Pages 1--80

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

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

Sponsored and administered by: The Association
Who may enroll in this Plan: Members of the Association
Annuitants (retirees) who are members of the Association may enroll in this Plan.

Enrollment codes for this Plan:
421-Self Only
422-Self andFamily

A PLAN FOR THE FUTURE
Association Benefit Plan 2003

Mutual of Omaha Insurance Company, the underwriter for Association 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. 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.

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

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 per-mission
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. 3.
3 Page 4 5
Amend any of your personal medical information created by OPM if you believe that it is wrong or if infor-mation
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. Bo x 7 0 7
Washington, DC 20004-0707

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your
personal medical information is used and given out. If OPM makes any changes, you will get a new notice by
mail within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
2003 Association Benefit Plan 2 Table of Contents
Table of Contents
Introduction..................................................................................... 4
Plain Language.................................................................................. 4
StopHealthCareFraud!........................................................................... 4
Section1. Factsabout thisfee-for-serviceplan......................................................... 6
Section2. Howwechangefor2003.................................................................. 7
Section3. Howyouget care........................................................................ 8
Identificationcard...................................................................... 8
Where youget coveredcare .............................................................. 8
Covered providers ................................................................... 8
Covered facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Whatyou must do togetcoveredcare...................................................... 10
How toGetApproval for.............................................................. 11
Your hospital stay( precertification)..................................................... 11
Otherservices ..................................................................... 13
Section4. Your costsforcoveredservices............................................................ 14
Copayments ....................................................................... 14
Deductible ........................................................................ 14
Coinsurance ....................................................................... 14
Differencesbetweenourallowance andthebill ........................................... 14
Yourcatastrophic protection out-of-pocketmaximum ......................................... 16
When government facilities bill us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Ifweoverpayyou..................................................................... 16
When you are age 65 or over and you do not haveMedicare.................................... 17
WhenyouhaveMedicare............................................................... 18
Section5. Benefits .............................................................................. 19
Overview............................................................................ 19
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . 20
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . 31
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . 36
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
(e) Mental healthandsubstanceabusebenefits............................................... 42
(f) Prescriptiondrug benefits............................................................. 47
(g) Specialfeatures .................................................................... 50
Flexible benefitsoption............................................................. 50
Healthymaternityprogram.......................................................... 50 5.
5 Page 6 7
2003 Association Benefit Plan 3 Table of Contents
Centersofexcellence .............................................................. 50
Serviceoverseas .................................................................. 50
Healthydirections sm ................................................................ 50
Glucosemonitors.................................................................. 50
Lifestyleprescription medications .................................................... 51
(h) Dental benefits .................................................................... 52
(i) Non-FEHBbenefitsavailable to Plan members ........................................... 53
Section6. Generalexclusions thingswe don'tcover.................................................. 55
Section7. Filingaclaimforcovered services......................................................... 56
Section8. Thedisputedclaimsprocess.............................................................. 58
Section9. Coordinatingbenefitswithother coverage................................................... 60
When youhaveotherhealthcoverage................................................... 60
What isMedicare? ................................................................. 60
Medicare managedcare plan.......................................................... 63
TRICAREandCHAMPVA........................................................... 63
Worker'sCompensation ............................................................. 64
Medicaid.......................................................................... 64
When otherGovernmentagenciesare responsiblefor yourcare .............................. 64
When othersareresponsible forinjuries................................................. 64
Section10. Definitionsoftermsweuse in thisbrochure ................................................ 65
Section11. FEHBfacts.......................................................................... 69
Coverageinformation.................................................................. 69
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Where you get information about enrolling in the FEHB Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Typesofcoverageavailableforyouandyour family....................................... 69
Children'sEquityAct ............................................................... 70
When benefitsandpremiumsstart...................................................... 70
When youretire.................................................................... 71
Whenyoulose benefits................................................................. 71
When FEHBcoverageends........................................................... 71
Spouse equitycoverage.............................................................. 71
Temporary Continuation of Coverage( TCC)............................................. 71
Convertingtoindividual coverage...................................................... 72
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Longtermcareinsuranceisstill available............................................................ 73
INDEX....................................................................................... 74
Summary of benefits ............................................................................ 75
Rates.................................................................................. BackCover 6.
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2003 Association Benefit Plan 4
Introduction
This brochure describes the benefits of the Association Benefit Plan under the Government Employees Health Associa-tion's
contract (CS 1065) with the Office of Personnel Management (OPM), as authorized by the Federal Employees
Health Benefits law. This Plan is underwritten by Mutual of Omaha Insurance Company. The address for the Association
Benefit Plan administrative office is:

Association Benefit Plan
PO Box 668587
Charlotte, NC 28266-8587).

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limita-tions,
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 are sum-marized
on page 75. 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 Association 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 physician, 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
toget it paid.

Introduction/ Plain Language 7.
7 Page 8 9
2003 Association Benefit Plan 5
Stop Health Care Fraud! (continued)
Carefully review explanations of benefits (EOBs) that you receive from us.

Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service,
or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-634-0069 and explain the situation.
Ifwe donotresolve theissue:

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

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB
benefits, or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in
the Plan. 8.
8 Page 9 10
2003 Association Benefit Plan 6 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.
We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The
type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We also have a Preferred Provider Organization (PPO):
Our fee-for-service plan offers services through a PPO. When you reside in the PPO network area and use our PPO
providers, you will receive covered services at reduced cost. Contact us at 1-800-634-0069 for information con-cerning
your PPO. You can also go to the Mutual of Omaha website, www. mutualofomaha. com, for PPO informa-tion.
Also, when you phone for an appointment, please verify that your physician is still a PPO provider. Contact
the Association Benefit Plan to request a PPO directory.

PPO benefits apply only when you reside in the PPO network area and use a PPO provider. You must present your
PPO identification (ID) card confirming your PPO participation to be eligible for PPO benefits. Provider networks
may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If
no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply. When you use a
PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emer-gency
room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will
be paid as non-PPO providers.

The PPO Network Area consists of Washington, D. C. and selected cities and counties in all states with the exception of
Hawaii, Vermont and Wyoming.

If you reside in the PPO network area and no PPO provider is available, or if you do not use a PPO provider, non-PPO
benefits apply.

If you reside outside the PPO network area, Out-of-network benefits apply.
How we pay providers
Our participating providers are generally reimbursed according to an agreed-upon fee schedule and are not offered addi-tional
financial incentives based on care provided or not provided to you. Our standard provider agreements do not con-tain
any contractual provisions that include incentives to restrict a provider's ability to communicate with and advise
patients of any appropriate treatment options. In addition, the Plan has no compensation, ownership, or other influential
interests that are likely to affect provider advice or treatment decisions.

