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Government Employees Hospital Association, Inc. 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 get care
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
- Coverage information
- When you lose benefits
Long term care insurance is still available
Index
Summary of Standard Option benefits
Summary of High Option benefits
Rates

Pages 1--102 from The Benefit Plan

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

Government Employees Hospital Association, Inc. Benefit Plan
http:// www. geha. com
2003 A fee-for-service plan

with a preferred provider organization

Sponsored and administered by: Government Employees Hospital Association, Inc.
Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program may become members of
GEHA. You must be, or must become a member of Government Employees Hospital Association, Inc.

To become a member: You join simply by signing a completed Standard Form 2809, Health Benefits Registration Form, evidencing your enrollment in the Plan.
Membership dues: There are no membership dues for the Year 2003.
Enrollment codes for this Plan:

311 Self Only High Option 312 Self and Family High Option

314 Self Only Standard Option 315 Self and Family Standard Option

RI 71-006

For changes in benefits,
see pages 8-9 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 3.
3 Page 4 5

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.
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.
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2003 GEHA 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Government Employees Hospital Association, Inc. under our contract (CS 1063) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. This plan is underwritten by Government Employees Hospital Association, Inc. The address for the Government Employees Hospital Association, Inc. administrative offices is:

Government Employees Hospital Association, Inc. P. O. Box 4665
Independence, Missouri 64051-4665
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 pages 8 and 9. 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 Government Employees Hospital Association, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve 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.
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2003 GEHA 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 (800-821-6136) and explain the situation.
If we do not resolve the issue:

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
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.
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2003 GEHA 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 providers, you will receive covered services at reduced cost. Government Employees Hospital Association, Inc. 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
Government Employees Hospital Association, Inc. to request a PPO directory.
We have entered into arrangements with Alliance PPO, Inc.; Arizona Foundation for Medical Care, FCHN; Freedom Network; HealthCare Preferred; HealthLink; MedSolutions; MultiPlan; PPO Oklahoma; PPO USA; Private
Healthcare Systems; Providence Preferred; and SouthCare, which are Preferred Providers or networks of hospitals and/ or doctors in all states. The doctors and hospitals participating in these networks have agreed to provide services
to Plan members. You always have the right to choose a PPO provider or a non-PPO provider for medical treatment.
PPO networks are now available in many metropolitan areas and additional coverage areas will be added throughout the year. Enrollees residing in a PPO network area will receive a directory of the PPO providers in their service area.
These providers are required to meet licensure and certification standards established by State and Federal authorities, however, inclusion in the network does not represent a guarantee of professional performance nor does it constitute
medical advice. To locate a participating provider in your area, call (800) 296-0776 or visit the GEHA web site at www. geha. com. When you phone for an appointment, please remember to verify that the physician is still a PPO
provider.
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
specialty in all areas. If no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply. However, if the services are rendered at a PPO hospital, we will pay the services of radiologists,
anesthesiologists and pathologists who are not preferred providers at the preferred provider rate. This non-standard benefit does not include the services of emergency room physicians. In addition, providers outside the United States
will be paid at the PPO level of benefits.
How we pay providers
Fee-for-service plans reimburse you or your provider for covered services. They do not typically provide or arrange for health care. Fee-for-service plans let you choose your own physicians, hospitals and other health care providers.

The FFS plan reimburses you for your health care expenses, usually on a percentage basis. These percentages, as well as deductibles, methods for applying deductibles to families, and the percentage of coinsurance you must pay vary by
plan.
We offer a preferred provider organization (PPO) arrangement. This arrangement with health care providers gives you enhanced benefits or limits your out-of-pocket expenses. 9.
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2003 GEHA 7 Section 1
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.
Government Employees Hospital Association, Inc. was founded in 1937 as the Railway Mail Hospital Association. For more than 60 years now, GEHA has provided health insurance benefits to federal employees and retirees.

GEHA is incorporated as a General Not-For-Profit Corporation pursuant to Chapter 355 of the Revised Statutes of the State of Missouri.
GEHA's Preferred Provider Organization includes more than 3,800 hospitals and more than 450,000 physician locations throughout the United States. In circumstances where there is limited access to PPO providers, GEHA may
negotiate discounts with some providers which will reduce your overall out-of-pocket expenses.
If you want more information about us, call (800) 821-6136, or write to GEHA, P. O. Box 4665, Independence, MO 64051. You may also contact us by fax at (816) 257-3233 or visit our website at www. geha. com. 10.
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2003 GEHA 8 Section 2
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 under the High Option will increase by 12.5% for Self Only or 12.5% for Self and Family. Under the Standard Option, your share of the premium will not increase.

