugs.
PPO: all charges after benefits stop at $100

Non-PPO: all charges after benefits stop at
$100 27.
27 Page 28 29
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Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals

2003 Alliance Health Benefit Plan 25 Section 5( b)
Here are some important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically necessary.

The calendar year deductibles are: PPO $200 per person ($ 600 per family); Non-PPO: $400
per person ($ 1,200 per family). Calendar year deductibles apply to almost all benefits in this
section. We added "( No deductible)" to show when a calendar year deductible does not apply.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how
cost sharing works, with special sections for members who are age 65 or over. Also read
Section 9 about coordinating benefits with other coverage, including with Medicare.

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.)

YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES.
Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

Benefit Description You Pay
After the calendar year deductible...

NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply

Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by a surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Electroconvulsive therapy
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

Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Surgically implanted contraceptives, and intrauterine devices (IUDs)
Treatment of burns
Assistant surgeons we cover up to 20% of our allowance for the
surgeon's charge

PPO: 10% of the Plan allowance
Non-PP0: 30% of the Plan allowance and any
difference between our allowance and the
billed amount.

Surgical procedures continued on next page 28.
28 Page 29 30
When multiple or bilateral surgical procedures performed during the same
operative session add time or complexity to patient care, our benefits are

For the primary procedure
PPO: 90% of the Plan allowance
Non-PPO: 70% of the reasonable and customary charge
For the secondary procedure( s):
PPO: 90% of one-half of the Plan allowance
Non-PPO: 70% of one-half of the reasonable and customary charge
Note: Multiple and bilateral surgical procedures performed through the
same incision are "incidental" to the primary surgery. That is, the
procedure would not add time or complexity to patient care. We do not pay
extra for incidental procedures.

2003 Alliance Health Benefit Plan 26 Section 5( b)

Surgical procedures (continued) You pay
PPO: 10% of the Plan allowance for the
primary procedure; 10% of one-half of the Plan
allowance for the secondary procedure( s) and
10% of one-quarter of the Plan allowance for
procedure( s) thereafter.

Non-PPO: 30% of the Plan allowance for the
primary procedure and 30% of one-half of the
Plan allowance for the secondary procedure( s)
and 30% of one-quarter of the Plan allowance
for procedure( s) thereafter and any difference
between our allowance and the billed amount

Not covered:
Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other high risk
procedures when we determine standbys are medically necessary

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; and webbed fingers and toes.

All stages of breast reconstruction surgery following a mastectomy, such
as:

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

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Note: We pay for internal breast prostheses as hospital benefits.
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 sexual transformations or sexual dysfunction.

All charges 29.
29 Page 30 31
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaw 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

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

2003 Alliance Health Benefit Plan 27 Section 5( b)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

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

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Small Intestine, including transplant with multiple organs (liver, stomach
or pancreas)

Lung: Single only for the following end-stage pulmonary diseases:
pulmonary fibrosis, primary pulmonary hypertension, or emphysema;
Double only for patients with cystic fibrosis

Pancreas (when condition is not treatable by use of insulin therapy)
Allogeneic bone marrow transplants only for patients with Acute
leukemia, Advanced Hodgkins lymphoma, Advanced non-Hodgkin's
lymphoma, Advanced neuroblastoma (limited to children over age one),
Aplastic anemia, Chronic myelogenous leukemia, Infantile malignant
osteopetrosis, Severe combined immunodeficiency, Thalassemia major,
and Wiskott-Aldrich syndrome

Autologous bone marrow transplants( autologous stem cell and
autologous peripheral stem cell support) for Acute lymphocytic or non-lymphocytic
leukemia, Advanced Hodgkin's lymphoma, Advanced non-Hodgkin's
lymphoma, Advanced neuroblastoma, Testicular, Mediastinal,
Retroperitoneal, and Ovarian germ cell tumors, Breast cancer, Multiple
myeloma, and Epithelial ovarian cancer.

United Resources Transplant Program:
10% of the Plan Allowance

PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan allowance and the
difference between our allowance and the
billed amount.

