Pages 1--72 from Foreign Service Benefit Plan

Foreign Service Benefit Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

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

Foreign Service Benefit Plan 2003
Sponsored and administered by: American Foreign Service Protective Association
Who may enroll in this Plan: You must be, or become, a member of the American Foreign Service Protective Association.
To become a member: When you enroll in the Foreign Service Benefit Plan, you automatically become a member of the Protective Association. New membership in the Protective Association is
limited to American Foreign Service personnel and direct hire employees (i. e., eligible for FEHB insurance) working for (1) the Department of State (2) the Department of Defense (3) the Agency
for International Development (4) the Foreign Commercial Service (5) the Foreign Agricultural Service; and to Executive Branch civilian employees assigned overseas or to U. S. possessions and
territories; and the direct hire domestic employees assigned to support those activities.
Direct hire employees and Executive Branch civilian employees must enroll in the Health Plan when actively employed in order to retain or choose the Plan in retirement. Only annuitants who are
eligible under the Foreign Service Retirement System may enroll under this Plan as annuitants.
Membership dues: There are no membership dues. Membership is for life.
Enrollment codes for this Plan:
401 High Option -Self Only 402 High Option -Self and Family

RI 72-001

A fee-for-service plan with a preferred provider organization
http:// www. afspa. org

Mutual of Omaha Insurance Company, the underwriter for the FOREIGN SERVICE
BENEFIT PLAN, has received accreditation from URAC (also known as the American Accreditation
Healthcare Commission) for Health Utilization Manage-ment Standards. See the 2003 Guide for more informa-tion
on accreditation.

For changes
in benefits see page 7. 1.
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

Page 2 3
2.
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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.
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. 3.
3 Page 4 5

Table of Contents
2003 Foreign Service Benefit Plan 2 Table of Contents
Introduction .............................................................................................................................................................................................. 4
Plain Language......................................................................................................................................................................................... 4
Stop Health Care Fraud!......................................................................................................................................................................... 4-5
Section 1. Facts about this fee-for-service plan ................................................................................................................................... 6
Section 2. How we change for 2003 ..................................................................................................................................................... 7
Section 3. How you get care ............................................................................................................................................................. 8-11
Identification cards ............................................................................................................................................................... 8
Where you get covered care ................................................................................................................................................ 8
Covered providers ...................................................................................................................................................... 8-9
Covered facilities ........................................................................................................................................................ 9
What you must do to get covered care .......................................................................................................................... 10-11
How to get approval for .................................................................................................................................................. 10-11
Your hospital stay (precertification) ..................................................................................................................... 10-11
Other services .............................................................................................................................................................. 11
Section 4. Your costs for covered services ...................................................................................................................................... 12-16
Copayments ................................................................................................................................................................. 12
Deductible.................................................................................................................................................................... 12
Coinsurance ................................................................................................................................................................. 12
Differences between our allowance and the bill .................................................................................................. 12-14
Your catastrophic protection out-of-pocket maximum ....................................................................................................... 14
When government facilities bill us ...................................................................................................................................... 14
If we overpay you ................................................................................................................................................................ 14
When you are age 65 or over and you do not have Medicare .......................................................................................... 15
When you have Medicare .................................................................................................................................................... 16
Section 5. Benefits ............................................................................................................................................................................ 17-49
Overview ............................................................................................................................................................................... 17
(a) Medical services and supplies provided by physicians and other health care professionals ............................... 18-26
(b) Surgical and anesthesia services provided by physicians and other health care professionals............................ 27-30
(c) Services provided by a hospital or other facility, and ambulance services .......................................................... 31-34
(d) Emergency services/ accidents .................................................................................................................................. 35-36
(e) Mental health and substance abuse benefits ........................................................................................................... 37-42
(f) Prescription drug benefits ........................................................................................................................................ 43-46
(g) Special features .............................................................................................................................................................. 47
Flexible benefits option ............................................................................................................................................ 47
Centers of excellence for tissue and organ transplants .......................................................................................... 47
Disease management programs ................................................................................................................................ 47
(h) Dental benefits ............................................................................................................................................................... 48
(i) Non-FEHB benefits available to Plan members .......................................................................................................... 49 4.
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Section 6. General exclusions things we don't cover .................................................................................................................... 50
Section 7. Filing a claim for covered services ............................................................................................................................... 51-52
Section 8. The disputed claims process .......................................................................................................................................... 53-54
Section 9. Coordinating benefits with other coverage ................................................................................................................... 55-59
When you have other health coverage ..................................................................................................................... 55
What is Medicare? ................................................................................................................................................ 55-57
Medicare managed care plan ..................................................................................................................................... 58
TRICARE and CHAMPVA ...................................................................................................................................... 58
Workers' Compensation ............................................................................................................................................ 58
Medicaid ..................................................................................................................................................................... 59
When other Government agencies are responsible for your care ........................................................................... 59
When others are responsible for injuries .................................................................................................................. 59
Section 10. Definitions of terms we use in this brochure ............................................................................................................... 60-62
Section 11. FEHB facts ..................................................................................................................................................................... 63-65
Coverage information ..................................................................................................................................................... 63-64
No pre-existing condition limitation ......................................................................................................................... 63
Where you get information about enrolling in the FEHB Program ....................................................................... 63
Types of coverage available for you and your family............................................................................................. 63
Children's Equity Act ........................................................................................................................................... 63-64
When benefits and premiums start ........................................................................................................................... 64
When you retire ......................................................................................................................................................... 64
When you lose benefits .................................................................................................................................................. 64-65
When FEHB coverage ends ...................................................................................................................................... 64
Spouse equity coverage ............................................................................................................................................. 64
Temporary Continuation of Coverage (TCC) .......................................................................................................... 64
Converting to individual coverage ............................................................................................................................ 65
Getting a Certificate of Group Health Plan Coverage ............................................................................................. 65
Long term care insurance is still available ............................................................................................................................................. 66
INDEX...................................................................................................................................................................................................... 67
Summary of benefits ........................................................................................................................................................................... 68-69
Rates ........................................................................................................................................................................................... Back cover

2003 Foreign Service Benefit Plan 3 Table of Contents 5.
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2003 Foreign Service Benefit Plan 4 Introduction/ Plain Language/ Stop Health Care Fraud
Introduction
This brochure describes the benefits of the Foreign Service Benefit Plan under our contract (CS 1062) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This plan is underwritten by

Mutual of Omaha. The address for the Foreign Service Benefit Plan administrative offices is:
Foreign Service Benefit Plan Phone: 202/ 833-4910 1716 N Street, NW Fax: 202/ 833-4918
Washington, DC 20036-2902 E-mail: afspa@ afspa. org
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 7. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we"
means the Foreign 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.