We now cover medically necessary charges from Audiologists. (Section 5 (a))
We now cover Orthognathic surgery only when conservative treatment has failed for severe sleep apnea. (Section 5 (b))

Certain outpatient radiology procedures now require precertification. You or your physician must contact MedSolutions at 866-879-8317 before scheduling the following procedures: CAT Scan, Magnetic Resonance
Imaging (MRI), Magnetic Resonance Angiography (MRA), Nuclear Cardiology (NC), Positron Emission Tomography (PET). If you do not obtain precertification of these procedures, we will reduce our benefit by $100.
If the procedure is not medically necessary, we will not pay any benefits. (Section 3)
The name of our prescription drug program Merck-Medco has changed to Medco Health. (Section 5 (f))

We have changed PPO Networks in the following states: Alabama, Arkansas, Arizona, California, Connecticut, Hawaii, Massachusetts, Maine, North Carolina, New Hampshire, Rhode Island, South Carolina, Vermont, Utah.
(Section 1)
Community Care Network and United Payors and United Providers are no longer Preferred Provider Networks for GEHA. (Section 1)

We have added Arizona Foundation for Medical Care and MedSolutions to our PPO Network. (Section 1)

Changes to High Option Only
The Calendar Year Deductible has increased to $350 per person. Under a family enrollment the maximum deductible is $700 per calendar year. (Section 4)

Under the High Option we have changed the Prescription Drug Copayments. (Section 5 (f)) The copayments are now:
NonMedicare Members:
Network Retail Pharmacy (Initial prescription not to exceed 30 days supply and first refill) $5 generic/$ 20 single source brand/$ 35 multisource brand (after 1 st refill you pay 50%)

Home Delivery Pharmacy (for up to 90 day supply) $10 generic/$ 40 single source brand/$ 55 multisource brand. 11.
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2003 GEHA 9 Section 2
Medicare A & B Primary Members:
Network Retail Pharmacy (initial prescription not to exceed 30 day supply and first refill). $3 generic/$ 10 single source brand/$ 25 multisource brand (after first refill you pay 50%)

Home Delivery Pharmacy (for up to 90 day supply) $5 generic/$ 20 single source brand/$ 35 multisource brand.
Under the High Option, the copayment for office visits for Preferred Providers is now $20. (Section 4)
In-hospital expenses at PPO hospitals including in-network mental health admissions are now subject to a $100 per admission deductible, up to a maximum of 2 per person per calendar year. In-hospital expenses at Non-PPO

hospitals are now subject to a $300 per admission deductible up to a maximum of 2 per person per calendar year. (Section 5 (e) and 5 (f))

We clarified the following:
We have clarified after the deductible amount is satisfied by an individual, covered services are payable for that individual. (Section 4)

We clarified diabetic shoes are not covered. (Section 5 (a))
We clarified Cold Therapy Units are not covered. (Section 5 (a))
We clarified Body Mass Index Criteria is used to determine benefits for surgical treatment of obesity. (Section 5 (b))

We clarified Air Ambulance is not covered if requested by the patient or physician for continuity of care or other reasons if transport is beyond the nearest available suitable facility. (Section 5 (c) and 5 (d))
We clarified Psychological tests are covered both in and out of Network. (Section 5 (e))
Prescription drug clarifications: (Section 5 (f))
Any Prescription purchased twice at retail, regardless of the quantity purchased is considered maintenance medication.

Orders for ostomy and insulin pump supplies through Home Delivery should include the product number.
At Network retail pharmacies and Home Delivery service, a program is in place to promote safe and appropriate use of medications. This program includes prior approval and quantity limitations on certain

drugs. Quantity limitations are based on FDA approval and manufacturer's recommended dosage.
Compound drug pricing at Medco Health Solutions is based on the contractual Average Wholesale Price (AWP) cost of each component, the professional fee and applicable sales tax and the applicable copayment.