We may, through a negotiated agreement with some non-PPO health care providers, apply a discount to covered services
that you receive from these providers.

To locate a non-PPO provider from whom a discount may be available, call the number on your identification card.
Your Ri ght s
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about
us, our networks, providers, and facilities by calling 1-800-634-0069, or writing to Association Benefit Plan, PO Box
668587, Charlotte, NC 28266-8587. 9.
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2003 Association 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

We expanded our optional hospital and physical preferred Provider Organization (PPO) to include selected counties
and cities in the following states: Idaho, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Montana,
Nebraska, New Hampshire, North Dakota, Oklahoma, Rhode Island, South Dakota and Wisconsin. (Section 1)

We added Audiologists and Licensed Acupuncturists to our list of covered providers. (Section 3)
We expanded our adult preventative care benefit to include one routine colonoscopy every 10 years for members age
50 and over. We also expanded our benefits to include one routine annual chlamydial screening and one routine non-fasting
blood cholesterol test every three consecutive calendar years. (Section 5( a))

PPO routine well child care coinsurance will change to a $10 copayment, not subject to the deductible. (Section 5( a))
PPO copayments for diagnostic and treatment services performed in a physician's office will change to a 10% coin-surance,
subject to the calendar year deductible. (Section 5( a))

Outpatient surgical facility charges, services and supplies will change to 90% coinsurance for PPO providers, 75% coinsur-ance
for Non-PPO providers, and 85% coinsurance for Out-of-Network providers, subject to the deductible. (Section 5( c))

Outpatient maternity care benefits will be considered the same as inpatient maternity care benefits. (Section 5( a))
Non-PPO coinsurance for physicians, diagnostic tests, and surgical services will change to 30%. (Sections 5( a) and (b))
Non-PPO coinsurance for outpatient nonsurgical facility charges, services, and supplies will increase to 30%, subject
to the deductible. (Section 5( c))

Non-PPO coinsurance for the remaining hospital charges, after your Non-PPO $200 inpatient deductible is met, will
change to 30%. (Section 5( c))

Your mail order generic prescription drug copayment will change to $20. (Section 5( f))
Your mail order formulary prescription drug copayment will change to $40. (Section 5( f))
Retail pharmacy and mail order prescription drug non-formulary brand name drugs will be paid at 30% of the cost of
the drug or the current copayment rate, whichever is greater. (Section 5( f))

Compound prescription drugs are covered under our nonformulary prescription drug benefit. (Section 5( f))
Your catastrophic protection out-of-pocket maximum for PPO and Out-of-Network providers will change to $3, 000,
and to $7,000 for Non-PPO providers. (Section 4)

Your share of the premiums will increase by 15. 4% for Self Only and 15.3% for Self and Family. 10.
10 Page 11 12
2003 Association Benefit Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card and a Prescription Drug Card when you enroll. You should carry both cards with you at all times. You
must show your ID card whenever you receive services from a medical or
dental provider, or your Prescription Drug Card to fill a prescription at a
participating Plan pharmacy. Until you receive your ID card, use your copy
of the Health Benefits Election Form, SF-2809, or your health benefits
enrollment confirmation (for annuitants).

If you do not receive your cards within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-634-0069.

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 network area and use our pre-ferred
providers, you will pay less.

Covered providers We consider the following to be covered providers when they perform ser-vices within the scope of their license or certification:

Physician: Doctors of medicine or psychiatry (M. D.), osteopathy
(D. O.), dental surgery (D. D. S.), medical dentistry (D. M. D.), podiatric
medicine (D. P. M.), and optometry (O. D.) when acting within the scope
of their licenses or certification.

Qualified Clinical Psychologist: An individual who has earned either a
Doctoral or Masters Clinical Degree in psychology or an allied disci-pline
and who is licensed or certified in the state where services are per-formed.
This presumes a licensed individual has demonstrated to the
satisfaction of state licensing officials that he/ she, by virtue of academic
and clinical experience, is qualified to provide psychological services in
that state.

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 Master's 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.

Physician Assistant: A person who is licensed, registered, or certified
in the state where services are performed. 11.
11 Page 12 13
2003 Association Benefit Plan 9 Section 3
Section 3. How you get care (continued)
Licensed Professional Counselor or Master's Level Counselor: A
person who is licensed, registered, or certified in the state where ser-vices
are performed.

Audiologist: A person who is licensed, registered, or certified in the
state where services are performed.

Licensed Acupuncturist (L. A. C.): A person who has completed the
required schooling and licensure to perform acupuncture in the state
where services are performed (see definition of acupuncture benefits,
Section 5( a)).

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 for by these clinics are considered outpatient
'office' services rather than facility charges.

Christian Science Practitioner: If you choose to visit a Christian Sci-ence
practitioner instead of a physician, the charges are still considered
allowable expenses. To qualify for benefits, you must make this choice
annually. The benefits will then apply to all subsequent expenses
incurred during the year. You can change your mind only at the time of
your first claim each year. The practitioner you choose must be listed as
such in the Christian Science Journal that is current at the time the ser-vice
is provided. Your choice will not apply to, or prevent payment of, a
physician's maternity charges.

Medically underserved areas. We cover any licensed medical practitio-ner,
including chiropractors, for any covered service performed within the
scope of that license in states OPM determines are "medically under-served."
For 2003, the states are: Alabama, Idaho, Kentucky, Lousiana,
Maine, Mississippi, Missouri, Montana, New Mexico, North Dakota,
South Carolina, South Dakota, Texas, Utah, West Virginia, and Wyoming.

Covered facilities Covered facilities include:
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
service, and that is primarily engaged in providing: 12.
12 Page 13 14
2003 Association Benefit Plan 10 Section 3
Section 3. How you get care (continued)
a) General patient 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 freestanding 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 that
provides convalescent skilled nursing care 24 hours a day and is
classified as a skilled nursing facility under Medicare.

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: A facility that meets all of the following:
1) primarily provides inpatient hospice care to terminally ill persons;
2) is certified by Medicare as such, or is licensed or accredited as
such by the jurisdiction it is in;

3) is supervised by a staff of M. D. s or D. O. s, at least one of whom
mustbeoncall at alltimes;

4) provides 24-hour-a-day nursing services under the direction of an
R. N. and has a full-time administrator; and

5) provides an ongoing quality assurance program.

What you must do to
get covered care
It depends on the kind of care you want to receive. You can go to any
provider you want, but we must approve some care in advance. 13.
13 Page 14 15
2003 Association Benefit Plan 11 Section 3
Section 3. How you get care (continued)
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 until the end of your postpartum care, even if it is
beyond the 90 days.

Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan
begins, call our customer service department immediately at
1-800-634-0069.

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

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or
The92 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 hospital admis-sion
we evaluate the medical necessity of your proposed stay and the
number of days required to treat your condition. Unless we are misled
by the information given to us, we will not change our decision on med-ical
necessity.

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

Warni ng 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. 14.
14 Page 15 16
2003 Association Benefit Plan 12 Section 3
Section 3. How you get care (continued)
How to precertify an
admission
You, your representative, your physician, or your hospital must call us
before the admission or care. The toll-free number is 1-800-634-0069.

Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting physician;
Name of hospital or facility; and
Number of planned days of hospital stay.

We will then tell your 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.

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

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

If your hospital stay needs to
be extended
If your hospital stay including for maternity care needs to be extended,
you, your representative, your physician or the hospital must ask us to
approve the additional days.

What happens when you
do not follow the
precertification rules

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

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

If we determine that it was not medically necessary for you to be an
inpatient, we will not pay inpatient hospital benefits. We will only
pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis. 15.
15 Page 16 17
2003 Association Benefit Plan 13 Section 3
Section 3. How you get care (continued)
If no one contacted us for specified services such as Hospice Care,
Skilled Nursing Facility Care, Home Health Care, we will disqualify
higher paid benefits.

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

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

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

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

Exceptions You do not need precertification in these cases:
You are admitted to a hospital outside the United States.

You have another group health insurance policy that is the primary
payer for the hospital stay.

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

Other services Some other services require precertification or prior authorization, such as:
Home health care (See Section 5( a))
Hospice care (See Section 5( c))
Skilled nursing facilities (See Section 5( c))
Psychiatric and substance abuse treatment (See Section 5( e))
Some prescription drugs (See Section 5( f)) 16.
16 Page 17 18
2003 Association Benefit Plan 14 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. You will only be responsible for
one copayment per day per provider.
Example: When you see your PPO physician you pay a copayment of $10
per day, and when you go in a PPO hospital, you pay a copayment of $100
per hospital stay.

Deductible A deductible is a fixed amount of covered expenses you must incur for cer-tain covered services and supplies before we start paying benefits for them.

Copayments do not count toward any deductible.
The calendar year deductible is $300 per person. Under a family enroll-ment,
the deductible is satisfied for all family members when the com-bined
covered expenses applied to the calendar year deductible for
family members reach $600.

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

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

Example: You pay 10% coinsurance of our allowance for an X-ray.
Note: If your provider routinely waives (does not require you to pay) your
copayments, deductibles, or coinsurance, the provider is misstating the fee
and may be violating the law. In this case, when we calculate our share, we
will reduce the provider's fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but
routinely waives your 10% coinsurance, the actual charge is $90. We will
pay $81 (90% of the actual charge of $90).

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

different ways, so their allowances vary. For more information about how
we determine our Plan allowance, see the definition of Plan allowance in
Section 10.

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

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.

PPO providers agree to limit what they will bill you. Because of that,
when you use a preferred provider, your share of covered charges
consists only of your deductible and coinsurance or copayment. Here is
an example about coinsurance: You see a PPO physician who charges
$350, but our allowance is $300. If you have met your deductible, you 17.
17 Page 18 19
2003 Association Benefit Plan 15 Section 4
are only responsible for your coinsurance. That is, you pay just 10% of
our $300 allowance ($ 30). Because of the agreement, your PPO physi-cian
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 facil-ity
is still a PPO provider and;

Present your PPO ID card confirming your PPO participation in order to
receive PPO benefits.

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 $350 and our
allowance is again $300. Because you've met your deductible, you
are responsible for your coinsurance, so you pay 30% of our $300
allowance ($ 90). 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 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 coinsur-ance.
You will pay 15% of our allowance ($ 45) and the physician
can bill you for the $50 difference between our allowance and his
bill.

The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician
when you reside in the PPO network area. The table uses our example of a
service for which the physician charges $350 and our allowance is $300.
The table shows the amount you pay if you have met your calendar year
deductible.

EXAMPLE PPO physician Non-PPO physician
Physician's charge $350 $350
Our allowance We set it at: $300 We set it at: $300
We pay 90% of our allowance: $270 70% of our allowance: $210
You owe:
Coinsurance
10% of our allowance: $30 30% of our allowance: $90

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

TOTAL YOU PAY $30 $140 18.
18 Page 19 20
2003 Association Benefit Plan 16 Section 4
Your catastrophic protection
out-of-pocket maximum
for deductibles, coinsurance,
and copayments

For those benefits where coinsurance or deductibles apply, we pay 100% of
the Plan allowance for the rest of the calendar year after your expenses total:

PPO providers: $3, 000 For you or any covered family member;

Non-PPO providers: $7, 000 For you or any covered family member;
Out-of-network providers: $3, 000 For you or any covered family
member.

Out-of-pocket expenses are:
Your $300/$ 600 calendar year deductible;

The percentage you pay for covered services after you have met your
deductibles;

The percentage you pay for surgery, anesthesia and extended medical
care after an accidental injury; and

Your copayment for hospital stays.
The following cannot be included in your out-of-pocket expenses:
Expenses in excess of the Plan allowance or maximum benefit
limitations;

Non-covered services and supplies;
Prescription drug copayments;
Copayments, except for hospital admission copayments;
Expenses for dental care including the 20% you pay for dental care after
an accidental injury; or

Any amounts you pay if benefits have been reduced because of
noncompliance with our precertification, prior authorization or prior
approval requirements.

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

If we overpay you We will make diligent efforts to recover benefit payments we made in error, but in good faith. If your claim has been paid in error for any reason,
we shall make a diligent effort to recover an overpayment to you from you.
If the overpayment was made to a provider, we shall make a diligent effort
to recover the overpayment from the provider. We may also reduce subse-quent
benefit payments to you or to a provider to offset overpayments
made in error. 19.
19 Page 20 21
2003 Association Benefit Plan 17 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; 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
Medicare assignment for the claim and
is a member of our PPO network,

your deductibles, coinsurance, copayments; and
any balance up to the Medicare approved amount;

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

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

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

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If
you have paid more than allowed, ask for a refund. If you need further assistance, call us. 20.
20 Page 21 22
2003 Association Benefit Plan 18 Section 4
When you the have the Original
Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that
Medicare would pay under Medicare A (Hospital insurance) and Medicare
B (Medical insurance), regardless of whether Medicare pays. Note: We pay
our regular benefits for emergency services to an institutional provider,
such as a hospital, that does not participate with Medicare and is not reim-bursed
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) form
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 physi-cian
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. 21.
21 Page 22 23
2003 Association Benefit Plan 19 Section 5
Section 5. Benefits OVERVIEW (See page 7 for how our benefits changed this year and page 75 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
1-800-634-0069.