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. 6.
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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 202/ 833-4910 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.

2003 Foreign Service Benefit Plan 5 Introduction/ Plain Language/ Stop Health Care Fraud 7.
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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 reside in a PPO area and use a PPO provider, you will receive covered services at reduced cost. Mutual of Omaha 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. Access our PPO directory either through Mutual of Omaha's web site, www. mutualofomaha. com, or as a link through our web site www. afspa. org or call 202/ 833-4910 for
information concerning the PPO. You can also go to our web page, which you can reach through the FEHB web site, www. opm. gov/ insure. Contact the Foreign Service Benefit Plan to request a PPO directory.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a PPO Network Area. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability
of every specialty in all areas. The selection of PPO providers is solely Mutual of Omaha's responsibility. We cannot guarantee the continued participation of any specific provider. In the PPO Network Areas, if no PPO provider is available or you do not
use a PPO provider, the standard non-PPO benefits apply. Follow these procedures when you use a PPO provider in order to receive PPO benefits:

Verify with us that your address of record is in a PPO area. Our records must reflect that you reside in a PPO area;
Verify that the provider is in the PPO network when you make your appointment;
Present your PPO Identification Card at the time you visit your health care provider, confirming your PPO participation to be eligible for PPO benefits. If you do not present your PPO ID Card, the provider may not accept

our PPO discount; and
Do not pay a PPO provider at the time of service. PPO providers must bill us directly. We must reimburse the provider directly. PPO providers will bill you for any balance after our payment to them.

This Plan offers its members in certain areas the opportunity to reduce out-of-pocket expenses by choosing facilities and providers that participate in the Plan's Preferred Provider Organization (PPO). The following are considered PPO Network Areas:
The Washington, D. C. metropolitan area and certain areas in all states except for Hawaii, Vermont and Wyoming.
Consider the PPO cost savings when you review Plan benefits, and if you live in these areas, check with the Plan to find out which local facilities and providers are PPO providers. Check with your doctor to see if he or she has admitting privileges at a

PPO hospital.
How we pay providers
We generally reimburse our PPO providers based on an agreed-upon fee schedule. We do not offer them additional financial incentives based on care provided or not provided to you. Our standard provider agreements do not contain any contractual

provisions that include incentives to restrict the providers' ability to communicate with and advise you of any appropriate treatment options. Also, we have no compensation, ownership or other influential interests that are likely to affect provider advice
or treatment decisions.
We may, through a negotiated arrangement with some health care providers, apply a discount to Covered Services that you receive from any such health care provider.

To locate a provider from whom a discount may be available, call the number on your Identification Card.
Your Rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB web site (www. opm. gov/ insure) lists the specific types of information that we

must make available to you. Some of the required information is listed below. Years in existence and profit status The American Foreign Service Protective Association was established in 1929 and
was incorporated in 1941 as a 501( c)( 9) not-for-profit organization. The Foreign Service Benefit Plan is provided in conjunction with the Mutual of Omaha Insurance Company. The Mutual of Omaha Insurance Company was organized in 1909
as a mutual legal reserve system (private). Licensing and certification The Mutual of Omaha Insurance Company meets all State and Federal licensing and
certification requirements. Fiscal solvency, confidentiality and transfer of medical records The Mutual of Omaha Insurance Company meets all
requirements for fiscal solvency, confidentiality and transfer of medical records.
If you want more information about us, call 202/ 833-4910, or write to the Foreign Service Benefit Plan, 1716 N Street, NW, Washington, DC 20036-2902. You may also contact us by fax at 202/ 833-4918, by e-mail at afspa@ afspa. org or visit our web

site at www. afspa. org.

2003 Foreign Service Benefit Plan 6 Section 1 8.
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2003 Foreign Service Benefit Plan 7 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.

Changes to this Plan
Your share of the premium will increase by 4.9% for Self Only and 5.7% for Self and Family.
We have increased your benefits for members who reside overseas. When you reside overseas, we pay overseas providers at the PPO coinsurance rate for each respective benefit that has a PPO coinsurance. We have also eliminated the $200

copayment for overseas hospitals when you reside overseas (Sections 5( a) through 5( h)).
We have added to your PPO service area. In addition to the states that had PPO providers last year, portions of the following states are now also considered within the PPO service area: Alaska, Idaho, Kansas, Kentucky, Mississippi, Montana,

Nebraska, North Dakota and South Dakota (Section 1).
We have changed your cost for a 30-day supply of prescription drugs to 25% coinsurance with a $10 minimum for generic drugs and a $20 minimum for brand name drugs at network pharmacies; and for a 30 to 90-day supply of prescription drugs

to $20 for generic drugs and $40 for brand name drugs at Home Delivery (Section 5( f)).
We have increased your Preventive care, adult benefit to include one routine colonoscopy screening every 10 years for members age 50 and older subject to the calendar year deductible and appropriate coinsurance (Section 5( a)).

We have increased your Preventive care, adult benefit to include one routine Double Contrast Barium Enema (DCBE) every 5 years for members age 50 and older subject to the calendar year deductible and appropriate coinsurance (Section 5( a)).
We have increased your Preventive care, adult benefit to include one routine fasting lipoprotein profile test every 5 years for members age 20 and older subject to the calendar year deductible and appropriate coinsurance (Section 5( a)).
We have eliminated the Special Outpatient Care Benefit under Maternity benefits to comply with Federal law (Section 5( a)).
We now pay preadmission testing the same as other X-ray, laboratory, pathology and machine diagnostic tests (Section 5( a)).
We now pay X-ray, laboratory, pathology and machine diagnostic tests performed within 72 hours of outpatient surgery the same as other X-ray, laboratory, pathology and machine diagnostic tests (Section 5( a) and 5( c)).

We have removed the separate definition of a new period of confinement for Skilled Nursing Facilities and increased your coverage from 60 to 90 days per calendar year for precertified admissions; and from 30 to 45 days per calendar year for non-precertified
admissions (Section 5( c)).
We now pay your ambulance services as a result of an accident at the appropriate coinsurance levels not subject to the calendar year deductible (Section 5( d)).