We clarified Telephone therapy is not covered for out-of-network mental health services. (Section 5 (e))
We clarified Travel time for providers to render therapy at patient's home is not covered for out-of-network mental health services. (Section 5 (e))

We updated the address for submitting claims for mental health services. (Section 5 (e))
We clarified when Medicare is the primary payer and does not cover a charge, we will determine our Plan allowance and pay our benefit up to this amount. (Section 9)

We clarified that if you sign a Medicare Private Contact agreement with a physician, neither you nor the physician can bill Medicare and you will be financially responsible for the entire balance after we make our
payment. (Section 9)
We have clarified Outpatient Cardiac Rehabilitation is covered. Section 5( a)) and 5( c)) 12.
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2003 GEHA 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
(800) 821-6136 or write to us at GEHA, P. O. Box 4665, Independence, MO 64051. You may also request replacement cards through our website:
www. geha. 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:

A licensed doctor of medicine (M. D.) or a licensed doctor of osteopathy (D. O.). Other covered providers include a chiropractor, nurse midwife,
nurse anesthetist, audiologist, dentist, optometrist, licensed clinical social worker, licensed clinical psychologist, podiatrist, speech, physical and
occupational therapist, nurse practitioner/ clinical specialist, nursing school administered clinic and physician assistant.

The term "doctor" includes all of these providers when the services are performed within the scope of their license or certification. The term
"primary care physician" includes family or general practitioners, pediatricians, obstetricians/ gynecologists and medical internists.

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, Louisiana, Maine, Mississippi,
Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas, Utah, West Virginia, and Wyoming.

Covered facilities Covered facilities include:
Freestanding ambulatory facility
A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center,

has permanent facilities and equipment for the primary purpose of performing surgical and/ or renal dialysis procedures on an outpatient
basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not
provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private
practice of a doctor or other professional. 13.
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2003 GEHA 11 Section 3
Hospice
A facility which meets all of the following: (1) primarily provides inpatient hospice care to terminally ill

persons; (2) is certified by Medicare as such, or is licensed or accredited as
such by the jurisdiction it is in; (3) is supervised by a staff of M. D. 's or D. O. 's, at least one of whom
must be on call at all times; (4) provides 24 hour a day nursing services under the direction of an
R. N. and has a full-time administrator; and (5) provides an ongoing quality assurance program.

Hospital
(1) An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation

of Healthcare Organizations (JCAHO); or (2) A medical institution which is operated pursuant to law, under the
supervision of a staff of doctors, and with 24 hour a day nursing service, and which is primarily engaged in providing general
inpatient care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which
facilities must be provided on its premises or have such arrangements by contract or agreement: or
(3) An institution which is operated pursuant to law, under the supervision of a staff of doctors and with 24 hour a day nursing
service and which provides services on the premises for the diagnosis, treatment, and care of persons with mental/ substance
abuse disorders and has for each patient a written treatment plan which must include diagnostic assessment of the patient and a
description of the treatment to be rendered and provides for follow-up assessments by or under the direction of the
supervising doctor.
The term hospital does not include a convalescent home or skilled nursing facility, or any institution or part thereof which a) is used principally as a
convalescent facility, nursing facility, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of
daily living; or c) is operating as a school or residential treatment facility.
What you must do to It depends on the kind of care you want to receive. You can go to any get covered care provider you 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 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 14.
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2003 GEHA 12 Section 3
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 (800) 821-6136.

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 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: For medical and surgical services, you, your representative, your
doctor, or your hospital must call Intracorp before admission. The toll-free number is (800) 747-GEHA or (800) 747-4342. (See page 55 for
mental health/ substance abuse precertification.)

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, 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;
Reason for hospitalization, proposed treatment, or surgery; 15.
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2003 GEHA 13 Section 3
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 If your hospital stay --including for maternity care --needs to be needs to be extended: extended, you, your representative, your doctor or the hospital must ask us
to approve the additional days.
What happens when you If no one contacted us, we will decide whether the hospital stay was do not follow the medically necessary.
precertification rules 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 and Puerto Rico.

