Document Body Page Navigation Panel Document Outline

Blue Cross and Blue Shield Service Benefit Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this fee-for-service Plan
Section 2. How we change for 2003
Section 3. How you receive benefits
Section 4. Your costs for covered services
Section 5. Benefits
Section 6. General exclusions things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance Is Still Available
Index
Summary of Standard Option benefits
Summary of Basic Option benefits
2003 Rate Information

Pages 1--124

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

Blue Cross and Blue Shield Service Benefit Plan
http:// www. fepblue. org
2003

A fee-for-service plan
with a preferred provider organization

Sponsored and administered by: The Blue Cross and Blue Shield Association and participating
Blue Cross and Blue Shield Plans

Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the
FEHB

Enrollment codes for this Plan:
104 Standard Option -Self Only 105 Standard Option -Self and Family
111 Basic Option -Self Only 112 Basic Option -Self and Family
This Plan has Case Management
accreditation from URAC (also
known as the American Accreditation
HealthCare Commission).

RI 71-005

For changes
in benefits
see page 8. 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 by mail 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 Blue Cross and Blue Shield
Service Benefit Plan 2 Table of Contents

2003 Blue Cross and Blue Shield
Service Benefit Plan 3 Table of Contents

2003 Blue Cross and Blue Shield
Service Benefit Plan 4 Introduction/ Plain Language/ Advisory

Introduction
This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan under our contract (CS 1039) with the
Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by
participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan on behalf of the Blue Cross and Blue Shield
Association (the Carrier). The address for the Blue Cross and Blue Shield Service Benefit Plan administrative offices is:

Blue Cross and Blue Shield Service Benefit Plan 1310 G Street, NW, Suite 900
Washington, DC 20005
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 care 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 8. 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 Blue Cross and Blue Shield Service 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. 7.
7 Page 8 9
2003 Blue Cross and Blue Shield
Service Benefit Plan 5 Introduction/ Plain Language/ Advisory

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-FEP-8440 and explain the situation.
If we do not resolve the issue:

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.

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 8.
8 Page 9 10

2003 Blue Cross and Blue Shield
Service Benefit Plan 6 Section 1

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 (Preferred) providers, you will receive covered
services at a reduced cost. Your Local Plan (or, for retail pharmacies, AdvancePCS) is solely responsible for the selection of PPO
providers in your area. Contact your Local Plan for the names of PPO (Preferred) providers and to verify their continued
participation. You can also go to our web page, which you can reach through the FEHB website, www. opm. gov/ insure. Contact
your Local Plan to request a PPO directory.

Under Standard Option, non-PPO (Non-preferred) benefits are the standard benefits available to you. PPO (Preferred) benefits
apply only when you use a PPO (Preferred) provider. PPO networks may be more extensive in some areas than in others. We
cannot guarantee the availability of every specialty in all areas. If no PPO (Preferred) provider is available, or you do not use a PPO
(Preferred) provider, the standard non-PPO (Non-preferred) benefits apply.

Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this
requirement.

How we pay professional and facility providers:
We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other health care
facilities, physicians, and other health care professionals in its service area, and is responsible for processing and paying claims for
services you receive within that area. Many, but not all, of these contracted providers are in our PPO (Preferred) network.

PPO providers. PPO (Preferred) providers have agreed to accept a specific negotiated amount as payment in full for covered services provided to you. We refer to PPO facility and professional providers as "Preferred." They will generally bill the
Local Plan directly, who will then pay them directly. You do not file a claim. Your out-of-pocket costs are generally less when
you receive covered services from Preferred providers, and are limited to your coinsurance or copayments (and, under Standard
Option only, the applicable deductible).

Participating providers. Some Local Plans also contract with other providers that are not in our Preferred network. If they are professionals, we refer to them as "Participating" providers. If they are facilities, we refer to them as "Member" facilities.
They have agreed to accept a different negotiated amount than our Preferred providers as payment in full. They will also
generally file your claims for you. They have agreed not to bill you for more than your applicable deductible, and coinsurance or
copayments, for covered services. We pay them directly, but at our Non-preferred benefit levels. Your out-of-pocket costs will be
greater than if you use Preferred providers.

Note: Not all areas have Participating providers and/ or Member facilities. To verify the status of a provider, please contact the
Local Plan where the services will be performed. 9.
9 Page 10 11

2003 Blue Cross and Blue Shield
Service Benefit Plan 7 Section 1

Non-participating providers. Providers who are not Preferred or Participating providers do not have contracts with us, and may or may not accept our allowance. We refer to them as "Non-participating providers" generally, although if they are facilities
we refer to them as "Non-member facilities." When you use Non-participating providers, you may have to file your claim with
us. We will then pay our benefits to you, and you must pay the provider.

You must pay any difference between the amount Non-participating providers charge and our allowance, in addition to any
applicable coinsurance amounts, copayment amounts, amounts applied to your calendar year deductible, and amounts for
noncovered services. Important: Under Standard Option, your out-of-pocket costs may be substantially higher when you
use Non-participating providers than when you use Preferred or Participating providers. Under Basic Option, you must use
Preferred providers to receive benefits. See page 11 for the exceptions to this requirement.

Note: In Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan
allowance as payment in full for covered services. As a result, you are only responsible for applicable coinsurance or copayments
(and, under Standard Option only, the applicable deductible), for covered services, and any charges for noncovered services.