(a) Medical services and supplies provided by physicians and other health care professionals .................................. 20-30

(b) Surgical and anesthesia services provided by physicians and other health care professionals............................... 31-35
(c) Services provided by a hospital or other facility, and ambulance services............................................................. 36-39

(d) Emergency services/ Accidents................................................................................................................................ 40-41
(e) Mental health and substance abuse benefits ........................................................................................................... 42-46
(f) Prescription drug benefits ....................................................................................................................................... 47-49
(g) Special features ....................................................................................................................................................... 50-51

(h) Dental benefits ........................................................................................................................................................ 52
(i) Non-FEHB benefits available to Plan members ..................................................................................................... 53-54
SUMMARY OF BENEFITS.......................................................................................................................................... 75-76

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical, occupational, and speech therapies
Hearing services (testing, treatment, and
supplies)

Vision services (testing, treatment, and
supplies)

Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

Inpatient hospital
Outpatient hospital or ambulatory surgical
center

Skilled nursing care facility

Hospice care
Ambulance

Accidental injury
Medical emergency
Ambulance

Flexible benefits option
Services overseas
Healthydirections sm

Centers of excellence
Glucose monitors
Lifestyle prescription medications 22.
22 Page 23 24
2003 Association Benefit Plan 20 Section 5 (a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I
M
P
O
R
T
A
N
T

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

The calendar year deductible is: $300 per person ($ 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.

PPO benefits apply only when you reside in the PPO network area and use a PPO pro-vider.
When no PPO provider is available, non-PPO benefits apply. Out-of-network
benefits apply when you reside outside the PPO network area.

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

Benefit Description You pa y After the calendar year deductible
NOTE: 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.

Diagnostic and treatment services

Professional services of physicians (not including surgery)
In physician's office

1) office visits
2) consultations (to include second surgical opinion)
3) injections (excluding specialty pharmacy drugs and
medicines)

Note: Drugs provided by the physician are covered under Section 5( f).
Note: Supplies provided by the physician are covered under Section
5( a).

PPO: $10 copayment (No Deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Professional services of physicians (not including surgery)
In a hospital
In an urgent care center
In a skilled nursing facility
Athome

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: 15% of the Plan allowance
and any difference between our allowance and
the billed amount 23.
23 Page 24 25
2003 Association Benefit Plan 21 Section 5 (a)
Lab, X-ray and other diagnostic tests You pa y
Tests, such as:
Blood tests

Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Sonograms

PPO: 10% of the Plan allowance
Note: If your PPO provider uses a non-PPO
lab or radiologist, we will pay non-PPO bene-fits
for any lab or X-ray charges

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

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Preventive care, adult
One annual routine physical examination per person to include a
history and physical, chest X-ray, urinalysis, blood tests, and EKG
(electrocardiogram).

One annual cervical cancer screening (pap smear) for women age
18 and older. Note: if you see another physician for your pap
smear, the office visit will be covered.

One annual Prostate Specific Antigen (PSA) test (prostate cancer
screening) for men age 40 and older.

One annual fecal occult blood test (colorectal cancer screening) for
members age 40 and older.

One routine sigmoidoscopy every five years starting at age 50.
One routine colonoscopy every ten years starting at age 50.
One annual routine mammogram (breast cancer screening) for
women age 35 and older.

One non-fasting blood cholesterol test every three consecutive
calendar years

Chlamydial screening
Note: Your physician's bill must clearly state "Routine Physical
Exam." If a medical diagnosis is provided on the bill, those services
will be paid under the medical benefit.

PPO: Services in physician's office$ 10
copayment (No Deductible)

PPO: Services outside physician's office
Nothing (No Deductible)

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

Out-of-Network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount (No Deductible) 24.
24 Page 25 26
2003 Association Benefit Plan 22 Section 5 (a)
Preventative care, adult -Continued You Pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

Pneumococcal vaccine, annually, age 65 and over
Influenza vaccine, annually

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Preventive care, children
Childhood immunizations recommended by the American
Academy of Pediatrics (to age 22)
PPO: Nothing (No Deductible)

Non-PPO: Only the difference between the
Plan allowance and the billed amount (No
Deductible)

Out-of-network: Only the difference between
the Plan allowance and the billed amount (No
Deductible)

Well-child care charges for routine examinations and care
(to age 2):

One annual routine examination (over age 2):

PPO: $10 copayment (No Deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount.

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Maternity care
Complete maternity (obstetrical) care such as:
Prenatal care
Amniocentesis
Delivery
Initial, routine examination of your newborn infant covered under
your family enrollment

Circumcision of your newborn infant
Postnatal care
One routine sonogram

PPO: 10% of the Plan allowance (No Deduct-
ible)

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

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount (No Deductible)

Note: Here are some things to keep in mind:
You do not have to precertify your normal delivery; see page 9 for
other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will cover an
extended stay, if medically necessary, but you, your representative,
your physician or your hospital must precertify. 25.
25 Page 26 27
2003 Association Benefit Plan 23 Section 5 (a)
Maternity care (Continued) You Pa y
We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment if we cover
the infant under a Self and Family enrollment.

If your baby stays in the hospital after your discharge and is
covered under your Self and Family enrollment, you must pay a
separate hospital stay copayment. See Section 5( c).

Bassinet or nursery charges on which you and your baby are
confined are considered your maternity expenses, not your baby's.

Sonograms and other related tests that are not included in your
routine prenatal or postnatal care are covered in Lab, X-ray, and
other diagnostic tests, page 21.

Not covered:

Routine sonograms to determine fetal age, size or sex; or 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.

All charges

Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Section 5( b) for surgical procedures)
Surgically implanted contraceptives (such as Norplant)
Fitting, inserting or removing intrauterine devices (such as
diaphragms IUDs)

PPO: 10% of the Plan allowance (No Deduct-ible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount (No Deductible)

Injection of contraceptive drugs (such as Depo-Provera)

Note: We cover FDA-approved prescription drugs and devices for
birth control in Section 5( f).

PPO: $10 copay (No Deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount.

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Not covered: reversal of voluntary surgical sterilization,
genetic counseling. All charges 26.
26 Page 27 28
2003 Association Benefit Plan 24 Section 5 (a)
Infertility services You Pa y
Diagnosis and treatment of infertility except as shown in Not covered.
Initial diagnostic tests and procedures done only to identify the
cause of infertility

Fertility drugs, hormone therapy and related services
Medical or surgical procedures done to create or enhance fertility
Note: We will pay up to $5, 000 per person per lifetime for covered
infertility services, including prescription drugs.