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.
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2003 GEHA 14 Section 3
Radiology/ Imaging Procedures Radiology precertification is the process by which prior to scheduling Precertification specific imaging procedures we evaluate the medical necessity of your
proposed procedure to ensure the appropriate procedure is being requested for your condition. In most cases your physician will take care of
precertification. Because you are still responsible for ensuring that we are asked to precertify your procedure, you should ask your doctor to contact
us.
The following outpatient radiology services need to be precertified:
CT -Computerized Axial Tomography MRI -Magnetic Resonance Imaging

MRA -Magnetic Resonance Angiography NC -Nuclear Cardiology
PET -Positron Emission Tomography
How to precertify a radiology/ For outpatient CT, MRI, MRA, NC and PET studies, you, your Imaging procedure: representative or your doctor must call MedSolutions before scheduling
the procedure. The toll free number is 866-879-8317. Provide the following information: patient's name, plan identification number, and
birth date, requested procedure and clinical support for request, name and telephone number of ordering provider, and name of requested imaging
facility.
Exceptions: You do not need precertification in these cases:
You have another health insurance policy that is primary payer including Medicare Part A & B or Part B only;

The procedure is performed outside the United States and Puerto Rico;
You are an inpatient in a hospital;
The procedure is performed as an emergency.

Warning: We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically
necessary, we will not pay any benefits.
Other services Some services require a referral, precertification, or prior authorization. You need to call us at (800) 821-6136 before receiving treatment care such
as:
Physical therapy Growth hormone therapy (GHT)

Surgical treatment of morbid obesity Certain prescription drugs
Organ and tissue transplant procedures Surgical correction of congenital anomalies
In-network Mental Health and Substance Abuse Benefits (See page 55) 17.
17 Page 18 19
2003 GEHA 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 services.

Example: When you see your PPO physician, under the High Option, you pay a copayment of $20 per office visit.

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 $350 per person under High Option and $450 per person under Standard Option. After the deductible amount is

satisfied for an individual, covered services are payable for that individual. Under a family enrollment, all family member's individual deductibles are
considered to be satisfied when the family member's deductibles are combined and reach $700 under High Option and $900 under Standard
Option.
We also have a separate deductible for:
A High Option per admission (including in-network mental health) deductible of $100 per person (PPO) and $300 (non-PPO) for inpatient

hospital services up to a maximum of two per person, per calendar year.
Mental health and substance abuse treatment of $350, per person, under High Option and $450, per person, under Standard Option. Under a
family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the mental health and
substance abuse treatment deductible for family members reach $700 under High Option and $900 under Standard Option.

Mental health and substance abuse treatment of $500, per person, per calendar year, for out-of-network hospital inpatient and hospital
outpatient/ intensive day treatment
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.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your
old option to the deductible of your new option.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible. We will
base this percentage on either the billed charge or the Plan Allowance, whichever is less.

Example: Under the High Option, you pay 25% of our allowance for non-PPO office visits.
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. 18.
18 Page 19 20
2003 GEHA 16 Section 4
For example, if your physician ordinarily charges $100 for a service but routinely waives your 25% coinsurance, the actual charge is $75. We will
pay $56.25 (75% of the actual charge of $75).

Differences between Our "Plan allowance" is the amount we use to calculate our payment our allowance and for covered services. Fee-for-service plans arrive at their allowances in
the bill 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, with High Option you pay just 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 with High Option you pay 25% of our $100 allowance
($ 25). 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, under the High Option, 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 75% of our allowance: 75
You owe: Coinsurance 10% of our allowance: 10 25% of our allowance: 25
+Difference up to charge? No: 0 Yes: 50
TOTAL YOU PAY $10 $75

Your catastrophic protection For those medical and surgical services with coinsurance, we pay 100% out-of-pocket maximum for of our allowable amount for the remainder of the calendar year after
deductibles, coinsurance, and out-of-pocket expenses for coinsurance exceed: copayments 19.
19 Page 20 21
2003 GEHA 17 Section 4
PPO $3,500 for Self and Family (High Option) or $4,500 (Standard Option) and $3,000 for Self Only (High Option) or $4,000 (Standard Option) if
you use PPO Providers. Out-of-pocket expenses from both PPO and non-PPO providers count toward this limit. If you reach this limit,
expenses from non-PPO providers must reach the non-PPO out-of-pocket limit before they are paid at 100% of our allowable amount.
Non-PPO $4,500 for Self and Family (High Option) or $5,500 (Standard Option) and $4,000 for Self Only (High Option) or $5,000 (Standard Option) if
you use non-PPO providers. Any of the above expenses for PPO providers also count toward this limit. Your eligible out-of-pocket
expenses will not exceed this amount whether or not you use PPO providers.