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

Care management, including medical practice guidelines;
Disease management programs; and
How we determine if procedures are experimental or investigational.
If you want more information about us, call or write to us. Our telephone number and address are shown on the back of your
Service Benefit Plan ID card. You may also visit our website at www. fepblue. org. 10.
10 Page 11 12

2003 Blue Cross and Blue Shield
Service Benefit Plan 8 Section 2

Section 2. How we change for 2003
Do not rely only 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

Under Standard Option, your share of the non-Postal premium will increase by 11. 0% for Self Only or 11. 0% for Self and Family.

Under Basic Option, your share of the non-Postal premium will increase by 10.7% for Self Only or 8.6% for Self and Family.
We no longer require prior approval for cardiac rehabilitation services.
We now provide benefits for certain organ/ tissue transplants provided at Blue Quality Centers for Transplant (BQCT). [See Sections 3 and 5( b).]

We now provide benefits for colonoscopies when performed for screening purposes. [See Section 5( b).]
We now provide preventive benefits for double contrast barium enemas as part of our colorectal cancer screening benefit. [See Section 5( a).]

We now provide preventive benefits for fasting lipoprotein profiles (total cholesterol, LDL, HDL, and triglycerides) when performed by a Preferred provider, or by any independent laboratory, as part of a routine physical examination. [See Section
5( a).]
We changed the address for filing claims for drugs purchased on and after January 1, 2003 from pharmacies outside the United States and Puerto Rico. [See Section 5( i).]

Under Standard Option, we now provide benefits for facility care you receive outside the United States and Puerto Rico at the Preferred benefit level. This means you pay the cost-sharing amounts listed in Section 5( c) wherever your facility care is
provided. Previously, we provided benefits in full for facility services received overseas. [See Sections 5( c) and 5( i).]
In all Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan allowance as payment in full for covered services. This applies even when you have other coverage. Previously, Preferred and

Participating providers in certain Local Plan areas could bill the patient for the difference between our allowance and the billed
amount when the member had other coverage. (See Section 1.)

Merck-Medco Rx Services, the administrator of our Mail Service Prescription Drug Program, has changed its name to Medco Health Solutions, Inc.

We now have Case Management accreditation from URAC (also known as the American Accreditation HealthCare Commission). 11.
11 Page 12 13

2003 Blue Cross and Blue Shield
Service Benefit Plan 9 Section 3

Section 3. How you receive benefits
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 will need it whenever you receive services from a
covered provider, or fill a prescription through a Preferred retail or internet pharmacy.
Until you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation letter (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 the Local Plan serving the area
where you reside and ask them to assist you, or write to us directly at: FEP Enrollment
Services, 550 12 th Street, SW, Washington, DC 20065-1463. You may also request
replacement cards through our website, www. fepblue. org.

Where you get covered care Under Standard Option, you can get care from any "covered professional provider" or "covered facility provider." How much we pay and you pay depends on the type
of covered provider you use. If you use our Preferred, Participating, or Member
providers, you will pay less.

Under Basic Option, you must use those "covered professional providers" or
"covered facility providers" that are Preferred providers for Basic Option in order to
receive benefits. Please refer to page 11 for the exceptions to this requirement. Refer
to page 6 for more information about Preferred providers.

Covered professional providers We consider the following to be covered professionals when they perform services within the scope of their license or certification:

Physicians Doctors of medicine (M. D.); osteopathy (D. O.); dental surgery (D. D. S.);
medical dentistry (D. M. D.); podiatric medicine (D. P. M.); and optometry (O. D.). For
Basic Option, the term "primary care provider" includes family practitioners, general
practitioners, medical internists, pediatricians, and obstetricians/ gynecologists.

Other Covered Health Care Professionals Professionals who provide additional
covered services and meet the state's applicable licensing or certification requirements
and the requirements of the Local Plan. Other covered health care professionals
include:

Audiologist A professional who, if the state requires it, is licensed, certified, or registered as an audiologist where the services are performed.

Clinical Psychologist A psychologist who (1) is licensed or certified in the state where the services are performed; (2) has a doctoral degree in psychology (or an
allied degree if, in the individual state, the academic licensing/ certification
requirement for clinical psychologist is met by an allied degree) or is approved by
the Local Plan; and (3) has met the clinical psychological experience requirements
of the individual State Licensing Board.

Clinical Social Worker A social worker who (1) has a master's or doctoral degree in social work; (2) has at least two years of clinical social work practice; and

(3) if the state requires it, is licensed, certified, or registered as a social worker
where the services are performed.

Diabetic educator A professional who, if the state requires it, is licensed, certified, or registered as a diabetic educator where the services are performed.

Dietician A professional who, if the state requires it, is licensed, certified, or registered as a dietician where the services are performed.
Independent Laboratory A laboratory that is licensed under state law or, where no licensing requirement exists, that is approved by the Local Plan.
Nurse Midwife A person who is certified by the American College of Nurse Midwives or, if the state requires it, is licensed or certified as a nurse midwife. 12.
12 Page 13 14

2003 Blue Cross and Blue Shield
Service Benefit Plan 10 Section 3

Nurse Practitioner/ Clinical Specialist A person who (1) has an active R. N. license in the United States; (2) has a baccalaureate or higher degree in nursing; and
(3) if the state requires it, is licensed or certified as a nurse practitioner or clinical
nurse specialist.

Nursing School Administered Clinic A clinic that (1) is licensed or certified in the state where services are performed; and (2) provides ambulatory care in an

outpatient setting primarily in rural or inner-city areas where there is a shortage of
physicians. Services billed for by these clinics are considered outpatient "office"
services rather than facility charges.