We have removed the 72 hour time limit under your Accidental injury benefit and now pay at 100% of the Plan allowance for Emergency Room (ER) facility charges and the ER physician's charge or the initial physician's office visit for services
received due to an accidental injury (Section 5( d)).
We now pay day care (Mental health and substance abuse benefits) under the partial hospitalization benefit. We have also removed the 20-day per calendar year limitation for out-of-network members (Section 5( e)).

We now pay 100% of all charges up to $60 per visit for up to 50 visits per person per calendar year for inpatient individual therapy under your Mental health and substance abuse benefit for In-Network area non-PPO benefits (Section 5( e)).
We now pay 100% of $20 for 30 chiropractic visits per calendar year subject to the calendar year deductible (Section 5( a)).
We now pay 100% of $20 for 30 acupuncture visits per calendar year subject to the calendar year deductible (Section 5( a)).
We now administer your Smoking cessation benefit on a calendar year basis; and the Plan has increased the benefit so that you pay nothing for the first $100 of covered charges (Section 5( a)).

We have increased your benefits for Alveolectomy (Section 5( h)).
We no longer offer the Optum Nurseline due to underutilization. 9.
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2003 Foreign Service Benefit Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you a combined Foreign Service Benefit Plan/ Medco Health Prescription Drug 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. Call us if you need to purchase prescriptions and have not received your card.
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 202/ 833-4910 or write to us at
1716 N Street, NW, Washington, DC 20036-2902. You may also request replacement cards through our web site: www. afspa. org.

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 reside in the PPO area and use our preferred providers, you will pay less.
Covered providers We consider the following to be covered providers when they perform covered services within the scope of their license or certification:

Physician Doctors of medicine (M. D.), osteopathy (D. O.), podiatric medicine (D. P. M.) and for certain specified services covered by this Plan, doctors of dental
surgery (D. D. S.), medical dentistry (D. M. D.), optometry (O. D.), chiropractic (D. C.), and Oriental Medicine (O. M. D.)

Qualified Clinical Psychologist An individual who has earned either a Doctoral or Masters Clinical Degree in psychology or an allied discipline and who is licensed
or certified in the state where services are performed (such as Licensed Professional Counselors).

Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure
or certification.
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) Is licensed or certified as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification.

Clinical Social Worker A social worker who
1) Has a Masters or Doctoral degree in social work;
2) Has at least two years of clinical social work practice; and
3) In states requiring licensure, certification, or registration, is licensed, certified, or registered as a social worker where the services are rendered.

Nursing School Administered Clinic A clinic that is
1) Licensed or certified in the state where the 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 by these clinics

are considered outpatient "office" services rather than facility charges.
Physician Assistant A person who is licensed, registered or certified in the state where services are performed. 10.
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Licensed Professional Counselor or Master's Level Counselor A person who is licensed, registered, or certified in the state where services are performed.
Audiologist A person who is licensed, registered or certified in the state where services are performed.
Licensed Acupuncturist (L. Ac.) An individual who has completed the required schooling and licensure to perform acupuncture in the state where services are
performed (see definition of acupuncture, Section 5( a)).
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:
Birthing Center A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries and to

provide immediate postpartum care.
Hospice Care Facility A facility providing Hospice Care Services that is appropriately licensed or certified as such under the law of the jurisdiction in which

it is located, and that:
1) Is certified (or is qualified and could be certified) under Medicare;
2) Is accredited by the Joint Commission on the Accreditation of Healthcare Organizations; or

3) Meets the standards established by the National Hospice Organization.
Hospital
1) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO); or
2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing services, and that is primarily

engaged in providing:
a) 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 under its control; or
b) Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and

laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized
provider of those facilities.
3) For inpatient and outpatient treatment of alcohol and drug abuse, the term hospital also includes a free-standing alcohol and drug abuse treatment

facility approved by the JCAHO.
In no event shall the term hospital include a convalescent nursing home or institution or part thereof that:

1) Is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged;
2) Furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or
3) Is operated as a school.
Skilled Nursing Facility An institution or that part of an institution, which provides convalescent skilled nursing care 24-hours-a-day and is classified as a
skilled nursing facility under Medicare.

2003 Foreign Service Benefit Plan 9 Section 3 11.
11 Page 12 13
2003 Foreign Service Benefit Plan 10 Section 3
What you must do to It depends on the kind of care you want to receive. You can go to any covered 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 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 specialist based on the above circumstances, you can continue to see your specialist

and any PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 202/ 833-4910.
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;
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: You, your representative, your doctor, or your hospital must call us at 1-800/ 593-2354 at least seven days before 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, the physician, 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;
Name of hospital, facility or home health agency; Name and phone number of admitting doctor; and
Number of planned days of hospital stay or care.
We will then tell the physician and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physician,

and the hospital. 12.
12 Page 13 14
2003 Foreign Service Benefit Plan 11 Section 3
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 within 2 business days for precertification of additional days for your baby.

If your hospital stay If your hospital stay including for maternity care needs to be extended, you, your needs to be extended: representative, your doctor or the hospital must ask us to approve the additional days.
What happens when you If no one contacts us, we will decide whether the hospital stay was medically do not follow the 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 hospital 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 covered 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 50 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 or you have no Medicare lifetime reserve days left, then we will become the primary payer and you must precertify.

Other services Other services require precertification or prior authorization. You, your representative, your doctor, or treating facility must call us at 1-800/ 593-2354 at least seven days
before the admission or care, such as:
Home health care (see Section 5( a));
Hospice care (see Section 5( c));
Organ/ tissue transplants (see Section 5( b));
Skilled nursing facility admission (see Section 5( c)); and
Mental health and substance abuse treatment (see Section 5( e)).

If no one contacted us for specified services such as Home health care, Hospice care, Skilled nursing facility care or Mental health and substance abuse care, we will pay a

reduced benefit as referenced in the appropriate benefit section.
Note: We do not require precertification, preauthorization or concurrent review if you receive treatment outside of the United States or when Medicare Part A and/ or Part B,

or another group health insurance policy is the primary payer. Precertification, preauthorization and concurrent review is required, however, when Medicare or the
other group health insurance policy stops paying benefits for any reason. 13.
13 Page 14 15
2003 Foreign Service Benefit Plan 12 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 purchase prescriptions from the Medco Health Home Delivery Pharmacy Service by mail, you pay a copayment of $20 for generic or $40 for brand name

prescriptions.
When you are admitted to a non-PPO hospital or an Out-of-Network hospital, you pay $200 per person per hospital stay.