Organ/ tissue transplants continued on next page 30.
30 Page 31 32
United Resources Transplant Program
Covered Transplant Services:
Pre-transplant evaluation;
Organ procurement;
Transplant procedures and associated hospitalization;
Transplant-related follow-up care provided by the designated transplant hospital for up to 1 year;

Pharmacy costs provided by the United Resources Transplant Program for immunosuppressant and other transplant-related medications while
hospitalized;
Donor expenses, if not covered under any other plan;
Transplant-related services provided by the United Resources Transplant facility that are associated with the transplant events listed

above, including laboratory and other diagnostic services;
Physician services related to the transplant events listed above
Travel and lodging benefit:
If the recipient lives more than 100 miles from a designated transplant facility, the Plan will provide an allowance for pre-approved travel and

lodging expenses up to $10,000 per transplant. The allowance will not be subject to the calendar year deductible or coinsurance. The
allowance will provide coverage of reasonable travel and temporary lodging expenses for the recipient and one companion (two
companions if the recipient is a minor). Covered travel and lodging expenses will be established by the Plan's case manager during the
precertification process. Travel and lodging to a designated facility for the pre-transplant evaluation is covered under this benefit even if the
transplant is not eventually certified as medically necessary.

Organ/ tissue transplants (continued) You pay
United Resources Transplant Program: 10% of
the Plan allowance

PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan allowance and the
difference between our allowance and the
billed amount.

PPO benefit:
If you do not use a United Resources Transplant facility, but you do use a PPO facility, 80% benefits will be applied to your expenses. Total benefit payments,

including donor expenses, the transplant procedure itself, and transplant-related follow-up care for one year at the transplant facility will be limited to a
maximum payment of $150,000 for a liver transplant and $100,000 for any other transplant. The travel and lodging allowance will not be available.
Charges incurred for prescription drugs and follow-up care outside of the transplant facility/ hospital will not be counted toward this maximum.

Note: Cornea and pancreas transplants are not available through the United Resources Transplant Program; therefore, the Travel/ Lodging benefit is not
available.
Precertification:
In order to receive benefits for the transplants listed above, you are required to call United Resources Transplant Program at 1/ 800-321-0347 as soon as the

need for a transplant is discussed with your physician. When you call, it will be necessary to provide the program with all information needed to complete
the review. In order to receive the highest level of benefits, all transplant-related services must be received at one of the designated hospitals within the
United Resources Transplant Program. All covered transplant benefits, including pre-transplant evaluation expenses (even if the transplant does not
occur) will be provided by the Plan.
If you do not follow the procedures required by the United Resources Transplant Program, the Plan's co-payment will be reduced to the PPO or non-PPO benefit

level for all related covered physician/ hospital expenses, after any applicable deductible. Also, no coverage will be provided for transportation or lodging and
meal expenses if a transplant procedure is not performed at a United Resources Transplant facility. The charges above the maximum payment of $150,000 or
$100,000 for transplants provided outside the United Resources Transplant Program do not apply toward your out-of-pocket maximum.

Organ/ tissue transplants continued on next page
2003 Alliance Health Benefit Plan 28 Section 5( b) 31.
31 Page 32 33
Limitations:
For the purposes of the maximum total payment, charges from doctors
and hospitals while the patient is confined in a transplant facility will be
counted toward the maximum. Charges incurred for prescription drugs
and follow-up care outside of the transplant facility/ hospital will not be
counted toward this maximum.

Note: If the Plan cannot refer a member in need of a transplant to a United
Resources Transplant facility, the $100,000/$ 150,000 maximum will not
apply.

Treatment for breast cancer, multiple myeloma, and epithelial ovarian
cancer may be provided in a National Cancer Institute (NCI) or National
Institute of Health (NIH) approved clinical trial at a Plan-designated center
of excellence and if approved by the Plan's medical director in accordance
with the Plan's protocols.

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

2003 Alliance Health Benefit Plan 29 Section 5( b)

Organ/ tissue transplants (continued) You pay
(See above)

Not covered:
Services, supplies, drugs and aftercare for, or related to, artificial or
non-human organ implants or transplants;

Services that are considered experimental/ investigational or not
medically necessary;

Expenses for services which are specifically excluded under the Medical
Expenses Not Covered section of this Plan; and

Transplants not listed as covered

All charges

Anesthesia
Professional services provided in
Hospital (inpatient)
PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Professional services provided in
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Note: If your PPO provider uses a non-PPO
anesthesiologist, we will pay non-PPO benefits
for the anesthesia charges. 32.
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Section 5 (c). Services provided by a hospital or other facility and ambulance services

2003 Alliance Health Benefit Plan 30 Section 5( c)
Here are some important things you should keep in mind about these benefits:
Please remember that all your benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
In this section, unlike Sections 5( a) and 5( b), the calendar year deductible applies to
only a few benefits. In that case we added "( calendar year deductible applies)". The
PPO calendar year deductible is: $200 per person ($ 600 per family) and the non-PPO
calendar year deductible is $400 per person ($ 1,200 per family).