Nutritionist A professional who, if the state requires it, is licensed, certified, or registered as a nutritionist where the services are performed.

Physical, Speech, and Occupational Therapist A professional who is licensed where the services are performed or meets the requirements of the Local Plan to
provide physical, speech, or occupational therapy services.
Other professional providers specifically shown in the benefit descriptions in Section 5.

Medically underserved areas. In states that OPM determines are "medically
underserved":

Under Standard Option, we cover any licensed medical practitioner for any covered service performed within the scope of that license.

Under Basic Option, we cover any licensed medical practitioner who is Preferred
for any covered service performed within the scope of that license.

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

Covered facility providers Covered facilities include those listed below, when they meet the state's applicable licensing or certification requirements.

Hospital An institution, or a distinct portion of an institution, that:
(1) Primarily provides diagnostic and therapeutic facilities for surgical and medical
diagnoses, treatment, and care of injured and sick persons provided or supervised
by a staff of licensed doctors of medicine (M. D.) or licensed doctors of osteopathy
(D. O.), for compensation from its patients, on an inpatient or outpatient basis;
(2) Continuously provides 24-hour-a-day professional registered nursing (R. N.)
services; and
(3) Is not, other than incidentally, an extended care facility; a nursing home; a place
for rest; an institution for exceptional children, the aged, drug addicts, or
alcoholics; or a custodial or domiciliary institution having as its primary purpose
the furnishing of food, shelter, training, or non-medical personal services.

Note: We consider college infirmaries to be Non-member hospitals. In addition, we
may, at our discretion, recognize any institution located outside the 50 states and the
District of Columbia as a Non-member hospital.

Freestanding Ambulatory Facility A freestanding facility, such as an ambulatory surgical center, freestanding surgi-center, freestanding dialysis center,

or freestanding ambulatory medical facility, that:
(1) Provides services in an outpatient setting;
(2) Contains permanent amenities and equipment primarily for the purpose of
performing medical, surgical, and/ or renal dialysis procedures;
(3) Provides treatment performed or supervised by doctors and/ or nurses, and may
include other professional services performed at the facility; and
(4) Is not, other than incidentally, an office or clinic for the private practice of a
doctor or other professional. 13.
13 Page 14 15

2003 Blue Cross and Blue Shield
Service Benefit Plan 11 Section 3

Note: We may, at our discretion, recognize any other similar facilities, such as birthing
centers, as freestanding ambulatory facilities.

Blue Quality Centers for Transplant (BQCT)
In addition to Preferred transplant facilities, you have access to the Blue Quality
Centers for Transplant (BQCT), a centers of excellence program. BQCT institutions
are selected based on their ability to meet defined clinical quality criteria that are
unique for each type of transplant. BQCT negotiates a payment for transplant services
performed during the transplant period (see page 113 for the definition of "transplant
period").

Members who choose to use a BQCT facility for a covered transplant only pay the
$100 per admission copayment under Standard Option, or the $100 per day copayment
($ 500 maximum) under Basic Option for the transplant period. Members are not
responsible for additional costs for included professional services. Regular Preferred
benefits (subject to the regular cost-sharing levels for facility and professional services)
are paid for pre-and post-transplant services performed in BQCT facilities before and
after the transplant period.

BQCT institutions are available for seven types of transplants: heart; heart-lung; single
or bilateral lung; liver; pancreas; simultaneous pancreas-kidney; and autologous or
allogeneic bone marrow (see pages 52 and 53 for limitations).

Contact us at the customer service number listed on the back of your ID card before
obtaining services. We will give you information about BQCT, a list of approved
facilities, and access to a Transplant Coordinator who will help your doctor arrange
your transplant at a BQCT facility.

Cancer Research Facility A facility that is:
(1) A National Cooperative Cancer Study Group institution that is funded by the
National Cancer Institute (NCI) and has been approved by a Cooperative Group as
a bone marrow transplant center;
(2) An NCI-designated Cancer Center; or
(3) An institution that has an NCI-funded, peer-reviewed grant to study allogeneic or
autologous bone marrow transplants and blood stem cell transplant support.

Other facilities specifically listed in the benefits descriptions in Section 5( c).
What you must do to get covered care Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance.

Under Basic Option, you must use Preferred providers in order to receive benefits,
except under the special situations listed below. In addition, we must approve certain
types of care in advance. Please refer to Section 4, Your costs for covered services, for
related benefits information.

(1) Medical emergency or accidental injury care in a hospital emergency room and
related ambulance transport as described in Section 5( d), Emergency
services/ accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
emergency room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information);
or
(6) Care received outside the United States and Puerto Rico. 14.
14 Page 15 16

2003 Blue Cross and Blue Shield
Service Benefit Plan 12 Section 3

Unless otherwise noted in Section 5, when services of Non-preferred providers are
covered in a special exception, benefits will be provided based on the Plan allowance.
You are responsible for the applicable coinsurance or copayment, and may also be
responsible for any difference between our allowance and the billed amount.

Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your 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 Preferred specialist because we terminate our contract with your specialist for other than cause,
you may be able to continue seeing your specialist and receiving any Preferred 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
specialist based on the above circumstances, you can continue to see your specialist
and any Preferred benefits will 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 us immediately.
If you have not yet received your Service Benefit Plan ID card, you can contact your
Local Plan at the telephone number listed in your local telephone directory. If you
already have your new Service Benefit Plan ID card, call us at the number on the back
of the card. If you are new to the FEHB Program, we will reimburse you for your
covered expenses while in the hospital.