PPO: 10% of the Plan allowance and charges
in excess of the $5, 000 maximum

Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount and charges in excess of the
$5, 000 maximum

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount and charges in excess of the
$5, 000 maximum

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

All charges

Allergy care
Allergy testing, injections and treatment

Note: We cover allergy serum in Section 5( f).
PPO services in physician's office:$ 10
copayment (No Deductible)

PPOservices outside physician's office: 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: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:
RAST tests
Foodtests
End Point titration techniques
Sublingual allergy desensitation
Hairanalysis

All charges 27.
27 Page 28 29
2003 Association Benefit Plan 25 Section 5 (a)
Treatment therapies You Pa y
Chemotherapy and radiation therapy (High dose chemotherapy in
association with autologous bone marrow transplants is limited to
those transplants listed in Section 5( b), Organ/ tissue transplants.)

Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic
therapy

Respiratory and inhalation therapies
Growth hormone therapy (GHT) (We only cover GHT when you
obtain prior approval. Call 1-800-634-0069 for preauthorization. We
will ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment; otherwise, we will only cover GHT services from the
date you submit the information. If you do not ask or if we deter-mine
GHT is not medically necessary, we will not cover the GHT or
related services and supplies. See services requiring our prior
approval in Section 3.)

Note: We cover drugs administered for the therapies listed above in
Section 5( f).

PPO services in physician's office:$ 10
copayment (No Deductible)

PPO services outside physician's office:
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: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Physical, occupational, and speech therapies
90 total combined visits per calendar year for the following:
Visits for the services of each of the following:

physicians;
qualified physical therapists;
speech therapists; and
occupational therapists

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: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: We only cover therapy when a physician:
1) orders the care;

2) identifies the specific professional skills you require and the
medical necessity for skilled services; and

3) indicates the length of time you need the services.
Note: We only cover physical and occupational therapy to restore
bodily function when there has been a total or partial loss due to illness
or injury. 28.
28 Page 29 30
2003 Association Benefit Plan 26 Section 5 (a)
Physical, occupational, and speech therapies (continued) You Pa y
Not covered:
Long-term rehabilitative therapy

Exercise programs

All charges

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental
injury or intra-aural surgery.

Note: Services must be received within one year of the date of the acci-dent
or surgery.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:
Hearing aids, testing and examinations for them, except for
accidental injury or intra-aural surgery.

All charges

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses per incident to correct an
impairment directly caused by:

Accidental ocular injury or
Specifically ordered by the physician in connection with a
diagnosis of:

Cataract

Keratoconus or
Glaucoma
Note: Services must be received within one year of the date of accident
or surgery.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:
Eyeglasses or contact lenses and examinations for them, except for
accidental injury and intraocular surgery

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye refractions

All charges 29.
29 Page 30 31
2003 Association Benefit Plan 27 Section 5 (a)
Foot care You pa y
We do not provide benefits for routine foot care, such as:
Treatment or removal of corns and calluses, or trimming of toenails

Orthopedic shoes, orthotics and other supportive devices for the feet

All charges

Orthopedic and prosthetic devices
Orthopedic braces

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,
cochlear implants, and surgically implanted breast implants
following mastectomy.

Note: See Section 5( b) for coverage of the surgery to insert the device
and Section 5( c) for hospital or facility coverage.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Two wigs per lifetime, up to a maximum of $150 each, when
required due to hair loss in connection with chemotherapy or radia-tion
treatment

PPO: 10% of the Plan allowance (No Deduct-ible)

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount (No Deductible)

Not covered:
Orthopedic and corrective shoes and other supportive devices for
the feet

Arch supports
Footorthotics
Heel pads and heel cups
Corsets, trusses, elastic stockings, support hose, and other
supportive devices

Lumbosacral supports

All charges 30.
30 Page 31 32
2003 Association Benefit Plan 28 Section 5 (a)
Durable medical equipment (DME) You Pa y
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician
who is treating your illness or injury);

2. Are medically necessary;
3. Are primarily and customarily used only for a medical pur-pose;

4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an ill-ness
or injury.

We cover purchase or rental up to the purchase price, at our option,
including repair and adjustment, of durable medical equipment. Under
this benefit, we also cover:

Oxygen;
Hospital beds;
Dialysis equipment;
Respirators;
Wheelchairs, crutches, canes, walkers, casts;
Cervical collars and traction kits; and
Splints and trusses

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered: Sun or heat lamps, whirlpool baths, heating pads, air
purifiers, humidifiers, air conditioners, and exercise devices
All charges

Home health services
For services provided on a part-time basis (less than an 8-hour shift):
If precertified, 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;

The attending physician orders the care;
The physician identifies the specific professional skills required by
the patient and the medical necessity for skilled services; and

The physician indicates the length of time the services are needed.

PPO: Charges in excess of $80 per visit (No
Deductible) (90 visit maximum)

Non-PPO: Charges in excess of $80 per visit
and any difference between the Plan allow-ance
and the billed amount (No Deductible)
(90 visit maximum)

Out-of-network: Charges in excess of $80 per
visit and any difference between the Plan
allowance and the billed amount
(No Deductible) (90 visit maximum) 31.
31 Page 32 33
2003 Association Benefit Plan 29 Section 5 (a)
Home health services (continued) You pa y
If not precertified, 40 visits per calendar year up to a maximum plan
payment of $40, subject to the above provisions.
PPO: Charges in excess of $40 per visit. (No
Deductible) (40 visit maximum)

Non-PPO: Charges in excess of $40 per visit
and any difference between the Plan allow-ance
and the billed amount (No Deductible)
(40 visit maximum)

Out-of-network: Charges in excess of $40 per
visit and any difference between the Plan
allowance and the billed amount (No
Deductible) (40 visit maximum)

For private duty nursing 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.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:
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, rehabilita-tive:

Custodial care as defined in Section 10.

All charges.

Chiropractic
No benefits. All charges

Alternative treatments
Acupuncture when used as an anesthetic agent for covered surgery PPO: 10% of the Plan allowance (No Deduct-ible)

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount (No Deductible) 32.
32 Page 33 34
2003 Association Benefit Plan 30 Section 5 (a)
Alternative treatments (Continued) You Pa y
Not covered:
Chiropractic services
Chelation therapy except for acute arsenic, gold, mercury, or lead
poisoning

Naturopathic services
Homeopathic services and medicines
(Note: Benefits of certain alternative treatment providers may be
covered in medically underserved areas; see page 9.)