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

When you use a PPO hospital, keep in mind that the professionals who provide
services to you in the hospital, such as radiologists, emergency room physicians,
anesthesiologists, and pathologists, may not all be preferred providers. If they are not,
they will be paid by this Plan as non-PPO providers.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works, with special sections for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.

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 in Sections 5( a) or (b).

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE
TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information in Section 3 to be sure which services require

precertification.

Benefit Description You Pay

NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.
NOTE: We only cover a private room when you must be isolated to
prevent contagion. Otherwise, we will pay the hospital's average charge for
semiprivate accommodations. If the hospital only has private rooms, we
base our payment on the average semiprivate rate of the most comparable
hospital in the area.

NOTE: When the non-PPO hospital bills a flat rate, we prorate the charge
to determine how to pay them, as follows: 30% room and board and 70%
other charges.

PPO: $150 per admission and 10% of
the covered charges

Non-PPO: $250 per admission and
30% of the covered charges

Note: If you use a PPO provider and a
PPO facility, we may still pay non-PPO
benefits if you receive treatment
from a radiologist, pathologist or
anesthesiologist who is not a PPO
provider

Inpatient hospital continued on next page 33.
33 Page 34 35
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take home items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home (Note: calendar year deductible
applies.)

NOTE: We base payment on whether the facility or a health care
professional bills for the services or supplies. For example, when the
hospital bills for its nurse anesthetists' services, we pay Hospital benefits
and when the anesthesiologist bills, we pay surgery benefits.

2003 Alliance Health Benefit Plan 31 Section 5( c)

Inpatient hospital (continued) You pay
(see above)

Not covered:
Any part of a hospital admission that is not medically necessary (see
definition), such as when you do not need acute hospital inpatient
(overnight) care, but could receive care in some other setting without
adversely affecting your condition or the quality of your medical care.
Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital physician care at the level they would
have been covered if provided in an alternative setting

Custodial care; see definition.
Non-covered facilities, such as nursing homes, schools, rest homes,
places for the aged, convalescent homes, residential treatment facilities,
and any place that is not a hospital

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

Private nursing care

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood 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.

PPO: 10% of the Plan allowance (calendar year
deductible applies)

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies)

Not covered: All services not listed All charges 34.
34 Page 35 36
Extended care benefits/ Skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): We cover semiprivate room, board, services,
supplies in a SNF for up to 60 days confinement when:

1) you are admitted within 14 days from a precertified hospital stay of at
least 3 consecutive days; and

2) you are admitted for the same condition as the hospital stay; and
3) your skilled nursing care is supervised by a physician and provided by
an R. N., L. P. N., or L. V. N.; and

4) SNF care is medically appropriate.

2003 Alliance Health Benefit Plan 32 Section 5( c)

PPO: 20% of the Plan allowance
Non-PPO: 20% of the Plan allowance

Not covered: Custodial care All charges
Hospice care
Hospice is a coordinated program of maintenance and supportive care for
the terminally ill provided by a medically supervised team under the
direction of a Plan approved independent hospice administration.

We pay $4,500 per lifetime for inpatient and outpatient services.

PPO: Nothing until Plan allowance stops at
$4,500

Non-PPO: Nothing until Plan allowance stops
at $4,500

Not covered: All charges
Bereavement counseling
Funeral arrangements
Pastoral counseling
Financial or legal counseling
Homemaker or caretaker services

Ambulance
Local professional ambulance service when medically appropriate PPO: 10% of the Plan allowance (calendar year
deductible applies)

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies) 35.
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Section 5 (d). Emergency services/ accidents

2003 Alliance Health Benefit Plan 33 Section 5( d)
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
The calendar year deductibles are: PPO $200 per person ($ 600 per family); Non-PPO
$400 per person ($ 1,200 per family). Calendar year deductibles apply to almost all
benefits in this Section. We added "( No deductible)" to show when a calendar year
deductible does not apply.

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

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works, with special sections for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.

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 is an accidental injury?
An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal
bites, poisonings and dental care required as a result of accidental injury to sound natural teeth.