However, if you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

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 will not 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 the telephone
number listed on the back of your Service Benefit Plan ID card any time prior to
admission.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function,

you, your representative, your doctor, or your hospital must telephone us within two
business days following the day of the emergency admission, even if you have been
discharged from the hospital. 15.
15 Page 16 17

2003 Blue Cross and Blue Shield
Service Benefit Plan 13 Section 3

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

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. [See Section 5( c) for payment information.]
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 or inpatient physician care 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 you 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 we
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. 16.
16 Page 17 18

2003 Blue Cross and Blue Shield
Service Benefit Plan 14 Section 3

Other services These services require prior approval under both Standard and Basic Option:
Home hospice care Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical evidence we

need to make our coverage determination and advise you which home hospice care
agencies we have approved.

Partial hospitalization or intensive outpatient treatment for mental health/ substance abuse Contact us at the mental health and substance abuse

number listed on the back of your ID card before obtaining services for intensive
outpatient treatment or partial hospitalization. We will request the medical evidence
we need to make our coverage determination. We will also consider the necessary
duration of either of these services.

Organ/ tissue transplants Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical

evidence we need to make our coverage determination. We will consider whether
the facility is approved for the procedure and whether you meet the facility's criteria.

Clinical trials for certain organ/ tissue transplants Contact our Clinical Trials Information Unit at 1-800-225-2268 for information or to request prior approval

before obtaining services. We will request the medical evidence we need to make
our coverage determination. Use this number only for prior approval of clinical
trials for bone marrow and peripheral blood stem cell transplant support procedures
for those conditions shown on page 53 as covered only in clinical trials.

Prescription drugs Certain prescription drugs require prior approval. Contact our Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077 for the hearing

impaired) to request prior approval, or to obtain an updated list of prescription drugs
that require prior approval. We will request the information we need to make our
coverage determination. You must periodically renew prior approval for certain
drugs. See page 84 for more about our prescription drug prior approval program,
which is part of our Patient Safety and Quality Monitoring (PSQM) program.

Note: Benefits for drugs to aid smoking cessation that require a prescription by Federal
law are limited to one course of treatment per calendar year. Prior approval is required
before benefits will be provided for additional medication. To obtain approval, the
physician must certify the patient is participating in a smoking cessation program that
provides clinical treatment, including counseling and behavioral therapies.

Note: Until we approve them, you must pay for these drugs in full when you
purchase them even if you purchase them at a Preferred retail pharmacy or through
an internet pharmacy and submit the expense( s) to us on a claim form. Preferred
pharmacies will not file these claims for you.

Under Standard Option, members may use our Mail Service Prescription Drug
Program to fill their prescriptions. However, the Mail Service Prescription Drug
Program also will not fill your prescription until you have obtained prior approval.
Medco Health Solutions, Inc., the administrator of the Mail Service Prescription
Drug Program, will hold your prescription for you up to thirty days. If prior approval
is not obtained within 30 days, your prescription will be returned to you along with a
Prior Approval Request Form and a letter explaining the prior approval procedures.

The Mail Service Prescription Drug Program is not available under Basic Option.
In addition to the types of care listed above, these services also require prior
approval under Basic Option:

Outpatient mental health and substance abuse treatment You must call us at the number listed on the back of your ID card for mental health and substance abuse

before receiving any outpatient professional or facility care. We will then
provide you with the names and phone numbers of several Preferred providers to
choose from and tell you how many visits we are initially approving. 17.
17 Page 18 19
2003 Blue Cross and Blue Shield
Service Benefit Plan 15 Section 4

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 certain services.

Example: If you have Standard Option when you see your Preferred physician, you pay
a copayment of $15 for the office visit and we then pay the remainder of the amount
billed for the office visit. (You may have to pay separately for other services you
receive while in the physician's office.) When you go into a Preferred hospital, you pay
a copayment of $100 per admission. We then pay the remainder of the hospital bill for
the covered services you receive.

Copayments do not apply to services and supplies that are subject to a deductible and/ or
coinsurance amount.

Note: If the billed amount (or the Plan allowance that providers we contract with have
agreed to accept as payment in full) is less than your copayment, you pay the lower
amount.

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 and

coinsurance amounts do not count toward your deductible. When a covered service or
supply is subject to a deductible, only the Plan allowance for the service or supply that
you then pay counts toward meeting your deductible.

Under Standard Option, the calendar year deductible is $250 per person. Under a family enrollment, the calendar year deductible for each family member is satisfied and

benefits are payable for all family members when the combined covered expenses of the
family reach $500.

Note: If the billed amount (or the Plan allowance that providers we contract with have
agreed to accept as payment in full) is less than the remaining portion of your
deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept
$80, and you have not paid any amount toward meeting your Standard Option calendar
year deductible, you must pay $80. We will apply $80 to your deductible. We will
begin paying benefits once the remaining portion of your Standard Option calendar year
deductible ($ 170) has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan
is after January 1 of the next year, 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.

Under Basic Option, there is no calendar year deductible.

Coinsurance Coinsurance is the percentage of the Plan allowance that you must pay for your care. Your coinsurance is based on the Plan allowance, or billed amount, whichever is less.

Under Standard Option only, coinsurance does not begin until you meet your deductible.

