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Group Health Cooperative
of Puget Sound

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits
Section 6. General exclusions things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance Is Still Available!
Index
Summary of Benefits
Rates

Pages 1--64

Page 1


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

http:// www. ghc. org
A Health Maintenance Organization

Serving: Most of Washington State and Northern Idaho
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.

Western Washington
Enrollment codes for this Plan:
541 Self Only
542 Self and Family

Eastern & Central Washington and Northern Idaho
Enrollment codes for this Plan:
VR1 Self Only
VR2 Self and Family

Group Health Cooperative
of Puget Sound 2003

For changes in benefits
see page
9.

RI 73-012
This plan has excellent accreditation
from the NCQA. See the 2003 Guide
for more information on NCQA. 1.
1 Page 2 3

UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT

WASHINGTON, D. C. 20415-0001

OFFICE OF THE DIRECTOR

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

CON 131-64-4 September 1993 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

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

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

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

OPM has the right to use and give out your personal medical information to administer the FEHB
Program. For example:

To communicate with your FEHB health plan when you or someone you have authorized to
act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under
limited circumstances:

For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or
education), and
To avoid a serious and imminent threat to health or safety. 3.
3 Page 4 5

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

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is
wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a
statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6
years. The listing will not cover your personal medical information that was given to you or
your personal representative, any information that you authorized OPM to release, or that
was given out for law enforcement purposes or to pay for your health care or a disputed
claim.
Ask OPM to communicate with you in a different manner or at a different place (for
example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However,
OPM may not be able to agree to your request if the information is used to conduct
operations in the manner described above.
Get a separate paper copy of this notice.

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

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the
way your personal medical information is used and given out. If OPM makes any changes, you will
get a new notice by mail within 60 days of the change. The privacy practices listed in this notice
will be effective April 14, 2003. 4.
4 Page 5 6
5.
5 Page 6 7

2003 Group Health Cooperative of Puget Sound 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits provided by Group Health Cooperative of Puget Sound under our contract (CS
1043) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.
The address for Group Health Cooperative of Puget Sound administrative offices is:

Group Health Cooperative of Puget Sound
521 Wall Street
Seattle WA 98121

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 changes
are summarized on page 9. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Group Health Cooperative of Puget Sound.

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. 9.
9 Page 10 11
2003 Group Health Cooperative of Puget Sound 6 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

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

Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1-888/ 901-4636 and explain the situation.
If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
202-418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self-support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer
enrolled in the Plan. 10.
10 Page 11 12

2003 Group Health Cooperative of Puget Sound 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific providers, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely respon-sible
for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing
any course of treatment.

When you receive covered services from Plan providers, you generally will not have to submit claim forms or pay bills.
You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency
services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans if a provider leaves our Plan. We cannot guarantee that any one provider, hospital, or
other provider will be available and/ or remain under contract with us.

How we pay providers
We contract with individual providers, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Who provides my health care?
Group Health Cooperative of Puget Sound is a Mixed Model Prepayment (MMP) Plan. The Plan provides medical care
by doctors, nurse practitioners, and other skilled Medical personnel working as medical teams. Specialists are available
as part of the medical teams for consultation and treatment.

For Central and Eastern Washington and Northern Idaho and Whatcom Division members only: All participating pro-viders
are practitioners who provide routine care within their private office settings in the community.

The first and most important decision each member must make is the selection of a primay care provider. The decision
is important since it is usually through this provider that all other health services, particularly those of specialists, are
obtained. It is the responsibility of your primary care provider to obtain any necessary authorizations from the Plan
before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered
only when there has been a Plan approved written referral by the member's primary care provider, with the following
exception: a woman may see a participating General and Family Practitioner, Physician's Assistant, Gynecologist, Cer-tified
Nurse Midwife, Doctor of Osteopathy, Obstetrician or Advanced Registered Nurse Practitioner who provide women's
health care services directly, without a referral from her primary care provider, for medically appropriate maternity care,
reproductive health services, preventive care and general examination, gynecological care and medically appropriate
follow-up visits for the above services. If your chosen provider diagnoses a condition that requires referral to other
specialists or hospitalization, you or your chosen provider must obtain preauthorization and care coordination in accor-dance
with applicable Plan requirements.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You can also find out about
Care Management, which includes medical practice guidelines, disease management programs and how we determine if
procedures are experimental or investigational. OPM's FEHB website www. opm. gov/ insure lists the specific types of
information that we must make available to you.