We do not reimburse you for copayments.
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. We do not
reimburse you for the deductible. Benefits paid by us do not count towards the deductible. Copayments and the amount you pay after coinsurance does not count
toward any deductible.
The calendar year deductible is $300 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses

applied to the calendar year deductible for family members reach $600. Expenses are "incurred" on the date on which the service or supply is received.

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

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.
Example: You pay 10% of the Plan allowance for surgery performed by a PPO provider.

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

For example, if your non-PPO physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49
(70% of the actual charge of $70).
Differences between Our "Plan allowance" is the amount we use to calculate our payment for covered our allowance and services. Fee-for-service plans arrive at their allowances in different ways, so their
the bill 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.
When you live in the Plan's PPO area, you should use a PPO provider. The following two examples explain how we will handle your bill when you go to a PPO provider

and when you go to a non-PPO provider. When you use a PPO provider, the amount you pay is much less. 14.
14 Page 15 16
2003 Foreign Service Benefit Plan 13 Section 4
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. Here is an example about coinsurance: You live in one of our PPO areas and you see a PPO physician who charges $150, but our
allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you 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. Follow these procedures when you use a PPO
provider in order to receive PPO benefits:
Verify with us that your address of record is in a PPO area;
When you phone for an appointment, verify that the physician or facility is still a PPO provider;

Present your PPO ID card confirming your PPO participation in order to receive PPO benefits; and
Do not pay a PPO provider at the time of service. PPO providers must bill us directly. We must reimburse the provider directly. PPO providers will
bill you for any balance after our payment to them.
Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. For instance:

When you reside in the PPO network area and 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. If you have met
your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($ 30). Plus, because there is no agreement between the non-PPO
physician and us, he can bill you for the $50 difference between our allowance and his bill.

When you reside outside of the PPO Network area you will pay your deductible and coinsurance plus any difference between our allowance and
charges on the bill. As in the example above, once you have met your deductible, you are responsible for your coinsurance. You will pay 20% of our allowance
($ 20) and the physician can bill you for the $50 difference between our allowance and his bill.

Overseas providers' charges are generally not subject to a Plan allowance. Similar to the PPO example above, when you reside overseas and you meet your deductible,
you are responsible for your coinsurance. You will pay just 10% of the charge ($ 15).

The following table illustrates the examples of how much you have to pay out-of-pocket for medical services from a PPO physician vs. a non-PPO physician vs. a
domestic Out-of-Network physician and vs. an overseas 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 Domestic Out-of-Network Overseas Physician Physician when you reside overseas
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: 150
We pay 90% of our allowance: 90 70% of our allowance: 70 80% of our allowance: 80 90% of our allowance: 135
You pay:
Coinsurance 10% of our allowance: 10 30% of our allowance: 30 20% of our allowance: 20 10% of our allowance: 15
+Difference up to charge? No: 0 Yes: 50 Yes: 50 No: 0
TOTAL YOU PAY 10 80 70 15 15.
15 Page 16 17
2003 Foreign Service Benefit Plan 14 Section 4
Regardless of the provider you choose, we subject benefits to all provisions of the Plan. Also, we do not supervise, control or guarantee the health care services of a
preferred provider or any other provider.

Your catastrophic protection For those services with coinsurance, we pay 100% of the Plan allowance for the out-of-pocket maximum for remainder of the calendar year when out-of-pocket expenses for coinsurance,
deductibles, coinsurance, and deductibles and inpatient hospital copayment in that calendar year exceed copayments $3,000 for Self Only and $3,500 for Self and Family enrollment (PPO and overseas
providers)
$4,000 for Self Only and $4,500 for Self and Family enrollment (non-PPO providers and Out-of-Network area providers).

This catastrophic protection out-of-pocket maximum is combined for medical/ surgical and mental health/ substance abuse.
The following cannot be counted toward catastrophic protection out-of-pocket expense:
Expenses in excess of Plan allowances, maximum benefit or visit limitations;
Expenses for dental care;
Any amounts you pay because benefits have been reduced for non-compliance with precertification or preauthorization requirements (see Section 3);

Coinsurance and copayments you pay for prescription drugs;
Expenses for prescriptions purchased at pharmacies in the 50 United States without using the Plan's combined Foreign Service Benefit Plan/ Medco Health Prescription

Drug Identification Card or purchased from a source other than the Plan's Medco Health Home Delivery Pharmacy Service; and

Non-covered services and supplies.
Lifetime maximums We have the following lifetime maximums:
We limit the Hospice benefit to $7,500 per person when you precertify hospice care and to $4,500 when you do not precertify.

We limit the Orthodontic benefit to $1,000 per person.
We limit diagnosis and treatment of infertility to a maximum benefit of $5,000.

When government facilities Facilities of the Department of Veterans Affairs, the Department of Defense, and the bill us 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. If we paid your claim in error for any reason, we shall make a diligent
effort to recover an overpayment to you from you or, if to the provider, from the provider. We may reduce subsequent benefit payments to you or to a provider on
behalf of the member to offset overpayments. 16.
16 Page 17 18
2003 Foreign Service Benefit Plan 15 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.
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 your deductibles and coinsurance; Medicare assignment for the claim and is a

PPO provider,
Participates with Medicare and is a non-PPO your deductibles, coinsurance, and any balance or Out-of-Network provider, up to the Medicare approved amount;

Does not participate with Medicare (PPO, your deductibles, coinsurance, and any balance non-PPO or Out-of-Network providers), 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 your physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask your physician or hospital to reduce the charges. If you
have paid more than allowed, ask for a refund. If you need further assistance, call us. 17.
17 Page 18 19
2003 Foreign Service Benefit Plan 16 Section 4
When you have the We limit our payment to an amount that supplements the benefits that Medicare Original Medicare Plan would pay, under Medicare Part A (Hospital insurance) and Medicare Part B (Medical
(Part A, or Part B, or both) insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not
participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
If your physician accepts Medicare assignment, then you pay nothing for covered charges.