Example: You pay 10% of the Plan allowance under Standard Option for durable
medical equipment obtained from a Preferred provider, after meeting your $250
calendar year deductible.

Note: If your provider routinely waives (does not require you to pay) your applicable
deductible (under Standard Option only), coinsurance, or copayments, 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. 18.
18 Page 19 20

2003 Blue Cross and Blue Shield
Service Benefit Plan 16 Section 4

Example: If your physician ordinarily charges $100 for a service but routinely waives
your 25% Standard Option coinsurance, the actual charge is $75. We will pay $56.25
(75% of the actual charge of $75).

Waivers In some instances, a Preferred, Participating, or Member provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility
for the total charge for any care that is not covered by your health plan. If you sign
such a waiver, whether you are responsible for the total charge depends on the content
of the contracts that the Local Plan has with its providers. If you are asked to sign this
type of waiver, please be aware that, if benefits are denied for the services, you could be
legally liable for the related expenses. If you would like more information about
waivers, please contact us at the customer service number on the back of your ID card.

Differences between our allowance and the bill Our "Plan allowance" is the amount we use to calculate our payment for certain types of covered services. Fee-for-service plans arrive at their allowances in different ways,

so allowances vary. For 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 type of provider you use. In this Plan, we have the following types of providers:

Preferred providers. These types of providers have agreements with the Local Plan to limit what they bill our members. Because of that, when you use a Preferred

provider, your share of the provider's bill for covered care is limited.
Under Standard Option, your share consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a

Preferred physician who charges $150, but our allowance is $100. If you have met
your deductible, you are only responsible for your coinsurance. That is, under
Standard Option, you pay just 10% of our $100 allowance ($ 10). Because of the
agreement, your Preferred physician will not bill you for the $50 difference between
our allowance and his/ her bill.

Under Basic Option, your share consists only of your copayment or coinsurance
amount, since there is no calendar year deductible. Here is an example involving a
copayment: You see a Preferred physician who charges $150 for covered services
subject to a $20 copayment. Even though our allowance may be $100, you still pay
just the $20 copayment. Because of the agreement, your Preferred physician will not
bill you for the $130 difference between your copayment and his/ her bill.

Remember, under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Participating providers. These types of Non-preferred providers have agreements with the Local Plan to limit what they bill our Standard Option members.
Under Standard Option, when you use a Participating provider, your share of covered charges consists only of your deductible and coinsurance or copayment.
Here is an example: You see a Participating physician who charges $150, but the
Plan allowance is $100. If you have met your deductible, you are only responsible
for your coinsurance. That is, under Standard Option, you pay just 25% of our $100
allowance ($ 25). Because of the agreement, your Participating physician will not bill
you for the $50 difference between our allowance and his/ her bill.

Under Basic Option, there are no benefits for care performed by Participating providers; you pay all charges. See page 11 for the exceptions to this requirement.

Non-participating providers. These Non-preferred providers have no agreement to limit what they will bill you. 19.
19 Page 20 21

2003 Blue Cross and Blue Shield
Service Benefit Plan 17 Section 4

Under Standard Option, when you use a Non-participating provider, you will pay
your deductible and coinsurance plus any difference between our allowance and the
charges on the bill. For example, you see a Non-participating physician who charges
$150. The Plan allowance is again $100, and you have met your deductible. You are
responsible for your coinsurance, so you pay 25% of the $100 Plan allowance or $25.
Plus, because there is no agreement between the Non-participating physician and us,
the physician can bill you for the $50 difference between our allowance and his/ her
bill.

Under Basic Option, there are no benefits for care performed by Non-participating providers; you pay all charges. See page 11 for the exceptions to

this requirement.

The following table illustrates examples of how much you have to pay out-of-pocket for
services from a Preferred physician, a Participating physician, and a Non-participating
physician. The table uses our example of a service for which the physician charges
$150 and the Plan allowance is $100. For Standard Option, the table shows the amount
you pay if you have met your calendar year deductible.

EXAMPLE
Preferred
physician
Standard Option

Preferred
physician
Basic Option

Participating
physician (Standard Option*)
Non-participating
physician (Standard Option*)

Physician's charge $150 $150 $150 $150
Our allowance We set it at: 100 We set it at: 100 We set it at: 100 We set it at: 100

We pay 90% of our allowance: 90 Our allowance less copay: 80 75% of our allowance: 75 75% of our allowance: 75
You owe:
Coinsurance
10% of our
allowance: 10 Not applicable
25% of our
allowance: 25
25% of our
allowance: 25

You owe:
Copayment Not applicable 20 Not applicable Not applicable

+Difference up to
charge? No: 0 No: 0 No: 0 Yes: 50

TOTAL YOU PAY $10 $20 $25 $75

*Under Basic Option, there are no benefits for care performed by Participating and Non-participating physicians. You must use Preferred providers in order to
receive benefits. See page 11 for the exceptions to this requirement.
Note: Under Standard Option, had you not met any of your deductible in the above
examples, only our allowance ($ 100), which you would pay in full, would count toward
your deductible.

Overseas providers. We pay overseas claims at Preferred benefit levels, using an Overseas Fee Schedule as our Plan allowance. Most overseas professional providers

are under no obligation to accept our allowance, and you must pay any difference
between our payment and the provider's bill. For facility care you receive overseas,
we provide benefits in full after you pay the applicable copayment or coinsurance
(and, under Standard Option, any deductible amount that may apply). See Section
5( i) for more information about our overseas benefits.