If you would like more information about us, call 1-888/ 901-4636, or write to Group Health Cooperative, Customer
Service, P. O. Box 34590, Seattle WA 98124-1590. You may also contact us by fax at 1-206/ 901-4612 or visit our
website at http:// www. ghc. org. You may get information about us, our networks, providers and facilities. 11.
11 Page 12 13
2003 Group Health Cooperative of Puget Sound 8 Section 1
Service Area
To enroll in this Plan, you must live or work in our Service Area. Group Health Cooperative providers practice in the
following areas. Our service area is:

Western Washington (entire counties):
Island San Juan
King Skagit
Kitsap Snohomish
Lewis Thurston
Mason Whatcom
Pierce

In Grays Harbor County, the following cities, by Zip Code:
Elma (98541) Oakville (98568)
Malone (98559) Porter (98573)
McCleary (98557)

In Jefferson County, the following cities, by Zip Code:
Brinnon (98320) Nordland (98358)
Chimacum (98325) Port Ludlow (98365)
Gardner (98334) Port Townsend (98368)
Hadlock (98339) Quilcene (98376)

Central and Eastern Washington (entire counties):
Benton Spokane
Columbia Walla Walla
Franklin Whitman
Kittitas Yakima

Northern Idaho (entire counties):
Kootenai
Latah

If you receive care outside our service area, we will pay only for emergency services as described on pages 29 and 30, or
those services covered under "Travel Benefit" described on page 36. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the service area (for example, if your child goes to college in another state), you should consider enrolling in
a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you
do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Plan members who are temporarily outside the service area of this Plan have access to care with Kaiser Permanente
Plans. If you need services when out of the area, and are in the service area of a Kaiser Permanente Plan, you may obtain
care from any Kaiser Permanente Provider, medical office, or medical center. If you plan to travel and wish to obtain
more information about the benefits available to you, please call Customer Service at 1-888/ 901-4636. 12.
12 Page 13 14
2003 Group Health Cooperative of Puget Sound 9 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 Policy 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. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium for Enrollment Code 54 will increase by 37.1% for Self Only or 33.% for Self and Family. Your share of the non-Postal premium for Enrollment Code VR will increase by 21.5% for Self Only or

47.5% for Self and Family.
For all covered outpatient office visits, you will now pay a $15 copayment per office visit. Previously, your outpatient office visit copayment was $10 per office visit. (Section 5( a)).

For all covered inpatient hospital services, you will now pay a $200 inpatient copayment per day for 3 days; maximum of $600 per person per hospitalization. Previously, you paid a $100 inpatient copayment per day for 3
days; maximum of $300 per person per calendar year. (Section 5( c)).
For all covered outpatient surgical services, you will now pay a $75 copayment per procedure or visit. Previously, you paid a $10 copayment per procedure or visit. (Section 5( c)).

For all prescription drugs, prescribed by your Plan doctor and obtained at a Plan pharmacy, you will now have a $15 copayment for generic formulary drugs, a $25 copayment for brand name formulary drugs and a $50 copayment for
any non-formulary drugs. Previously, your pharmacy copayment was $10 for generic formulary drugs and $20 for
brand name formulary drugs. (Section 5( f)).