Refer to pages 56 and 59 for separate in-and out-of-network catastrophic protection out-of-pocket maximums for mental health and substance abuse.
Out-of-pocket expenses for this benefit are:
The 10% (High Option) or 15% (Standard Option) you pay for PPO charges under medical services and supplies, surgical and anesthesia
services and hospital, facility and ambulance services.
The 25% (High Option) or 35% (Standard Option) you pay for non-PPO charges under medical services and supplies, surgical and

anesthesia services and hospital, facility and ambulance services.
The following cannot be counted toward catastrophic protection out-of-pocket expenses:

The $350 (High Option) or $450 (Standard Option) calendar year deductible;
The (High Option) $100 (PPO) or $300 (non-PPO) per in-hospital admission deductible;
The $20 copayment for doctor's office visits (High Option); or the $10 copayment for primary care physician/$ 25 specialist office visits
(Standard Option);
Expenses in excess of our allowable amount or maximum benefit limitations;

Expenses for well child care and immunizations; Expenses for dental and chiropractic care;

Any amounts you pay because benefits have been reduced for non-compliance with our cost containment requirements (see pages12-13);
Expenses for prescription drugs purchased through retail or Home Delivery Pharmacy service.

When government facilities Facilities of the Department of Veterans Affairs, the Department of bill us 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. 20.
20 Page 21 22
2003 GEHA 18 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 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.
When inpatient claims are paid according to a Diagnostic Related Group (DRG) limit (for instance, for admissions of certain retirees who do not have Medicare), we will pay 30% of the total covered amount as

room and board charges and 70% as other charges and will apply your coinsurance accordingly.
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

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. 21.
21 Page 22 23
2003 GEHA 19 Section 4
When you have the We limit our payment to an amount that supplements the benefits that Original Medicare Plan Medicare would pay under Medicare Part A (Hospital insurance) and
(Part A, Part B, or both) 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 we waive some of
your deductibles, copayment and coinsurance 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. Please see Section 9, Coordinating benefits

with other coverage, for more information about how we coordinate benefits with Medicare.

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) 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. 22.
22 Page 23 24

2003
GEHA

Section
5

20
Section
5.
Benefits

OVERVIEW

(See
pages

8
and

9
for

how

our
benefits

changed

this
year

and
pages

97
and

98
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
(800)

821-6136

or
at
our

website

at
www.

geha.
com.

(a)
Medical

services
and
supplies

provided

by
physicians

and
other

health

care
professionals

..................................................................................................

21-33

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

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

...............................................................................................

34-42

Surgical

procedures

Reconstructive

surgery

Oral

and
maxillofacial

surgery

Organ/

tissue
transplants

Anesthesia

provided

by
a
hospital

or
other

facility,

and
ambulance
services.............................................................................................................................

43-49

Inpatient

hospital

Outpatient

hospital
or
ambulatory

surgical
center

Extended

care
benefits/

Skilled
nursing
care

facility
benefits

Hospice

care

Ambulance

(d)
Emergency

services/
Accidents
...............................................................................................................................................................................................

50-52

Accidental

injury

Medical

emergency

Ambulance

(e)
Mental

health
and
substance

abuse
benefits
...........................................................................................................................................................................

53-60

(f)
Prescription

drug
benefits
.......................................................................................................................................................................................................

61-67

(g)
Special
features............................................................................................................................................................................................................................

Flexible

benefits
option

Services

for
deaf

and
hearing

impaired

High

risk
pregnancies

(h)
Dental
benefits........................................................................................................................................................................................................................

69-70

(i)
Non-
FEHB

benefits

available

to
Plan

members
.....................................................................................................................................................................

71-72

SUMMARY
OF
BENEFITS
...........................................................................................................................................................................................................

97-98 23.
23 Page 24 25
2003
GEHA

21
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.

The

calendar

year
deductible

is
$350

per
person

($
700

per
family)

under
the
High

Option

and
$450

per
person

($
900

per
family)

under

the
Standard

Option.
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.

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.

When

you
use
a
PPO

hospital

the
professionals

who
provide

services

to
you

in
a
hospital

may
not
all
be
preferred

providers.