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

Note: The physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its 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. 18.
18 Page 19 20

2003 Foreign Service Benefit Plan 17 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and pages 68-69 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 by phone at 202/ 833-4910, e-mail at afspa@ afspa. org or at our web site at www. afspa. org.

(a) Medical services and supplies provided by physicians and other health care professionals ................................................... 18-26
Diagnostic and treatment services Hearing services (testing, treatment, and supplies) Lab, X-ray, and other diagnostic tests Vision services (testing, treatment, and supplies)

Preventive care, adult Foot care Preventive care, children Orthopedic and prosthetic devices
Maternity care Durable medical equipment (DME) Family planning Home health services
Infertility services Chiropractic Allergy care Alternative treatments
Treatment therapies Educational classes and programs Physical, occupational and speech therapies

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................................... 27-30
Surgical procedures Organ/ tissue transplants Reconstructive surgery Anesthesia

Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 31-34
Inpatient hospital Hospice care Outpatient hospital or ambulatory surgical center Ambulance

Extended care benefits/ Skilled nursing care facility benefits
(d) Emergency services/ Accidents ................................................................................................................................................... 35-36
Accidental injury Ambulance Medical emergency

(e) Mental health and substance abuse benefits .............................................................................................................................. 37-42
(f) Prescription drug benefits ........................................................................................................................................................... 43-46
(g) Special features ................................................................................................................................................................................ 47
Flexible benefits option Centers of excellence for tissue and organ transplants

Disease management programs
(h) Dental benefits ................................................................................................................................................................................. 48
(i) Non-FEHB benefits available to Plan members ............................................................................................................................. 49
SUMMARY OF BENEFITS .............................................................................................................................................................. 68-69 19.
19 Page 20 21
2003 Foreign Service Benefit Plan 18 Section 5( a)
Here are some important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductible is: $300 per person ($ 600 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.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area or when you reside overseas. When no

PPO provider is available in a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply. When you reside overseas, all covered overseas
providers are paid at the PPO coinsurance rate.
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.

I M
P O
R T
A N
T

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

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of physicians during a hospital stay, skilled nursing facility stay, in the physician's office, at home, or consultations

Office consultation including second opinion
Psychological tests and pharmacological visits
Drugs and medical supplies billed by a physician

Not covered: All charges.
Telephone consultations
Procedures, services, drugs, and supplies related to impotency, sex
transformations, sexual dysfunction, or sexual inadequacy

Office visits by a dentist in relation to the removal of impacted teeth and other dental services. Office visits by a dentist in relation to

covered oral and maxillofacial surgical procedures are covered.

Lab, X-ray and other diagnostic tests
X-ray, laboratory and pathology services and machine diagnostic tests

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

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas 20.
20 Page 21 22
Preventive care, adult You pay
Routine physical examination limited to a maximum charge of $750 per person, per calendar year

In addition Routine Cancer Screenings limited to:
Colorectal Cancer Screening, limited to
Fecal occult blood test one annually for members age 40 and older
Sigmoidoscopy, screening one every five years for members age 50 and older

Colonoscopy, screening one every 10 years for members age 50 and older
Double Contrast Barium Enema (DCBE) one every five years for members age 50 and older

Breast Cancer Screening (Mammogram) one annually for women age 35 and older
Cervical Cancer Screening Pap smear one annually for women age 18 and older
Prostate Cancer Screening Prostate Specific Antigen (PSA) one annually for men age 40
and older
Other Routine Services limited to:
Non-fasting total blood cholesterol test once every three consecutive calendar years

Chlamydial screening
Fasting lipoprotein profile test one every five years for members age 20 and older

Routine immunizations limited to:
Tetanus-diphtheria (Td) booster one every 10 consecutive calendar years for members age 22 and older

Influenza vaccine and pneumococcal vaccine one every calendar year for members age 65 and older

Note: These benefits do not apply to children under age 22 (See Preventive care, children).

2003 Foreign Service Benefit Plan 19 Section 5( a)

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas 21.
21 Page 22 23
2003 Foreign Service Benefit Plan 20 Section 5( a)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

deductible)
Out-of-Network Area: Only the difference between our allowance and the billed amount

(No deductible)
Overseas Providers: Nothing (No deductible) when you reside overseas

Preventive care, children You pay
Preventive care for children is limited to:
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
Related office visits

Immunizations for children are limited to:
Childhood immunizations recommended by the American Academy of Pediatrics are covered for members under age 22.

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
One Routine sonogram

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see Section 3 for other circumstances when you must precertify, 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.

For facility care related to maternity, including care at birthing facilities, we pay at the inpatient hospital rate in accordance with Section 5( c) of
the Brochure. We pay surgeon services (delivery) the same as for illness and injury. See Surgical benefits Section 5( b).

We consider bassinet or nursery charges during the covered portion of the mother's maternity stay to be the expenses of the mother and not
expenses of the newborn child. We consider expenses of the child after the mother's discharge to be the expenses of the child. We cover these
expenses only if the child is covered by a Self and Family enrollment. See Surgical benefits (Section 5( b)) for routine circumcision.

Not covered: All charges.
Procedures, services, drugs, and supplies related to abortions except when
the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

See Hospital benefits (Section 5( c)) and Surgical benefits (Section 5( b)).
Note: If your child stays after your discharge and is covered under a Self and Family
enrollment, you must pay a separate hospital copayment of $200 for non-PPO and Out-of-Network
facilities. If your child is not covered under a Self and Family enrollment
you pay all of your child's charges after your discharge. 22.
22 Page 23 24
2003 Foreign Service Benefit Plan 21 Section 5( a)
Infertility services continued on next page

Family planning You pay
A range of voluntary family planning services limited to surgery, medicine and IUDs.

Surgery limited to (See Surgical benefits Section 5( b)):
Voluntary sterilization
Surgery to implant contraceptives (such as Norplant)

Medicine and IUDs limited to:
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover FDA-approved drugs, prescriptions, and devices for birth control covered under the Prescription drug benefit in Section 5( f).

Not covered: All charges.
reversal of voluntary surgical sterilization
genetic counseling

Infertility services
Diagnosis and treatment of infertility, except as shown in Not covered, includes:

Initial diagnostic tests and procedures done only to identify the cause of infertility;
Fertility drugs, hormone therapy and related services; and
Medical or surgical procedures done to create or enhance fertility.

Note: The Plan will pay up to $5,000 per person per lifetime for covered infertility services, including prescription drugs.