Dental care. Under Standard Option, we pay scheduled amounts for routine dental services and you pay any balance. Under Basic Option, you pay $20 for any

covered evaluation and we pay the balance for covered services. See Section 5( h) for
a listing of covered dental services and additional payment information. 20.
20 Page 21 22

2003 Blue Cross and Blue Shield
Service Benefit Plan 18 Section 4

Hospital care. You pay the coinsurance or copayment amounts listed in Section 5( c). Under Standard Option, you must meet your deductible before we begin
providing benefits for certain hospital-billed services. Under Basic Option, you
must use Preferred facilities in order to receive benefits. See page 11 for the
exceptions to this requirement.

Your catastrophic protection out-of-pocket maximum for

deductibles, coinsurance, and copayments

If the total amount of out-of-pocket expenses in a calendar year for you and your
covered family members for deductibles (Standard Option only), coinsurance, and
copayments (other than those listed below) exceeds $6,000 under Standard Option, or
$5, 000 under Basic Option, then you and any covered family members will not have to
continue paying them for the remainder of the calendar year.

Standard Option Preferred maximum: If the total amount of these out-of-pocket
expenses from using Preferred providers for you and your covered family members
exceeds $4,000 in a calendar year under Standard Option, then you and any covered
family members will not have to pay these expenses for the remainder of the calendar
year when you continue to use Preferred providers. You will, however, have to pay
them when you use Non-preferred providers, until your out-of-pocket expenses (for the
services of both Preferred and Non-preferred providers) reach $6,000 under Standard
Option, as shown above.

Basic Option maximum: If the total amount of these out-of-pocket expenses from
using Preferred providers for you and your covered family members exceeds $5,000 in
a calendar year under Basic Option, then you and any covered family members will not
have to pay these expenses for the remainder of the calendar year.

The following expenses are not included under this feature. These expenses do not
count toward your catastrophic protection out-of-pocket maximum, and you must
continue to pay them even after your expenses exceed the limits described above.

The difference between the Plan allowance and the billed amount. See pages 16-18; Expenses for services, drugs, and supplies in excess of our maximum benefit

limitations;
Under Standard Option, your 30% coinsurance for inpatient care in a Non-member hospital;

Under Standard Option, your 25% coinsurance for outpatient care by a Non-member facility;
Your expenses for mental conditions and substance abuse care by a Non-preferred professional or facility provider;
Your expenses for dental services in excess of our fee schedule payments under Standard Option. See Section 5( h);
The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with our cost containment
requirements;
Under Basic Option, coinsurance you pay for non-formulary brand-name drugs; and Under Basic Option, your expenses for care received from Participating/ Non-participating

professional providers or Member/ Non-member facilities, except for
coinsurance and copayments you pay in those special situations where we do pay for
care provided by Non-preferred providers. Please see page 11 for the exceptions to
the requirement to use Preferred providers.

Note: If you change to another plan during Open Season, we will continue to provide
benefits between January 1 and the effective date of your new plan.

If you had already paid the out-of-pocket maximum, we will continue to provide benefits as described on this page until the effective date of your new plan.

If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in January (before the effective date of your new plan) to our prior year's out-of-
pocket maximum. Once you reach the maximum, you don't need to pay our
deductibles, copayments or coinsurance amounts (except as shown on this page) from
that point until the effective date of your new plan. 21.
21 Page 22 23
2003 Blue Cross and Blue Shield
Service Benefit Plan 19 Section 4

Note: Because benefit changes are effective January 1, we will apply our next year's
benefits to any expenses you incur in January.

Note: If you change options in this Plan during the year, we will credit the amounts
already accumulated toward the catastrophic protection out-of-pocket limit of your old
option to the catastrophic protection out-of-pocket limit of your new option. If you
change from Self Only to Self and Family, or vice versa, during the calendar year,
please call us about your out-of-pocket accumulations and how they carry over.

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.

Note: We will generally first seek recovery from the provider if we paid the provider
directly, or from the person (covered family member, guardian, custodial parent, etc.) to
whom we sent our payment. 22.
22 Page 23 24
2003 Blue Cross and Blue Shield
Service Benefit Plan 20 Section 4

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, 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 and not on the actual charge;

you are responsible for your deductible (Standard Option only), 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 equivalent Medicare amount.
And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment 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

Standard Option: your deductibles, coinsurance, and copayments Participates with Medicare or accepts Medicare assignment for the claim and is in our Preferred
network Basic Option: your copayments and coinsurance

Standard Option: your deductibles, coinsurance, and copayments, and any balance up to the Medicare approved amount Participates with Medicare or accepts Medicare
assignment and is not in our Preferred network Basic Option: all charges

Standard Option: your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare approved amount
Basic Option: your copayments and coinsurance Does not participate with Medicare, and is in
our Preferred network Note: In many cases, your payment will be less because
of our Preferred agreements. Contact your Local Plan
for information about what your specific Preferred
provider can collect from you.

Standard Option: your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount Does not participate with Medicare and is not in
our Preferred network Basic Option: all charges

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. 23.
23 Page 24 25

2003 Blue Cross and Blue Shield
Service Benefit Plan 21 Section 4

When you have the Original Medicare Plan
(Part A, Part B, or both)

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 a facility 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: Under Basic Option, you must see Preferred providers in order to receive
benefits. See page 11 for the exceptions to this requirement.