All charges

Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $100 maximum for one program per 12
months to include

Individual/ Group counseling and over-the-counter (OTC) drugs

PPO: 10% of the Plan allowance and all
charges in excess of the $100 maximum

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount and all charges in excess of the
$100 maximum

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount and all charges in excess of
the $100 maximum

Office visits for Smoking Cessation PPO: $10 copayment (No Deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: Prescription drugs are covered under Section 5( f). 33.
33 Page 34 35
2003 Association Benefit Plan 31 Section 5 (b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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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 exclu-sions
in this brochure and are payable only when we determine they are medically
necessary.

The calendar year deductible does not apply for these benefits; however, we added
(No Deductible) -to show that the calendar year deductible does not apply.

PPO benefits apply only when you reside in the PPO network area and use a PPO pro-vider.
When no PPO provider is available, non-PPO benefits apply. Out-of-network
benefits apply when you reside outside the PPO network area.

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

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

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

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Benefit Description You pa y
NOTE: We added -(No Deductible) -to show when the calendar year deductible does not apply

Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an
individual (1) is the greater of 100 pounds or 100% over his/ her nor-mal
weight (in accordance with our underwriting standards) with
complicating conditions; (2) has been so for at least five years with
documented unsuccessful attempts to reduce under a doctor-moni-tored
diet and exercise program and (3) is age 18 or older.

Insertion of internal prosthetic devices. See Section 5( a) for device
coverage information.

PPO: 10% of the Plan allowance (No Deduct-ible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount (No Deductible) 34.
34 Page 35 36
2003 Association Benefit Plan 32 Section 5 (b)
Surgical procedures Continued You Pa y
Voluntary sterilization (e. g., tubal ligation, vasectomy)

Surgically implanted contraceptives (such as Norplant), and intrau-terine
devices (IUDs)

Treatment of burns
Surgical treatment of bunions or spurs
Assistant surgeons -we cover up to 20% of our allowance for the
surgeon's charge

Note: For related services, see applicable benefits section (i. e., for
inpatient hospital benefits, see Section 5( c)).

PPO: 10% of the Plan allowance (No Deduct-ible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount (No Deductible)

When multiple or bilateral surgical procedures performed during the
same operative session add time or complexity to patient care, our
benefits are:

For the primary procedure:

PPO: 90% of the Plan allowance or (No Deductible)
Non-PPO: 70% of the Plan allowance or (No Deductible)
Out-of-network: 85% of the Plan allowance (No Deductible)
For the secondary procedure( s):
PPO: 90% of one-half of the Plan allowance or (No Deductible)
Non-PPO: 70% of one-half of the Plan allowance (No Deduct-ible)

Out-of-network: 85% of one-half of the Plan allowance (No
Deductible)

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.

PPO: 10% of the Plan allowance for the
primary procedure and 10% of one-half 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 one-half of
the Plan allowance for the secondary
procedure( s); and any difference between our
payment and the billed amount (No Deduct-ible)

Out-of-network: 15% of the Plan allowance
for the primary procedure and 15% of
one-half of the Plan allowance for the
secondary procedure( s); and any difference
between our payment and the billed amount
(No Deductible)

Note: For certain surgical procedures, we
may apply a value of less than 50% of subse-quent
procedures.

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

All charges 35.
35 Page 36 37
2003 Association Benefit Plan 33 Section 5 (b)
Reconstructive surgery You Pa y
Surgery to correct a functional defect

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

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

Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birthmarks; and webbed fingers and toes.

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

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

PPO: 10% of the Plan allowance (No Deduct-ible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount (No Deductible)

Note: Internal breast prostheses are covered under Section 5( a).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation or sexual dysfunction

All charges 36.
36 Page 37 38
2003 Association Benefit Plan 34 Section 5 (b)
Oral and maxillofacial surgery You Pa y
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion

Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as
independent procedures

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

20% of the Plan allowance and any difference
between the Plan allowance and the billed
amount (No Deductible)

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)

Pre-and post-operative examinations in preparation for surgical
removal of impacted teeth

All charges

Organ/ tissue transplants
Limited to the following transplants:

Lung: Single only for the following end-stage pulmonary dis-eases:
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
Autologous bone marrow transplants (autologous stem 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;

PPO: 10% of the Plan allowance (No Deduct-ible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount (No Deductible)

Cornea Heart Kidney/ Pancreas
Kidney Liver Heart/ Lung
Pancreas 37.
37 Page 38 39
2003 Association Benefit Plan 35 Section 5 (b)
Organ/ tissue transplants Continued You Pa y
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.

Note: We have special arrangements with facilities to provide services
for tissue and organ transplants our 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 us at
1-800-634-0069.

Not covered:
Donor screening tests and donor search expenses, except those per-formed
for the actual donor

Transplants not listed as covered
Implants of artificial organs

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)

Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

PPO: 10% of the Plan allowance (No Deduct-ible)
Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount (No Deductible) 38.
38 Page 39 40
2003 Association Benefit Plan 36 Section 5 (c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things 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 Sections 5( a) and 5( b), the calendar year deductible applies to only
a few benefits. We added -(No Deductible) -to show when the calendar year does not
apply.

PPO benefits apply only when you reside in the PPO network area and use a PPO pro-vider.
When no PPO provider is available, non-PPO benefits apply. Out-of-network ben-efits
apply when you reside outside the PPO network area.

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

The amounts listed below are for the charges billed by the facility (i. e. hospital or
surgical center) or ambulance service for your surgery or care. Any costs associated with
the professional charge (i. e. physicians, etc.) are in Section 5( a) or (b).

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

TO OBTAIN THE MAXIMUM BENEFITS, YOU SHOULD GET PRECERTIFI-CATION
OF CARE YOU RECEIVE IN SKILLED NURSING FACILITIES,
HOSPICE, AND ALSO HOME HEALTH CARE. Please refer to this section
(Skilled nursing facility benefits and Hospice care) andSection 5( a)( Home health
services) for details on how your benefits are affected if you do not certify. Also,
please refer to Section 3 for additional details on precertification.

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Benefit Description You pa y
NOTE: We added -(No Deductible) -to show when the calendar year deductible does not apply.

Inpatient hospital
Room and board, such as
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 pre-vent
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 com-parable
hospital in the area.

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced

PPO: $100 copayment per hospital stay (No
Deductible)

Non-PPO: $200 copayment per hospital stay
and 30% of the covered charges (No Deduct-ible)

Out-of-network: $200 per hospital stay
(No Deductible) 39.
39 Page 40 41
2003 Association Benefit Plan 37 Section 5 (c)
Inpatient hospital (Continued) You Pa y
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics

Note: Take-home drugs are covered under Section 5( f).
Note: Take-home medical supplies, appliances, medical equipment, and
any covered items billed by a hospital are covered under Section 5( a).