PPO: 10% of the Plan allowance (No deductible on surgery)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible on surgery)
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible on surgery)

Overseas Providers: 10% of the Plan allowance (No deductible on surgery) when
you reside overseas

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

PPO: 10% of the Plan allowance until benefits stop at $5,000 and all charges after
the Plan's maximum payment of $5,000
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount until benefits stop at $5,000 and all charges after the Plan's maximum
payment of $5,000
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount until benefits stop at $5,000 and all charges after
the Plan's maximum payment of $5,000
Overseas Providers: 10% of the Plan allowance until benefits stop at $5,000 when

you reside overseas and all charges after the Plan's maximum payment of $5,000 23.
23 Page 24 25
Infertility services (continued) You pay
Not covered: All charges.
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination
in vitro fertilization
embryo transfer and gamete intrafallopian transfer (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

Allergy care
Testing, treatment, and injections including materials (such as allergy serum)

Not covered: All charges.
Provocative food testing, end point titration techniques, sublingual allergy
desensitization, RAST tests and hair analysis

Treatment therapies
Chemotherapy and radiation therapy (includes radium and radioactive isotopes)

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Surgical
benefits Section 5( b), Organ/ tissue transplants
Intravenous (IV)/ Infusion Therapy (supplies) Home IV and antibiotic therapy (supplies)

Note: See also Home health services, this Section.
Growth hormone therapy
Respiratory and inhalation therapies (includes oxygen and equipment for its administration)

2003 Foreign Service Benefit Plan 22 Section 5( a)

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

Treatment therapies continued on next page 24.
24 Page 25 26
2003 Foreign Service Benefit Plan 23 Section 5( a)
Treatment therapies (continued) You pay
Renal dialysis
Note: This benefit includes only the actual charge for the dialysis treatment. Other covered charges associated with the dialysis treatment are

payable under Section 5( a) Lab, X-ray and other diagnostic tests.

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

Physical, occupational and speech therapies
Physical therapy, occupational therapy, and speech therapy: 90 total combined visits per calendar year for all three listed therapies provided by:

Licensed physical therapists;
Licensed physicians;
Licensed speech therapists; and
Licensed occupational therapists

Note: We only cover physical, occupational and 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 frequency and length of time the services are needed.
Note: We only cover physical and occupational therapy to restore bodily function when there has been a total or partial loss of bodily function due to

illness or injury.
Not covered: All charges.
Custodial care (see definition Section 10)
Exercise programs

Hearing services (testing, treatment, and supplies)
Limited to:
Initial hearing exam

Not covered: All charges.
Hearing aids and examinations for them, except for the initial exam

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

(No deductible)
Out-of-Network Area: Only the difference between our allowance and

the billed amount (No deductible)
Overseas Providers: Nothing (No deductible) when you reside overseas 25.
25 Page 26 27
2003 Foreign Service Benefit Plan 24 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses per incident if required to correct an impairment directly caused by:

Accidental ocular injury or
Specifically ordered by the doctor in connection with a diagnosis of
Cataract
Keratoconus
Glaucoma

Note: Expenses in relation to an accident or removal of cataract or keratoconus must be incurred within one year of the date of the accident

or surgery.
Not covered: All charges.
Routine eye examinations
Eyeglasses and contact lenses, except as shown above
Eye exercises and visual training (orthoptics)
Refractions
All refractive surgeries

Foot care
We do not provide benefits for routine foot care. Routine foot care would All charges. include such items as:

treatment or removal of corns and calluses, or trimming of toenails
orthopedic shoes, orthotics and other supportive devices for the feet

Orthopedic and prosthetic devices
Artificial limbs and eyes to replace natural 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, intraocular lenses, cochlear implants, and surgically implanted breast
implants following mastectomy
Note: A prosthetic device is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.

Note: See Section 5( b), for coverage of the surgery to insert the device and Section 5( c) if billed by the facility.

Not covered: All charges.
Orthopedic shoes, orthotics and other supportive devices for the feet,
such as:

Arch supports
Heel pads and heal cups
Corsets
Elastic stocking and support hose that do not require a physician's
written prescription

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

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

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas 26.
26 Page 27 28
Home health services continued on next page
2003 Foreign Service Benefit Plan 25 Section 5( a)

Durable medical equipment (DME) You pay
Rental, up to the purchase price, or purchase (at our option), including necessary repair and adjustment, of durable medical equipment such as:

Wheelchairs Hospital beds
Oxygen and equipment for its administration Dialysis equipment
Crutches Braces
Casts, splints, and trusses Walkers

Also included are:
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies).

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

Are medically necessary; Are primarily and customarily used only for a medical purpose;
Are generally useful only to a person with an illness or injury; Are designed for prolonged use; and
Serve a specific therapeutic purpose in the treatment of an illness or injury.
Not covered: All charges.
Other items that do not meet the definition of durable medical
equipment such as sun or heat lamps, whirlpool baths, heating pads, air purifiers, humidifiers, air conditioners, and exercise devices

Home health services
For services provided on a part-time basis (less than an 8-hour shift):
If you precertify your home health care, 90 visits per calendar year up to a maximum Plan payment of $80 per visit when:

A Registered Nurse (R. N.) or Licensed Practical Nurse (L. P. N.) provides the services;
A licensed therapist provides physical, occupational or speech therapy; A licensed social worker provides the services (limited to two visits per
calendar year); A home health aide provides services under the supervision of a Registered
Nurse (R. N.) consisting of mainly medical care and therapy provided solely for the care of the insured person;
The attending physician orders the care; and The physician identifies the specific professional skills required by the
patient and the medical necessity for skilled services; and indicates the length of time the services are needed.

A home health agency (or visiting nurses where services of a home health agency are not available) must furnish the care in accord with a home
health care plan (see definition below). The home health care plan must be certified by your doctor and furnished in your home.

Note: We define Home Health Agency as a public or private agency or organization appropriately licensed, qualified and operated under the law
of the state in which it is located.
Note: We define Home Health Care Plan as a written plan, approved in writing by a Physician, for continued care and treatment of a plan member:

(a) Who is under the care of a Physician; and (b) Who would need a continued stay in a Hospital or Skilled Nursing Facility
without the home health care.