Note: The physician who does not accept Medicare assignment may not bill you for
more than 115% of the amount Medicare bases its payment on, called the "limiting
charge." The Medicare Summary Notice (MSN) form that you receive from Medicare
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. 24.
24 Page 25 26

2003 Blue Cross and Blue Shield
Service Benefit Plan 22 Section 5

Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and pages 119-120 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 the customer
service telephone number on the back of your Service Benefit Plan ID card or at our website at www. fepblue. org.

(a) Medical services and supplies provided by physicians and other health care professionals..................................................... 23-43
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 therapy
Occupational and speech therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................................. 44-55
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services............................................................................... 56-65
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ Skilled nursing care
facility benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents ................................................................................................................................................. 66-70
Accidental injury
Medical emergency
Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................. 71-77
(f) Prescription drug benefits ......................................................................................................................................................... 78-85
(g) Special features.............................................................................................................................................................................. 86

2003 Blue Cross and Blue Shield
Service Benefit Plan 23 Section 5( a)

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

Here are some important things 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.

Under Standard Option, the calendar year deductible is $250 per person ($ 500 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to
show when the calendar year deductible does not apply.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Please refer to Section 3, How you receive benefits, for a list of providers we consider to be primary care providers (under Basic Option) and other health care professionals.
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 Medicare.
We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because

how they are paid depends on what type of provider bills for the service. For example, physical
therapy is paid differently depending on whether it is billed by an inpatient facility, a doctor, a
physical therapist, or an outpatient facility.

The amounts listed below are for the charges billed by a physician or other health care professional for your medical care. Look in Section 5( c) for charges associated with the facility (i. e., hospital or other

outpatient facility, etc.).
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

Benefit Description You Pay
NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Diagnostic and treatment services You Pay Standard Option You Pay Basic Option

Professional services of physicians and other
health care professionals:

Outpatient consultations
Outpatient second surgical opinions
Office visits
Home visits
Initial examination of a newborn needing definitive treatment when covered under a

family enrollment

Preferred: $15 copayment for
the office visit charge (No
deductible)

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Diagnostic and treatment services continued on next page 26.
26 Page 27 28

2003 Blue Cross and Blue Shield
Service Benefit Plan 24 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Diagnostic and treatment services (continued) You Pay Standard Option You Pay Basic Option

Outpatient professional services:
Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Neurological testing

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Inpatient professional services:
During a hospital stay
Services for nonsurgical procedures when ordered, provided, and billed by a physician

during a covered inpatient hospital admission
Medical care by the attending physician (the physician who is primarily responsible for

your care when you are hospitalized) on days
we pay inpatient hospital benefits

Note: A consulting physician employed by
the hospital is not the attending physician.

Consultations when requested by the attending physician

Concurrent care hospital inpatient care by a physician other than the attending physician
for a condition not related to your primary
diagnosis, or because the medical complexity
of your condition requires this additional
medical care

Physical therapy by a physician other than the attending physician

Initial examination of a newborn needing definitive treatment when covered under a
family enrollment
Pharmacotherapy [see Section 5( c) for prescription drug coverage]

Neurological testing
Second surgical opinion

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons. You
are responsible for any
difference between our
allowance and the billed
amount.

Diagnostic and treatment services continued on next page 27.
27 Page 28 29

2003 Blue Cross and Blue Shield
Service Benefit Plan 25 Section 5( a)

Diagnostic and treatment services (continued) You Pay Standard Option You Pay Basic Option

Not covered:
Routine services except for those Preventive care services described on pages 27-30

Inpatient private duty nursing
Standby physicians
Routine radiological and staff consultations required by hospital rules and regulations

Inpatient physician care when your hospital admission or portion of an admission is not
covered [see Section 5( c)]
Note: If we determine that a hospital admission
is not covered, we will not provide benefits for
inpatient room and board or inpatient
physician care. However, we will provide
benefits for covered services or supplies other
than room and board and inpatient physician
care at the level that we would have paid if they
had been provided in some other setting.

All charges All charges 28.
28 Page 29 30

2003 Blue Cross and Blue Shield
Service Benefit Plan 26 Section 5( a)

Lab, X-ray, and other diagnostic tests You Pay Standard Option You Pay Basic Option

Diagnostic tests provided, or ordered and billed
by a physician, such as:

Blood tests
CT scans/ MRIs
EKGs and EEGs
Laboratory tests
Pathology services
Ultrasounds
Urinalysis
X-rays
Laboratory and pathology services billed by an
independent laboratory

Note: See Section 5( c) for services billed for by
a facility, such as the outpatient department of a
hospital.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: If your Preferred
provider uses a Non-preferred
laboratory or
radiologist, we will pay Non-preferred
benefits for any
laboratory and X-ray charges.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Other diagnostic tests provided, or ordered and
billed by a physician, such as:

Fecal occult blood tests
Non-routine mammograms
Non-routine Pap tests
Prostate Specific Antigen (PSA) tests
Sigmoidoscopies
Note: See Section 5( c) for services billed for by
a facility, such as the outpatient department of a
hospital.