If
they

are

not,
they

will
be
paid

by
this

plan

as
non-PPO

providers.
However,
if
the

services

are
rendered

at
a
PPO

hospital,

we
will

pay
the

services
of
radiologists,

anesthesiologists

and
pathologists

who
are
not
preferred

providers

at
the

preferred

provider
rate.
This
non-

standard
benefit
does
not
include

the
services

of
emergency

room
physicians.

YOU

MUST

GET
PRECERTIFICATION

OF
CERTAIN

OUTPATIENT

IMAGING
PROCEDURES.

FAILURE
TO
DO
SO

WILL
RESULT

IN
A
MINIMUM

OF
$100

PENALTY.

Please
refer
to
precertification

information
in
Section

3
to

sure

which

procedures
require
precertification.

I M P O R T A N T

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

Standard
Option

High
Option

Professional
services
of
physicians

In
physician's

office

Routine

physical
examinations

Office

medical

consultations

Second

surgical
opinions

Note:
The
facility

charge
for
clinic

or
office

visits
is
considered

a
part

of
the

fee
charged

by
the
physician.

PPO:
$10
copayment

for

office
visits
to
primary

care

physicians;
$25
copayment

for
office

visits
to
specialists

(No
deductible) Non-PPO: 35%

of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount.

PPO:
$20
copayment

(No

deductible) Non-PPO: 25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Diagnostic
and
treatment

services

continued

next
page 24.
24 Page 25 26
2003
GEHA

22
Section
5( a)

You
pay

Diagnostic
and
treatment

services
(continued)

Standard
Option

High
Option

Professional
services
of
physicians

Emergency

room
physician

care
(non-accidental

injury)

During

a
hospital

stay

At
home

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Urgent care

facilities
except
for
services

of
covered

physicians,

xray
and
laboratory

services.

All
charges

Lab,
X-ray

and
other

diagnostic

tests

Tests,
such
as:

Blood

tests

Urinalysis Non-routine

pap
tests

Pathology X-rays Non-routine

mammograms

CAT

Scans/ MRI

(Outpatient
requires
precertification)

Ultrasound Electrocardiogram

and
EEG

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
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.

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
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. 25.
25 Page 26 27
2003
GEHA

23
Section
5( a)

You
Pay

Preventive
care,
adult

Standard
Option

High
Option

Routine
screenings,

limited
to:

Total

Blood
Cholesterol

screenings

Chlamydial

infection

Colorectal

cancer
screening,

including

Annual

coverage

of
one

fecal

occult

blood
test
for
members

age
40
and

older

Sigmoidoscopy Prostate cancer screening Annual coverage

of
one

PSA

(Prostate

Specific
Antigen)

test
for
men

age
40
and

older

Routine

pap
test

Annual

coverage

of
one

pap
smear

for
women

age
18
and

older

Routine

mammogram

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Mammograms

for
diagnostic

and/
or
routine

screening

Routine

immunizations Tetanus-diphtheria

(Td)
booster

Influenza/

Pneumococcal

vaccines

Preventive
care,
children

For
dependent

children
under
age
22:

Childhood

immunizations

recommended
by
the
American

Academy
of
Pediatrics

For

well-child

care
charges

for
routine

examinations,

immunizations

and
care

Initial

examination

of
a
newborn

child
covered

under
a
family

enrollment

PPO:
Nothing

(No
deductible)

Non-PPO:
Nothing,
except
any

difference
between
our
Plan

allowance
and
the
billed

amount.
(No
deductible)

PPO:
Nothing

(No
deductible)

Non-PPO:
Nothing,
except
any

difference
between
our
Plan

allowance
and
the
billed

amount.
(No
deductible)

Vision

examinations,

limited
to:

Examinations

for
amblyopia

and
strabismus

PPO:
$10
copayment

for
office

visits
to
primary

care
physicians;

$25
copayment

for
office

visits
to

specialists
(No
deductible)

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
$20
copayment

(No

deductible) Non-PPO: 25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount 26.
26 Page 27 28
2003
GEHA

24
Section
5( a)

You
Pay

Maternity
Care

Standard
Option

High
Option

Complete
maternity
(obstetrical)

care,
such
as:

Prenatal

care

Delivery Postnatal

care

Physician

care
such

as
non-routine

sonograms.