A mail order drug program has been added. For all prescription drugs prescribed by your Plan doctor and obtained by the Group Health mail order pharmacy, you will have a $10 copayment for generic formulary drugs, a $20 copayment

for brand name formulary drugs and a $45 copayment for all non-formulary drugs, for each 30-day supply (If your
prescription allows, you can obtain up to a 90-day supply by mail order; in this case, you would pay three times the
30-day copayment) (Section 5( f)).

Your catastrophic protection out-of-pocket maximum will now be $1,500 per person or $3,000 per family enrollment in any calendar year. Previously, your catastrophic protection out-of-pocket maximum was $1,000 per person or

$2,000 per family enrollment in any calendar year. (Section 4).
For all covered full-time skilled nursing care, you will now be covered up to 60 days per calendar year. Previously, your covered full-time skilled nursing care was covered up to 30 days per calendar year. (Section 5( c)).

For all covered services provided by a hospital or other facility, you will now have whole blood covered in full. Previously, whole blood was not covered and was listed in the not covered section. (Section 5( c)). 13.
13 Page 14 15
2003 Group Health Cooperative of Puget Sound 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan phar-macy.
Until you receive your ID card, use your copy of the Health Benefits
Election Form, SF-2809, your health benefits enrollment confirmation (for
annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, please call our Customer
Service at 1-888/ 901-4636 or write to us at Group Health Cooperative,
Customer Service, P. O. Box 34590, Seattle WA 98124-1590.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file
claims.

Plan providers Plan providers are physicians and other health care professionals in our ser-vice area that we contract with to provide covered services to our members.

We list Plan providers in our provider directories, which we update periodi-cally.
You may call Customer Service at 1-888/ 901-4636. The list is also on
our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in
our provider directories. The list is also on our website.
What you must do You and each family member should choose a primary care physician. to get covered care This decision is important, since your primary care physician provides or
arranges for most of your health care. There are several ways to select a
physician; you may contact Customer Service 1-888/ 901-4636 or your
chosen plan facility for assistance.

Primary care Your primary care physician (such as a family practitioner or pediatrcian), will arrange for most of your health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary care phy-sician
leaves the Plan, call Customer Service at 1-888/ 901-4636 or contact
your chosen plan facility. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without addi-tional
referrals. The primary care physician must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see a
woman's health care specialist or a mental health provider without a refer-ral.
A woman may see a participating General or Family Practitioner,
Physician's Assistant, Gynecologist, Certified Nurse Midwife, Doctor of
Osteopathy, Obstetrician or Advanced Registered Nurse Practitioner who
provide women's health care services directly, without a referral from her 14.
14 Page 15 16
2003 Group Health Cooperative of Puget Sound 11 Section 3
primary care provider, for medically appropriate maternity care, reproductive
health services, preventive care and general examination, gynecological care,
and medically appropriate follow-up visits for the above services. If the chosen
provider diagnoses a condition that requires a referral to other specialists or
hospitalization, you or your chosen provider must obtain preauthorization
and care coordination in accordance with applicable Plan requirements.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop
a treatment plan that allows you to see your specialist for a certain num-ber
of visits without additional referrals. Your primary care physician
will use our criteria when creating your treatment plan (the physician
may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does not
participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Programand you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact our Customer Service Department
at 1-888/ 901-4636 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 be-yond
the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to
a skilled nursing or other type of facility if required.
If you are in the hospital when your enrollment in our Plan begins, call our
Customer Service department immediately at 1-888/ 901-4636. If you are
new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until: 15.
15 Page 16 17
2003 Group Health Cooperative of Puget Sound 12 Section 3
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may our control have to delay your services or we may be unable to provide them. In that
case, we will make all reasonable efforts to provide you with the necessary
care.

Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.

We call this review and approval process "prior approval." Your physician
must obtain "prior approval" for the following services: Hospitalization,
Specialty Care and orders for Durable Medical Equipment. Upon obtaining
"prior approval," all of the above are subject to the applicable copays or
coinsurance. 16.
16 Page 17 18
2003 Group Health Cooperative of Puget Sound 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment
of $15 per office visit. When you are admitted to the hospital you pay $200
per day up to $600 per person per hospitalization.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not
count toward any deductible.
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 allowed charges for specific benefits that you must pay for your care.