Pre-admission testing when testing is:
performed within 7 days before your scheduled hospital admission;
related to your covered hospital stay;
accepted by the hospital instead of tests performed during your hos-pital
stay; and

repeated only if your medical record shows the pre-admission test
results and the need for repeated tests when you are admitted.

Note: Charges for professional services of a physician when billed by
the hospital are paid separately. For example, when the hospital bills for
your surgeon's charges, we pay under Section 5( b); and for your physi-cal
therapist's charges, we pay under Section 5( a).

PPO: Nothing (No Deductible)
Non-PPO: Nothing (No Deductible)
Out-of-network: Nothing (No Deductible)

Not covered:
Any part of a hospital admission that is not medically necessary (see
definition in Section 10) such as when you do not need the acute hos-pital
inpatient (overnight) setting but could receive care in some
other setting without adversely affecting your condition or the qual-ity
of the medical care.

Note: In this event, we pay benefits for services and supplies, excluding
room and board and in-patient physician care, at the level of benefits
that would have been covered if provided in another approved setting.

Inpatient hospital services and supplies for surgery that we do not
cover

Custodial care (see definition) even when provided by a hospital
Non-covered facilities, such as nursing homes, rest homes, places for
the aged, convalescent homes or any place that is not a hospital,
skilled nursing facility, or hospice

Personal comfort items, such as radio, television, telephone, beauty
and barber services

Private nursing care

All charges 40.
40 Page 41 42
2003 Association Benefit Plan 38 Section 5 (c)
Outpatient hospital or ambulatory surgical center You Pa y
Services and supplies related to surgery, such as:
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines for use in the facility
X-ray, laboratory and pathology services, and machine
diagnostic tests

Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount

Services and supplies not related to surgery, such as:
Outpatient facility room charges
Prescribed drugs and medicines for use in the facility
X-ray, laboratory and pathology services and machine diagnostic tests
Medical supplies, including oxygen

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: 15% of the Plan allowance
and any difference between our allowance
and the billed amount

Note: Take-home drugs are covered under Section 5( f).
Note: Take-home medical supplies, appliances, medical equipment and
any covered items billed by a hospital are covered under Section 5( a).

Note: We cover hospital services related to dental procedures (even
though the dental procedure itself may not be covered) only when a
nondental physical impairment exists that makes hospitalization neces-sary
to safeguard your health.

Skilled nursing care facility benefits
If precertified, we cover semiprivate room, board, services and sup-plies
in a Skilled Nursing Facility (SNF) for up to 60 days when:

1) hospital stay is medically necessary and
2) when the hospital stay is under the supervision of a physician

PPO: Charges in excess of 60-day maximum
(No Deductible)

Non-PPO: Charges in excess of 60-day maxi-mum
and the difference between the Plan
allowance and the billed amount (No Deduct-ible)

Out-of-network: Charges in excess of 60-day
maximum and the difference between the
Plan allowance and the billed amount (No
Deductible) 41.
41 Page 42 43
2003 Association Benefit Plan 39 Section 5 (c)
Skilled nursing care facility benefits (Continued)
If not precertified, we cover semiprivate room, board, services and
supplies for up to 30 days subject to the above conditions

Note: SNF benefits will be restored for each new period of hospital
stay. There is a new period of hospital stay when at least 60 days have
elapsed since you were last confined in a SNF.

PPO: 20% and charges in excess of the
30-day maximum (No Deductible)

Non-PPO: 20% of the Plan allowance
and any difference between our allow-ance
and the billed amount for 30 days,
then all additional charges (No Deduct-ible)

Out-of-network: 20% of the Plan
allowance and any difference between
our allowance and the billed amount
for 30 days, then all additional charges
(No Deductible)

Not covered: Custodial care All charges

Hospice care You Pay
Hospice is a coordinated inpatient and outpatient program of
maintenance and supportive care for the terminally ill provided by a
medically supervised team under the direction of a
Plan-approved independent hospice administration.

If precertified, we pay $7500 for inpatient or outpatient hospice care

PPO: Charges in excess of $7500
maximum (No Deductible)

Non-PPO: Charges in excess of $7500
maximum and the difference between the
Plan allowance and the billed amount (No
Deductible)

Out-of-network: Charges in excess of $7500
maximum and the difference between the
Plan allowance and the billed amount (No
Deductible)

If not precertified, we pay $4500 for inpatient or outpatient hospice
care
PPO: Charges in excess of $4500 maximum
(No Deductible)

Non-PPO: Charges in excess of $4500
maximum and the difference between the
Plan allowance and the billed amount (No
Deductible)

Note: One hospice program is covered per lifetime. This benefit does
not apply to services covered under any other provisions of the Plan.
Out-of-network: Charges in excess of $4500
maximum and the difference between the
Plan allowance and the billed amount (No
Deductible)

Ambulance
We pay the first $50 for:
Professional ambulance service (including air ambulance when med-
ically necessary) to or from the nearest hospital equipped to handle
your condition.

Transportation by professional ambulance, railroad or commercial air-
line on a regularly scheduled flight to the nearest hospital equipped to
furnish special and unique treatment when medically appropriate

PPO: 10% of Plan allowance after $50 benefit
Non-PPO: 25% of Plan allowance and any
difference between our allowance and the
billed amount after $50 benefit

Out-of-network: 15% of Plan allowance and
any difference between our allowance and the
billed amount after $50 benefit

Not covered: Ambulance transport for you or your family's
convenience.
All charges 42.
42 Page 43 44
2003 Association Benefit Plan 40 Section 5 (d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure 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.

PPO benefits apply only when you reside in the PPO network area and use a PPO pro-vider.
When no PPO provider is available, non-PPO benefits apply. Out-of-network
benefits apply when you reside outside the PPO network area.

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.

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What is an accidental injury? An accidental injury is a bodily injury that requires immediate medical attention and is sustained solely through violent,
external, and accidental means, such as broken bones, animal bites, insect bites and stings, and poisonings. Accidental
dental injury is under Section 5( h).

Benefit Description You pa y After the calendar year deductible
NOTE: We added -(No Deductible) -to show when the calendar year deductible does not apply
Accidental injury
If you are accidentally injured, we will pay 100% of the Plan allowance
up to the maximum benefit of $500 per incident for:

Outpatient facility charges
Outpatient physician services and supplies
Related x-ray, laboratory expenses, or durable medical equipment
Note: We pay Hospital benefits if you are admitted to the hospital. See
Section 5( c).