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.

cover

routine

nursery

care
of
the

newborn

child
during

the
covered

portion
of
the

mother's
maternity

stay.

will
cover

other
care
of
an
infant

who
requires

non-routine

treatment
if
we

cover

the
infant

under
a
Self

and
Family

enrollment.

See
Hospital

benefits
(Section

5
(c))

and
Surgery

benefits
(Section

5
(b))

Circumcision

is
covered

under
Surgery

benefits.
(Section
5
(b))

PPO:
Nothing

(No
deductible)

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
Nothing

(No
deductible)

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Approved
fetal
monitors

are
covered

the
same

as
other

medical

benefits
for
diagnostic

and

treatment
services

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
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.

Home

uterine

monitoring

devices,
unless
preauthorized

by
our

Medical

Director.

Charges

related
to
abortions

except
when
the
life
of
the

mother

would
be
endangered

the
fetus

were
carried

to
term

or
when

the
pregnancy

is
the

result

of
rape

or
incest.

Charges

for
services

and
supplies

incurred
after
termination

of
coverage.

All
charges

All
charges 27.
27 Page 28 29
2003
GEHA

25
Section
5( a)

You
Pay

Family
planning

Standard
Option

High
Option

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

oral
contraceptives

under
the
prescription

drug
benefit.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
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

Infertility
services
Diagnosis
and
treatment

of
infertility,

except
as
shown

in
Not

covered.

Note:
Benefits

are
limited

to
a
maximum

of
$3,000

per
calendar

year
per
person.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Infertility

services
after
voluntary

sterilization

Fertility

drugs

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

All
charges 28.
28 Page 29 30
2003
GEHA

26
Section
5( a)

You
Pay

Allergy
care

Standard
Option

High
Option

Testing
and
treatment,

including
materials
(such
as
allergy

serum)

Allergy
testing
is
limited

to
$500

per
person

per
calendar

year

Allergy
injections

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Clinical ecology

and
environmental

medicine

Provocative

food
testing

and
sublingual

allergy
desensitization

All
charges

Treatment
therapies

Antibiotic

therapy

Outpatient

cardiac
rehabilitation

Chemotherapy

and
radiation

therapy

Note:
High-dose

chemotherapy

in
association

with
autologous

bone
marrow

transplants

limited
to
those

transplants

listed
on
page

39.

Dialysis

hemodialysis

and
peritoneal

dialysis

Intravenous

(IV)/
Infusion

Therapy

Growth

hormone

therapy
(GHT)

Note:
GHT
is
covered

under
the
prescription

drug
benefit.

We
only

cover

GHT
when
we

preauthorize
the
treatment.

Call
(800)

821-6136

for
preauthorization.

We
will
ask
you

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

Respiratory

and
inhalation

therapies

Note

Some

medications

required
for
treatment

therapies
may
be
available

through
the
Home

Delivery
Pharmacy

service
or
a
Medco

Participating

Pharmacy.
Medications

obtained
from

these
sources

are
covered

under
the
Prescription

Drug
Benefits

in
Section

5
(f).

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Treatment
therapies

continued

next
page 29.
29 Page 30 31
2003
GEHA

27
Section
5( a)

You
Pay

Treatment
therapies

(continued)

Standard
Option

High
Option

Not
covered: Chelation

therapy
except
for
acute

arsenic,

gold
or
lead

poisoning

Maintenance

cardiac
rehabilitation

All
charges

Physical
and
occupational

therapies

60
visits

per
calendar

year
for
the
combined

services
of
the
following:

qualified

physical
therapists

and

qualified

occupational

therapists

Prior
to
beginning

physical
therapy
treatments,

you
should

contact

our
Medical

Management
Department,
(800)
821-6136,

to
preauthorize

benefits.
Continuing

physical

therapy
claims
will
be
subject

to
concurrent

review
for
medical

necessity.

Physical

therapy
claims
will
be
denied

if
we

determine

the
therapy

is
not

medically

necessary.

Please
preauthorize.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

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
medical

necessity

for

skilled
services;

and

3)
indicates

the
length

of
time

the
services

are
needed.

Note:
When
you
receive

medically

necessary
physical
or
occupational

therapy
on
an
outpatient

basis

from
a
qualified

professional

therapist
at
a
skilled

nursing

facility,
your
therapy

is
covered

up
to
plan

limits. Not covered: Exercise
programs

Long-

term
rehabilitative

therapy

All
charges

All
charges 30.
30 Page 31 32
2003
GEHA

28
Section
5( a)

You
Pay

Speech
therapy

Standard
Option

High
Option

30
visits

per
calendar

year
for
the
services

of
a
qualified

speech
therapist.