Example: In our Plan, you pay 50% of our allowed charges for infertility
services, 20% of our allowed charges for durable medical equipment; de-vices,
equipment and supplies and ambulance services; and varying amounts
for dental care.

Your catastrophic protection After your copayments, coinsurance and deductibles total $1,500 per person out-of-pocket maximum for or $3,000 per family enrollment in any calendar year, you do not have to
deductibles, coinsurance, and pay any more for covered services. However, copayments, coinsurance and copayments deductibles for the following services do not count toward your catastrophic
protection out-of-pocket maximum, and you must continue to pay
copayments and coinsurance, and deductibles for these services:

Infertility services Medical devices, equipment and supplies
Dental care $125 non-Plan emergency care copayment
Ambulance services
Be sure to keep accurate records of your copayments, coinsurance and
deductibles since you are responsible for informing us when you reach the
maximum. 17.
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2003 Group Health Cooperative of Puget Sound 14 Section 5
Section 5. Benefits OVERVIEW
(See page 9 for how our benefits changed this year and page 58 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 subsection. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at
1-888/ 901-4636 or at our website at www. ghc. org.

(a) Medical services and supplies provided by physicians and other health care professionals ............................. 15 22
Diagnostic and treatment services Speech therapy Lab, X-ray, and other diagnostic tests Hearing services (testing and treatment)

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ......................... 23 25
Surgical procedures Oral and maxillofacial surgery Reconstructive surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ........................................................ 26 28
Inpatient hospital Extended care benefits/ skilled nursing care Outpatient hospital or ambulatory facility benefits

surgical center Hospice care
Ambulance Rehabilitative therapies

(d) Emergency services/ accidents ............................................................................................................................ 29 30
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ....................................................................................................... 31 32
(f) Prescription drug benefits ................................................................................................................................... 33 35
(g) Special features ......................................................................................................................................................... 36
Consulting Nurse Services for deaf and hearing impaired Flexible benefits option Travel benefit

Reciprocity benefit
(h) Dental benefits .................................................................................................................................................... 37 38
(i) Non-FEHB benefits available to Plan members ....................................................................................................... 39
Summary of benefits ........................................................................................................................................................ 58 18.
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2003 Group Health Cooperative of Puget Sound 15 Section 5( a)
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Preventive care, Adult -continued on next page

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

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and ex-clusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange your care.

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 .

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $ 15 per office visit
In provider s office

Professional services of physicians $ 15 per visit
In an urgent care center
Office medical consultations
Second surgical opinion

At home Nothing

Lab, X-ray and other diagnostic tests
Tests, such as: Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Preventive care, adult
Routine screenings according to the Plan s well adult schedule, such as Nothing
but not limited to:

Total Blood Cholesterol once every five years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50 Nothing 19.
19 Page 20 21
2003 Group Health Cooperative of Puget Sound 16 Section 5( a)
Maternity care -continued on next page

Preventive care, adult (continued) You Pay
Routine Prostate Specific Antigen ( PSA) test one annually for men age 40 and older Nothing

Routine pap test Nothing
Routine mammogram covered for women age 35 and older, as follows: Nothing
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every one to two years according to risk

Not covered: Physical exams required for obtaining or continuing All charges
employment or insurance, or travel.