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

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

For precertified home health care: Nothing (No deductible) up to $80 per visit up to 90
visits per calendar year; All charges above $80 per visit and/ or 90 visits per calendar
year and all charges above one visit per day 27.
27 Page 28 29
2003 Foreign Service Benefit Plan 26 Section 5( a)
Home health services (continued) You pay
For services provided on a part-time basis (less than an 8-hour shift):
If you do not precertify your home health care, 40 visits per calendar year up to a maximum plan payment of $40, subject to the provisions on

the previous page

For private duty nursing we pay $12 per hour when provided on a full-time basis (more than an 8-hour shift) by a Registered Nurse (R. N.) or Licensed
Practical Nurse (L. P. N.) when:
The care is ordered by the attending physician; and
Your physician identifies the specific professional nursing skills that you require, as well as the length of time needed.

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

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
Custodial care as defined in Section 10, Definitions
Chiropractic
Covered services are limited to:
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy and cold pack application

Note: Chiropractic is a system of therapy that attributes disease to abnormal function of the nervous system and attempts to restore normal function by
manipulation of the spinal column and other body structures.
Alternative treatments
Acupuncture only when performed by an M. D, D. O., O. M. D., or L. Ac.
Note: The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical

anesthesia, or for therapeutic purposes.

Not covered: All charges.
Chelation therapy except for acute arsenic, gold, mercury or lead poisoning
Naturopathic services and medicines
Homeopathic services and medicines

(Note: Services of certain alternative treatment providers may be covered in
medically underserved areas; see Section 3, Covered providers)

Educational classes and programs
Coverage is limited to:
Smoking Cessation Office visits, individual and group counseling and purchase of over-the-counter smoking cessation drugs and supplies up

to a maximum payable of $100 for one program per person per calendar year.

Note: Prescription drugs are covered only under the Prescription drug benefit not subject to the $100 limitation (see Section 5( f)).
Note: Over-the-counter smoking cessation drugs and supplies you receive in conjunction with a smoking cessation program cannot be purchased with
your drug card. You must file a claim for them.

For non-precertified home health care: Nothing (No deductible) up to $40 per visit
up to 40 visits per calendar year; All charges above $40 per visit and/ or 40 visits per
calendar year and all charges above one visit per day

Nothing (No deductible) up to $12 per hour; All charges after $12 per hour and all
charges after 500 hours per calendar year

PPO, Non-PPO, Out-of-Network and Overseas Providers: Nothing up to the Plan
maximum of $20 per visit and all charges above $20 per visit and/ or 30 visits per
person per calendar year

PPO, Non-PPO, Out-of-Network, and Overseas Providers: Nothing up to $100 and
all charges after $100 28.
28 Page 29 30
2003 Foreign Service Benefit Plan 27 Section 5( b)
Here are some important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year deductible does not apply to any benefits in this Section. We added "( No deductible)" to
show that 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 and reside in a Network area or when you reside overseas. When no

read Section 9 about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e. hospital, surgical center, etc.).

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Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals

Surgical procedures continued on next page
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible does not apply to benefits in this Section. We say "( No deductible)" when it does not apply.
Surgical procedures
A comprehensive range of services, such as: Operative procedures

Treatment of fractures, including casting Normal post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Surgical treatment of morbid obesity a condition in which an individual: 1) is the greater of 100 pounds or 100% over his or her normal weight (in
accordance with the Plan's underwriting standards) with complicating conditions; and 2) has been so for at least five years, despite documented
unsuccessful attempts to reduce under a doctor-monitored diet and exercise program. Eligible members must be age 18 and older.
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization (e. g. Tubal ligation, Vasectomy) Surgical implantation of Norplant (a contraceptive) and intrauterine devices
(IUDs) Treatment of burns
Amniocentesis Routine circumcision of a newborn child (only when the child is covered
under a Self and Family enrollment)
Note: Office surgery and office visits on the day of surgery and up to 90 days following surgery are covered under Section 5( b) of the brochure.

Note: Second opinion is covered under Section 5( a) Diagnostic and treatment services. 29.
29 Page 30 31
Surgical procedures (continued) You pay
Assistant Surgeon (inpatient/ outpatient)

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, we pay:
For the primary procedure:
PPO: 90% of the Plan allowance
Non-PPO: 70% of the Plan allowance
Out-of-Network: 90% of the Plan allowance

For the secondary procedure( s):
PPO: 90% of 50% of the Plan allowance
Non-PPO: 70% of 50% of the Plan allowance
Out-of-Network: 90% of 50% of the Plan allowance.

Note: For certain surgical procedures, we may apply a value of less than 50% for subsequent procedures.

Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary surgery. That is, the procedure
would not add time or complexity to patient care. We do not pay extra for incidental procedures.

Not covered: All charges.
Cosmetic surgery except for the repair of accidental injuries sustained
while covered under the FEHB Program; to correct a congenital anomaly;
or for the reconstruction of a breast following a mastectomy

Note: We define cosmetic surgery as any operative procedure or any
portion of a procedure performed primarily to improve physical
appearance and/ or treat a mental condition through change in bodily form.

All refractive surgeries
Routine surgical treatment of conditions of the foot (see Section 5( a)
Foot care)

Services of a standby surgeon
Reversal of voluntary sterilization
Surgeries related to impotency, sex transformation, sexual dysfunction or sexual inadequacy

2003 Foreign Service Benefit Plan 28 Section 5( b)

PPO: 20% of the Plan allowance (based on 20% of the Plan allowance allocated to the
surgery charge) (No deductible)
Non-PPO and Out-of-Network Area: 20% of the Plan allowance (based on 20% of the Plan

allowance allocated to the surgery charge) and any difference between our allowance
and the billed amount (No deductible)
Overseas Providers: 20% of the Plan allowance (based on 20% of the Plan

allowance allocated to the surgery charge) (No deductible) when you reside overseas

PPO: 10% of the Plan allowance for the primary procedure and 10% of 50% of the
Plan allowance for the secondary procedure( s) (No deductible)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of 50% of the
Plan allowance for the secondary procedure( s); and any difference between our
allowance and the billed amount (No deductible)

Out-of-Network Area: 10% of the Plan allowance for the primary procedure and
10% of 50% of the Plan allowance for the secondary procedure( s); and any difference
between our allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance for the primary procedure and
10% of 50% of the Plan allowance for the secondary procedure( s) (No deductible) when
you reside overseas 30.
30 Page 31 32
2003 Foreign Service Benefit Plan 29 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm (Congenital anomaly).

Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers and toes and other conditions
that we may determine to be congenital anomalies. We will not consider the term congenital anomaly to include conditions relating to teeth or
intra-oral structures supporting the teeth.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
surgical treatment of any physical complications, such as lymphedemas;
breast prostheses; and surgical bras and replacements (see Section 5( a) Orthopedic and prosthetic devices for coverage)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Not covered: All charges.
Cosmetic surgery except for the repair of accidental injuries sustained while
covered under the FEHB Program; to correct a congenital anomaly; or for the reconstruction of a breast following a mastectomy

Note: We define cosmetic surgery as any operative procedure or any
portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through change in bodily form.

Surgeries related to impotency, sex transformation, sexual dysfunction or sexual inadequacy

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional malocclusion (when we determine the correction of the malocclusion to be

medically necessary)
Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of non-dentigerous cysts and incision of non-dentigerous abscesses
Surgical correction of temporomandibular joint (TMJ) dysfunction
Surgical removal of impacted teeth, including anesthesia charges
Other surgical procedures that do not involve the teeth or their supporting structures

Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingival and alveolar bone) except as provided under Dental benefits (see Section 5( h))

Pre-and post-operative medical examinations
Excision of non-impacted teeth

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas 31.
31 Page 32 33
Organ/ tissue transplants You pay
Limited to the following transplants:
Cornea Heart
Kidney Liver
Pancreas Heart/ lung
Lung: Single only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, or emphysema;

Double only for patients with cystic fibrosis
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and

pancreas for irreversible intestinal failure
Bone marrow and stem cell support as follows:
Allogeneic bone marrow transplants only for patients with acute leukemia, advanced Hodgkin's disease

Autologous bone marrow transplants (autologous stem cell support) and autologous peripheral stem cell support for
1) Acute lymphocytic or non-lymphocytic leukemia; 2) Advanced Hodgkin's and non-Hodgkin's lymphoma;
3) Advanced neuroblastoma; 4) Testicular, mediastinal, retroperitoneal and ovarian germ cell tumors;
5) Breast cancer; 6) Multiple myeloma; and
7) Epithelial ovarian cancer
Note: We cover related medical and hospital expenses of the donor when we cover the recipient. You are a recipient when you surgically receive a

body organ( s) transplant. You are a donor when you surgically donate a body organ( s) for transplant surgery. Transplant surgery means transfer of a
body organ( s) from the donor to the recipient.
Note: Mutual of Omaha has special arrangements with facilities to provide services for tissue and organ transplants its Medical Specialty Network. The

network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplant patients. Your physician
can coordinate arrangements by calling a case manager in Mutual of Omaha's Medical Management Department at 1-800/ 593-2354. For additional
information regarding the transplant network, please call this number.
Not covered: All charges.
Donor screening tests and donor search expenses, except those performed for the actual donor

Services or supplies for, or related to, surgical transplant procedures for
artificial or human organ transplants not listed as covered

Transplants not listed as covered

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Note: Anesthesia rendered by a dentist only in relation to covered oral and maxillofacial surgery is also covered (see Oral and maxillofacial surgery,

this Section).

2003 Foreign Service Benefit Plan 30 Section 5( b)

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas 32.
32 Page 33 34
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.

In this Section, unlike the other subsections in Section 5, the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible
applies)". The calendar year deductible is: $300 per person ($ 600 per family).
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area or when you reside overseas. When no

read Section 9 about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e. hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the

professional charge (i. e. physicians, etc.) are in Sections 5( a), (b), (d) or (e).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information

shown in Section 3 for additional details on precertification.
YOU MUST ALSO GET PRECERTIFICATION OF CARE YOU RECEIVE IN SKILLED NURSING FACILITIES and HOSPICE and also HOME HEALTH CARE.

Please refer to this section (Skilled Nursing Facilities and Hospice) and Section 5( a) (Home Health Care) for details on how your benefits are affected if you do not precertify. Also,
please refer to the precertification information shown in Section 3 for additional details on precertification.

2003 Foreign Service Benefit Plan 31 Section 5( c)

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Section 5 (c). Services provided by a hospital or other facility, and ambulance services

Inpatient hospital continued on next page
Benefit Description You pay
NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital's average charge for

semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average semiprivate rate of the most comparable
hospital in the area.

PPO: Nothing
Non-PPO: $200 copayment per hospital stay and 20% of charges.

Out-of-Network Area: $200 copayment per hospital stay
Overseas Providers: Nothing when you reside overseas 33.
33 Page 34 35
Inpatient hospital (continued) You pay
Other services and supplies you receive while in a hospital, such as: See previous page.
Use of operating, recovery, maternity and other treatment rooms
Prescribed drugs and medicines for use in the hospital
X-ray, laboratory and pathology services and machine diagnostic tests
Blood or blood plasma, if not donated or replaced, and its administration
Dressings, splints, casts and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home (Note: We

cover these items only under Section 5( a) and the calendar year deductible and coinsurance apply.)

Special Overseas Benefit Inpatient private duty nursing services by an R. N. or L. P. N. when the services are rendered outside of North America

Note: We provide specified benefits for professional services of a doctor, even when billed by the hospital. For example, when the hospital bills for
such professional services as surgery, anesthesiology, medical or therapy services, etc., we pay the specific surgery, anesthesia, medical or therapy
benefit.
Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the

health of the patient, even though we may not cover the services of dentists or doctors in connection with the dental treatment.

Not covered: All charges.
Admission to nursing homes, rest homes, places for the aged, convalescent homes, or any place that is not a hospital, skilled nursing

care facility, or hospice (see Section 3, Covered providers and Covered facilities)

Custodial care (see definition Section 10)
Any part of a hospital admission that is not medically necessary (see definition Section 10), such as when you do not need acute hospital

inpatient (overnight) care, but could receive care in some other setting
without adversely affecting your condition or the quality of your medical care

Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital physician care at the level we would have covered if provided in an alternative setting.

Inpatient private duty nursing except as provided above
Personal comfort items such as radio, television, beauty and barber services, identification tags, baby beads, footprints, guest cots and meals,

newspapers and similar items
Inpatient hospital services and supplies for surgery that we do not cover except as noted above for non-covered dental procedures

2003 Foreign Service Benefit Plan 32 Section 5( c) 34.
34