Note:
We
only

cover

speech

therapy

when
a
physician:

1)
Orders

the
care;

2)
Identifies

the
specific

professional

skills
the
patient

requires

and
the
medical

necessity
for
skilled

services;

and

3)
Indicates

the
length

of
time

the
services

are
needed.

Note:
When
you
receive

medically

necessary
speech
therapy

on
an
outpatient

basis
from
a
qualified

speech
therapist

at
a
skilled

nursing

facility,
your
therapy

is
covered

up
to
plan

limits

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Computer

devices
to
assist

with
communications

Computer

programs
of
any

type,

including

but
not
limited

to
those

to
assist

with

speech
therapy

All
charges

Hearing
services
(testing,
treatment,

and
supplies)

Diagnostic
hearing
tests
performed

by
a
M.

D.,

D.
O.

or
audiologist.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Hearing aids,

testing
and
examinations

for
them

All
charges

All
charges 31.
31 Page 32 33
2003
GEHA

29
Section
5( a)

You
Pay

Vision
services

(testing,
treatment,

and
supplies)

Standard
Option

High
Option

First

pair
of
contact

lenses
or
ocular

implant

lenses
if
required

to
correct

impairment
existing
after
intraocular

surgery
or
accidental

injury.

30
outpatient

vision
therapy

visits
by
an
ophthalmologist

or
optometrist

per
person

per

lifetime

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Computer

programs

of
any

type,

including

but
not
limited

to
those

to
assist

with
vision

therapy. Eyeglasses Radial keratotomy
and
other

refractive

surgeries

All
charges

Foot
care
Routine

foot
care
only
when

you
are
under

active
treatment

for
a
metabolic

or
peripheral

vascular
disease,
such
as
diabetes.

PPO:
$10
copayment

for
office

visits
to
primary

care
physicians;

$25
copayment

for
office

visits
to

specialists
(No
deductible)

plus
15%

of
the

Plan

allowance

for
other

services
performed

during
the
visit

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
$20
copayment

for
the

office
visit
(No
deductible)

plus
10%

of
the

Plan

allowance
for
other

services

performed
during
the
visit

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Cutting or

trimming
of
toenails

or
removal

of
corns,

calluses,

or
similar

routine

treatment
of
conditions

of
the

foot,

except

as
stated

above.

All
charges

All
charges 32.
32 Page 33 34
2003
GEHA

30
Section
5( a)

You
Pay

Orthopedic
and
prosthetic

devices

Standard
Option

High
Option

Artificial

limbs
and
eyes;

stump

hose

Externally

worn
breast
prostheses

and
surgical

bras,
including

necessary
replacements

following
a
mastectomy

Internal

prosthetic

devices,
such
as
artificial

joints,
pacemakers,

cochlear
implants,

and

surgically
implanted
breast
implant

following

mastectomy.

Note:
See
Section

5
(b)

for
coverage

of
the

surgery

to
insert

the
device.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
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

Diabetic

shoes

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.

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; Crutches; and Walkers.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount DME -continued

next
page 33.
33 Page 34 35
2003
GEHA

31
Section
5( a)

You
Pay

Durable
medical
equipment

(DME)
-( continued)

Standard
Option

High
Option

Note:
Call
us
at
(800)

821-6136

as
soon

as
your

physician

prescribes

this
equipment.

will
arrange

with
a
health

care
provider

to
rent

or
sell

you
durable

medical
equipment

discounted
rates
and
will
tell
you

more

about

this
service

when
you
call.

Note:
Benefits

for
durable

medical
equipment

are
limited

to
$10,000

per
person,

lifetime

maximum.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Computer

devices
to
assist

with
communications

Computer

programs
of
any

type,

including

but
not
limited

to
those

to
assist

with
vision

therapy
or
speech

therapy

Air
purifiers,

air
conditioners,

heating
pads,
cold
therapy

units,
whirlpool

bathing

equipment,
sun
and
heat
lamps,

exercise

devices
(even
if
ordered

by
a
doctor),

and
other

equipment
that
does

not