Routine immunizations, limited to: Nothing
Tetanus-diphtheria ( Td) booster once every 10 years, , ages 19 and over ( except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

Preventive care, children
Childhood immunizations recommended by the American Academy Nothing of Pediatrics

Well-child care charges for routine examinations, immunizations, Nothing immunization updates and care according to the Plan s well child
schedule ( under age 22)
Examinations, such as: $ 15 per visit
Eye exams to determine the need for vision correction once every
12 months

Ear exams to determine the need for hearing correction

Maternity care
Complete maternity ( obstertrical) care, such as: Copays are waived for prenatal
Prenatal care and postnatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to have prior approval for your normal delivery; ; see below 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 extend

your inpatient stay if medically necessary.
We cover routine nursery care including circumcision 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 only if we cover the infant under a Self and Family enrollment. 20.
20 Page 21 22
2003 Group Health Cooperative of Puget Sound 17 Section 5( a)
Maternity care (continued) You pay
We pay hospitalization and surgeon services ( delivery) the same as Copays are waived for prenatal for illness and injury. See Hospital benefits ( ( Section 5c) and and postnatal care

Surgery benefits ( ( Section 5b) .

Not Covered: Routine sonograms to determine fetal age, size or sex. All charges
Family planning
A range of voluntary family planning services, limited to: $ 15 per office visit
Voluntary sterilization. ( See Surgical procedures Section 5( b)
Intrauterine devices ( IUDs) -insertion
Injectable contraceptive drugs
Diaphragms-fitting

Note: We cover oral contraceptives and implantable contraceptives
under the prescription drug benefits ( Section 5( f)

Not covered: reversal of voluntary or involuntary surgical sterilization. All charges
Infertility services
Nonexperimental infertility services limited to general diagnostic services $ 15 per office visit
Specific diagnosis and treatment of infertility, such as:

Artificial insemination: 50% of all charges
intravaginal insemination ( ( IVI)

intracervical insemination ( ( ICI)
intrauterine insemination ( ( IUI)

Not covered: All charges
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization

embryo transfer, gamete GIFT and zygote ZIFT
zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
Fertility drugs

Allergy care
Testing and treatment $ 15 per office visit
Allergy injection Nothing

Allergy serum Nothing
Not covered: any testing or treatment that does not meet Plan protocols All charges 21.
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2003 Group Health Cooperative of Puget Sound 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy $15 per visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
"Organ/ Tissue Transplants" on page 25.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy Home IV and antibiotic Nothing when administered therapy at home

Growth hormone therapy (GHT) Covered under prescription drug benefit
Dietary formula for the treatment of Phenylketonuria (PKU) Nothing
Enteral nutritional therapy when necessary due to malabsorption, 20% of charges for enteral including equipment and supplies nutritional therapy. Equipment
and supplies are covered
under Durable medical
equipment (DME)

Total parenteral nutritional therapy and supplies necessary for Nothing for formula. its administration Equipment and supplies
are covered under Durable
medical equipment (DME)

Routine nutritional counseling $15 per visit
Not covered: over the counter formulas All charges
Physical and occupational therapies
Physical therapy, occupational therapy, and speech therapy are subject $15 per outpatient visit
to a combined limit of sixty (60) visits per condition per calendar year.
Speech therapy benefit is described in the next section. The following Nothing when provided on an
physical and occupational therapy benefits are covered: inpatient basis (See Section 5( c)
for Hospital charges)
qualified physical therapists; and

qualified occupational therapists
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction when provided at a Plan facility

Not covered: All charges
long-term rehabilitative therapy
exercise programs 22.
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2003 Group Health Cooperative of Puget Sound 19 Section 5( a)
Speech therapy You pay
Speech therapy, physical therapy and occupational therapy are subject $ 15 per outpatient visit
to a combined limit of sixty ( 60) visits per condition per calendar year.
The physical and occupational therapy benefits are described under Nothing when provided on
Physical and Occupational therapies. Speech therapy is covered: : an inpatient basis ( see
Section 5( c) for Hospital
Qualified speech therapists charges)

Hearing services (testing, treatment, and supplies)
Hearing testing to determine hearing loss $ 15 per office visit

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

Vision services (testing, treatment, and supplies)
When dispensed through a Plan facility one contact lens per diseased $ 15 per visit eye following cataract surgery provided by a Plan doctor in lieu of an
intraocular lens. Replacement will be provided only when needed due
to change in your medical condition and will be replaced only one time
within any 12 month period.