Note: Charges in excess of the $500 benefit will be paid under the
appropriate benefit (i. e., for follow-up physician visits, see Section
5( a)).

PPO: Nothing up to the $500 maximum
benefit (No Deductible).

Non-PPO: Only the difference between our
allowance and the billed amount up to the
$500 maximum benefit (No Deductible).

Out-of-network: Only the difference between
our allowance and the billed amount up to the
$500 maximum benefit (No Deductible). 43.
43 Page 44 45
2003 Association Benefit Plan 41 Section 5 (d)
Medical emergency You Pay
Regular Plan benefits apply when you receive care because of a non-accidental
medical emergency. See Section 5( a).
PPO services in physician's office: $10
copayment (No Deductible)

PPO services outside physician's office:
10% of the Plan allowance

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

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount.

Ambulance
We pay the first $50 for:
Professional ambulance service (including air ambulance when med-ically
necessary) to or from the nearest hospital equipped to handle
your condition.

Transportation by professional ambulance, railroad or commercial
airline on a regularly scheduled flight to the nearest hospital
equipped to furnish special and unique treatment when medically
appropriate

PPO: 10% of the Plan allowance after the $50
benefit

Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount after the $50 benefit

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount after the $50 benefit

Not covered: Ambulance transport for you or your family's
convenience.
All charges 44.
44 Page 45 46
2003 Association Benefit Plan 42 Section 5 (e)
Section 5 (e). Mental health and substance abuse benefits
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If you reside in the PPO Network Area, you may choose to get PPO or Non-PPO care. If
you reside outside the network area, you will receive out-of-network care. PPO members
who choose PPO care must get our approval for services and follow a treatment plan we
approve. Cost-sharing and limitations for PPO or out-of-network mental health and
substance abuse benefits will be no greater than for similar benefits for other illnesses
and conditions

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

The calendar year deductible is $300 per person ($ 600 per family) and applies to
almost all benefits in this Section. We added -(No Deductible) -to show when the
calendar year deductible does not apply.

PPO benefits apply only when you reside in the PPO network area and use a PPO pro-vider.
When no PPO provider is available, non-PPO benefits apply. Out-of-network
benefits apply when you reside outside the PPO network area.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

PPO MEMBERS WHO CHOOSE PPO CARE MUST GET PREAUTHORIZA-TION
OF THESE SERVICES. BENEFITS MAY BE REDUCED IF YOU FAIL
TO GET PRECERTIFICATION OF THESE SERVICES. See the instructions
after the benefits descriptions below.

PPO mental health and substance abuse benefits are listed below, then Non-PPO and
Out-of-network benefits begin on page 44.

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Benefit Description You Pa y After the calendar year deductible
NOTE: 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

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

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

Your cost sharing responsibilities are no
greater than for other illness or conditions. 45.
45 Page 46 47
2003 Association Benefit Plan 43 Section 5 (e)
PPO Network benefits-Continued You Pa y
Professional services provided by a physician PPO: 10% of the Plan allowance (No
Deductible)

Other professional services (i. e., psychologists, clinical social
workers, licensed counselors), inpatient professional services, and
outpatient hospital services

Services in approved alternative care settings, such as partial
hospitalization or facility-based intensive outpatient treatment
(See definitions, Section 10).

Diagnostic tests (including psychological testing)

PPO: 10% of the Plan allowance

Medical management
Note: No preauthorization is required.
PPO: $10 copayment (No Deductible)

Inpatient hospital charges PPO: $100 copayment per hospital stay (No
Deductible)

Not covered:
Services we have not approved.
All charges for chemical aversion therapy, conditioned reflex
treatments, narcotherapy or any similar aversion treatments and all
related charges (including room and board)

Any provider not specifically listed as covered
Counseling or therapy for marital, educational or behavioral
problems, or related to mental retardation or learning disabilities

Community-based programs such as self-help groups or 12 step
program

Treatments for learning disabilities and mental retardation
Services by pastoral (except in medically underserved areas),
marital, or drug/ alcohol counselors

Conjoint therapy, hypnotherapy, interpretation/ preparation of
reports

All charges

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

Preauthorization and Precertification To be eligible to receive these enhanced mental health and substance abuse benefits,
you must obtain a treatment plan and follow
all of our network authorization processes.
These include:

Outpatient mental health and substance
abuse benefits will be reduced by 50% if
services are not preauthorized within two
business days of the initial visit. 46.
46 Page 47 48
2003 Association Benefit Plan 44 Section 5 (e)
Preauthorization and Precertification (Continued) Preauthorization and concurrent review are required for all levels of care whether
in-or out-of-network.

The medical necessity of your inpatient
services must be precertified for you to
receive full Plan benefits. Otherwise, the
benefits payable will be reduced by $500.
Emergency admissions must be reported
within two business days following the
day of admission even if you have been
discharged.

You, your representative, your physician, or
your hospital must call Mutual of Omaha's
Care Review Unit prior to admission. The
toll-free number is 1-800-634-0069.

You must provide the following information:
enrollee's name and Plan identification num-ber;
patient's name, birth date and phone
number; reason for hospitalization, proposed
treatment; name of hospital or facility; name
and number of admitting physician; and
number of planned days of hospital stay.

Network limitation We will reduce your benefits if you do not follow all of our preauthorization process
and your treatment plan.

Non-PPO and Out-of-network benefits You Pa y
Mental Health
Professional services by physicians, psychologists, clinical social
workers or licensed counselors, and inpatient professional services

Non-PPO: 50% of the Plan allowance and
any difference between our allowance and
the billed amount and all charges in excess
of 50 visit maximum

Out-of-network: 15% of the Plan allowance
and the difference between our allowance
and the billed amount

Diagnostic testing (including psychological testing)

Medical management
Non-PPO: 25% of the Plan allowance and
the difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and the difference between our Plan and the
billed amount

Outpatient hospital charges Non-PPO: 50% of the Plan allowance and
the difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and the difference between our Plan and the
billed amount 47.
47 Page 48 49
2003 Association Benefit Plan 45 Section 5 (e)
Non-PPO and Out-of-network benefits (Continued) You Pa y
Inpatient hospital charges Non-PPO: $200 copayment per hospital stay
and 30% of the covered charges (No
Deductible)

Out-of-network: $200 copayment per
hospital stay (No Deductible)

Services in approved alternative care settings, such as partial
hospitalization or facility-based intensive outpatient treatment (See
definitions, Section 10)

Non-PPO: All charges
Out-of-network: 15% of the Plan allowance