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
services or tests

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: If your Preferred
provider uses a Non-preferred
laboratory or
radiologist, we will pay Non-preferred
benefits for any
laboratory and X-ray charges.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount. 29.
29 Page 30 31

2003 Blue Cross and Blue Shield
Service Benefit Plan 27 Section 5( a)

Preventive care, adult You Pay Standard Option You Pay Basic Option

Home and office visits for routine (screening)
physical examinations

Under Standard Option, benefits are limited
to the following services when performed as
part of a routine physical examination:

History and risk assessment
Chest X-ray
EKG
Urinalysis
Basic or comprehensive metabolic panel test
CBC
Fasting lipoprotein profile (total cholesterol, LDL, HDL, and triglycerides) when

performed by a Preferred provider or any
independent laboratory

Note: The benefits listed above do not apply to
children up to age 22. (See benefits under
Preventive care, children, this section.)

Chlamydial infection test
Under Basic Option, benefits are provided for
all of the services listed above and for other
appropriate screening tests and services.

Preferred: $15 copayment for
the examination (No
deductible); nothing for
services or tests

Note: We cover one routine
physical examination every
three calendar years for
members under age 65 and
one each calendar year for
members age 65 and older.

Note: We provide benefits
for adult routine physical
examinations only when you
receive these services from a
Preferred provider.

Participating:
You pay all charges

Non-participating:
You pay all charges

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital.

Preventive care, adult continued on next page 30.
30 Page 31 32

2003 Blue Cross and Blue Shield
Service Benefit Plan 28 Section 5( a)

Preventive care, adult (continued) You Pay Standard Option You Pay Basic Option

Cancer screening
Colorectal cancer screening, including:
Fecal occult blood test
Sigmoidoscopy
Double contrast barium enema
Prostate cancer screening Prostate Specific Antigen (PSA) test

Cervical cancer screening
Breast cancer screening (routine mammograms)

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
services or tests

Note: We provide benefits in
full for preventive
(screening) tests and
immunizations only when
you receive these services
from a Preferred provider
on an outpatient basis. If
these services are billed
separately from the routine
physical examination, you
may be responsible for
paying an additional
copayment for each office
visit billed.

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital.

Preventive care, adult continued on next page 31.
31 Page 32 33

2003 Blue Cross and Blue Shield
Service Benefit Plan 29 Section 5( a)

Preventive care, adult (continued) You Pay Standard Option You Pay Basic Option

Cancer screening (continued) Note: If you go to a
Participating or Non-participating
provider for
these services, the following
limits apply:

Fecal occult blood test one annually starting at age

40
Sigmoidoscopy one every five years starting at age 50

Double contrast barium enema one every five
years starting at age 50
Prostate Specific Antigen (PSA) test one annually

for males age 40 and older
Cervical cancer screening one routine Pap test

annually for females of any
age

Breast cancer screening routine mammograms for

females age 35 and older,
as follows

From age 35 through 39, one during this five-year

period
From age 40 through 64, one annually

At age 65 and older, one every two consecutive
calendar years
Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

See page 28

Preventive care, adult continued on next page 32.
32 Page 33 34

2003 Blue Cross and Blue Shield
Service Benefit Plan 30 Section 5( a)

Preventive care, adult (continued) You Pay Standard Option You Pay Basic Option

Routine immunizations without regard to age,
limited to:

Hepatitis immunizations (Types A and B) for patients with increased risk or family history

Influenza and pneumococcal vaccines, annually
Lyme disease vaccine
Tetanus-diphtheria (Td) booster once every 10 years

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
immunizations

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
for associated office visits;
nothing for immunizations

Preferred specialist: $30
copayment for associated
office visits; nothing for
immunizations

Participating/ Non-participating:
You pay all
charges

Not covered: Office visit charges associated
with preventive services and routine
immunizations performed by Participating and
Non-participating providers

All charges All charges

Preventive care, children
We provide benefits for the following services:
All healthy newborn visits including routine screening (inpatient or outpatient)

The following routine services as recommended by the American Academy of
Pediatrics for children up to the age of 22,
including children living, traveling, or
adopted from outside the United States:

Routine physical examinations
Routine hearing tests
Laboratory tests
Immunizations
Related office visits

Preferred: Nothing (No
deductible)

Participating: Nothing (No
deductible)

Non-participating: Nothing
(No deductible) up to the
Plan allowance. You are
responsible only for any
difference between our
allowance and the billed
amount.

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit; you pay nothing for
inpatient visits

Preferred specialist: $30
copayment per visit; you pay
nothing for inpatient visits

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital. 33.
33 Page 34 35

2003 Blue Cross and Blue Shield
Service Benefit Plan 31 Section 5( a)

Maternity care You Pay Standard Option You Pay Basic Option
Complete maternity (obstetrical) care including
related conditions resulting in childbirth or
miscarriage when provided, or ordered and
billed by a physician or nurse midwife, such as:

Prenatal care (including laboratory and diagnostic tests)

Delivery
Postpartum care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 13 for other circumstances,

such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours

after a cesarean delivery. We will cover an
extended stay, if medically necessary, but
you, your representative, your doctor, or your
hospital must precertify the extended stay.
See Section 3 for information on requesting
additional days.

We cover routine nursery care of the newborn child during the covered portion of the mother's

maternity stay, or if the child is covered under
the father's Self and Family enrollment.

Preferred: Nothing (No
deductible)

Note: For facility care related
to maternity, including care
at birthing facilities, we
waive the per admission
copayment and pay for
covered services in full when
you use Preferred providers.

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
for the delivery; nothing for
prenatal and postpartum care

Note: For facility care related
to maternity, including care
at birthing facilities, see
Section 5( c).

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories and
radiologists, you are
responsible only for any
difference between our
allowance and the billed
amount.

Note: When a newborn re