Eye exam to determine the need for vision correction $ 15 per office visit
Annual eye exams or refractions

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

Not covered: All charges
Eyeglasses
Contact lenses and related supplies including examinations and fittings for them, except as provided above

Eye exercises and orthoptics
Evaluations and surgical procedures to correct refractions which are not related to eye pathology including complications

Foot care
Routine foot care when you are under active treatment for a metabolic $ 15 per office visit
or peripheral vascular disease, such as diabetes.

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

Not covered: All charges
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery) 23.
23 Page 24 25
2003 Group Health Cooperative of Puget Sound 20 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose 20% of charges
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Ostomy supplies necessary for the removal of bodily secretions or waste through an artificial opening
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, intraocular lenses, and surgically implanted
breast implant following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c)
for payment information. See Section 5( b) for coverage of the surgery
to insert the device.

Occlusal splints ( including fittings) for non-dental treatment of temporomandibular joint ( TMJ) pain dysfunction syndrome.

Therapeutic shoe inserts for severe diabetic foot disease
Braces, such as back, knee, and leg braces, but not dental braces

Not covered: All charges
Orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

cost of artificial or mechanical heart
cost of penile implanted device
Orthopedic and prosthetic replacements provided except when medically necessary

Replacement of devices, equipment and supplies due to loss, breakage or damage

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of 20% of charges
durable medical equipment prescribed by your Plan physician. Under
this benefit, we cover:

hospital beds;
standard wheelchairs;
crutches;
walkers;
canes;
oxygen and oxygen equipment for home use;
nasal CPAP device
blood glucose monitors;
external insulin pumps; and medically necessary replacement of supplies.

Durable medical equipment (DME) -continued on next page 24.
24 Page 25 26
2003 Group Health Cooperative of Puget Sound 21 Section 5( a)
Durable medical equipment (DME) (continued) You Pay
Not covered: All charges
Motorized wheelchairs except when approved by the medical director as medically necessary

Replacement of devices, equipment and supplies due to loss, breakage or damage
Equipment not listed as covered in our DME formulary

Home health services
Home health care ordered by a Plan physician and provided by a Nothing per visit by provider registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed

vocational nurse ( L. V. N. ) , or home health aide. 20% for oxygen therapy
Services include oxygen therapy, intravenous therapy and medications $ 15 copay per prescription for generic formulary oral

medications and $ 25 copay
per prescription for brand
name formulary oral
medications

A $ 50 copay for non
formulary oral medications
when prescribed by a Plan
doctor.

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

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

Chiropractic
Manipulative therapy services for manipulation of the spine and $ $ 15 copay per visit
extremities when treatment is received from a Plan provider and meets
Plan protocols.

Not covered: All charges
maintenance therapy
care given on a non-acute asymptomatic basis
services provided for the convenience of the member 25.
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2003 Group Health Cooperative of Puget Sound 22 Section 5( a)
Alternative treatments You Pay
Acupuncture for pain relief for such conditions as chronic arthritis; ; $ 15 per visit
chronic myofascial pain and chronic headaches when authorized in
advance by your Plan provider and treatment meets Plan protocols.

Naturopathic services for treatment of conditions such as chronic $ $ 15 per visit
arthritis; chronic fatigue syndrome and fibromyalgia when authorized in

advance by your Plan provider and treatment meets Plan protocols.

Not covered: All charges
maintenance therapy
vitamins
food supplements
care given on a non-acute asymptomatic basis
services provided for the convenience of the member
hypnotherapy
biofeedback
botanical and herbal medicines

Educational classes and programs
Coverage is limited to:
Tobacco Cessation Participation in the Plan s Free and Clear Nothing for the Program; ( tobacco cessation) Program is required in order to receive coverage ( ( See Section 5( f) for pharmacy

for one course of nicotine replacement or other approved pharmacy charges for nicotine
product therapy per year. replacement therapy)

Diabetes self-management $ 15 copay 26.
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2003 Group Health Cooperative of Puget Sound 23 Section 5( b)
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals

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.