Benefit Description You Pay
After the calendar year deductible...

NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply

Accidental injury
If you receive care for your accidental injury within 72 hours, we cover:
Non-surgical physician services and supplies
Related outpatient hospital services
Note: We pay Hospital benefits if you are admitted.

PPO: Nothing (No deductible)
Non-PPO: Only the difference between
our allowance and the billed amount

If you receive care for your accidental injury after 72 hours, we cover:
Non-surgical physician services and supplies
Surgical care
Note: We pay Hospital benefits if you are admitted.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 36.
36 Page 37 38
Medical emergency You pay
Outpatient medical or surgical services and supplies in an emergency room.

2003 Alliance Health Benefit Plan 34 Section 5( d)
PPO: (No deductible) $50 copayment
Non-PPO: $50 copayment and the difference
between our allowance and the billed amount

Care in a physician's office PPO: $15 and/ or 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount.

Ambulance
Professional ambulance service
Note: If hospital treatment requiring special equipment is necessary but not
locally available, the Plan covers transportation within the United States
and Canada by professional ambulance, railroad, or scheduled commercial
airlines to the nearest hospital equipped to furnish the treatment.

Note: See 5 (c) for non-emergency service.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:
Routine transportation necessary to obtain the services of a All charges
doctor or any other practitioner 37.
37 Page 38 39

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Section 5 (e). Mental health and substance abuse benefits

2003 Alliance Health Benefit Plan 35 Section 5( e)
You may choose to get care In-Network or Out-of-Network. When you receive In-Network
care, you must get our approval for services and follow a treatment plan we
approve. If you do, cost-sharing and limitations for In-Network 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
and are payable only when we determine they are medically necessary.

The calendar year deductibles or, for facility care, the inpatient deductibles apply to
almost all benefits in this section. We added "( No deductible)" to show when a
deductible does not apply.

Be sure to read Section 4, Your cost 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 descriptions below.

In-Network mental health and substance abuse benefits are below, then Out-of-Network
benefits begin on page 36.

Benefit Description You Pay
After the calendar year deductible...

NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply

In-Network benefits
All diagnostic and treatment services contained in a treatment plan that we
approve. The treatment plan may include services, drugs, and supplies
described elsewhere in this brochure.

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

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

Medication management

$15 per visit (No deductible)

Diagnostic tests 10% of the Plan allowance
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

$150 per admission copayment and 10% of the
Plan allowance

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

All charges.

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

In Network benefits continued on next page 38.
38 Page 39 40

Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits you must obtain a treatment plan and follow all of the following network authorization processes:
Pre-certification: The medical necessity of your admission to a hospital or other covered facility must
be precertified for you to receive full Plan benefits. Emergency admissions must be reported within
two business days following the day of the admission even if you have been discharged. Otherwise,
the benefits payable will be reduced by $500. See page 9 for details. For precertification call 1/ 800-
321-0347.

You may obtain a provider directory by calling 1/ 800-321-0347.
Outpatient approval procedures: Covered outpatient services for treatment of mental conditions or
substance abuse require pre-certification. Pre-certification is required when treatment continues
beyond 2 visits per person, per calendar year. For precertification call 1/ 800-321-0347.

Network limitation If you do not obtain an approved treatment plan, we will provide only Out-of-Network benefits.

Out-of-Network benefits
Inpatient and outpatient professional services to treat mental conditions. 30% of our allowance and any difference
between our allowance and the billed amount
for up to 45 visits; all charges after 45 visits

Inpatient and outpatient professional services to treat substance abuse conditions. 50% of our allowance and any difference
between our allowance and the billed amount
and all charges after the $4000 calendar year
maximum

Inpatient care to treat mental conditions includes ward or semiprivate
accommodations and other hospital charges

2003 Alliance Health Benefit Plan 36 Section 5( e)

After a $500 deductible per admission to a
non-PPO hospital, 30% of charges for up to 45
days per calendar year; all charges after 45
days

Inpatient care to treat substance abuse includes room and board and
ancillary charges for confinement in a treatment facility for rehabilitative
treatment of alcoholism or substance abuse

30% of Plan allowance and any difference
between our allowance and the billed amount
and all charges after the $4000 calendar year
maximum

Not covered out-of-network:
Services by pastoral and marital counselors
Treatment for learning disabilities and mental retardation
Servic