Plan physicians must provide or arrange your care.
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 cover-age,

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. ) .
YOUR PLAN DOCTOR MUST GET "PRIOR APPROVAL" OF SOME SURGICAL PROCEDURES. Please refer to the prior approval information shown in Section 3 to be

sure which services require prior approval and identify which surgeries require prior
approval.

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: $ 15 per visit for outpatient care
Operative procedures Nothing when provided on an
Treatment of fractures, including casting inpatient basis
Normal pre-and post-operative care by the surgeon ( See Section 5( c) for
Correction of amblyopia and strabismus hospital charges)
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( see reconstructive surgery)
Surgical treatment of morbid obesity a condition for which an individual s Body Mass Index ( BMI) must be 40 or greater, and

when all other medical criteria is met including the requirement that
eligible members must be age 20 or over.

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

Voluntary sterilization ( e. g. , tubal ligation, vasectomy)
Treatment of burns
Circumcision
Note: Generally, we pay for internal prostheses ( devices) according to where
the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care
Cost of a penile implanted device
Cost of an artificial or mechanical heart
Weight loss programs 27.
27 Page 28 29
2003 Group Health Cooperative of Puget Sound 24 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect $ 15 per visit for outpatient care.
Surgery to correct a condition caused by injury or illness if: Nothing, when provided on an
the condition produced a major effect on the member s inpatient basis ( See Section
appearance and 5( c) for Hospital charges)

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as: See above
surgery to produce a symmetrical appearance on the other breast;

treatment of any physical complications, such as lymphedemas;
compression garments to treat lymphedema ( see Durable
Medical Equipment)

breast prostheses and surgical bras and replacements ( see
Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48

hours after the procedure.

Not covered: All charges
Cosmetic surgery 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

Oral and maxillofacial surgery
Oral surgical procedures, limited to: $ 15 per visit
Reduction of fractures of the jaws or facial bones; Nothing, when provided on an
Surgical correction of cleft lip or cleft palate; inpatient basis ( See Section
Removal of stones from salivary ducts; 5( c) for Hospital charges)
Excision of malignancies;
Excision of non-dental cysts and incision of non-dental abscesses when done as independent procedures; and

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

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

Surgical correction of malocclusion done solely to improve appearance 28.
28 Page 29 30
2003 Group Health Cooperative of Puget Sound 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea $ 15 per visit for outpatient care
Heart Nothing when provided on
Heart/ lung inpatient basis ( See Section
Kidney 5( c) for Hospital charges)
Kidney/ Pancreas
Liver
Lung: Single or Double
Allogenic ( donor) bone marrow transplants
Autologous bone marrow transplants ( autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin s
lymphoma; advanced non-Hodgkin s lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors.

Intestinal transplants ( small intestine) and small intestine with the liver or small intestine with multiple organs such as, the liver, stomach

and pancreas.
Note: We cover related medical and hospital expenses of the donor when
we cover the recipient. These expenses are limited to procurement center
fees, travel costs for a surgical team, excision fees, and matching tests.

Not covered: All charges
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered
Transportation and living expenses

Anesthesia
Professional services provided in Nothing
Hospital ( inpatient)
Skilled nursing facility

Professional services provided in $ 15 per visit
Hospital outpatient department
Ambulatory surgical center
Provider s office 29.
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2003 Group Health Cooperative of Puget Sound 26 Section 5( c)
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Section 5 (c). Services provided by a hospital or other facility, and ambulance services
Here are some important things to remember 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.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

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.
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 covered in
Section 5( a) or ( b) .

Benefit Description You pay
Inpatient hospital
Room and board, such as
Semiprivate room accommodations; A $ 200 inpatient copayment per
special care units such as intensive care or cardiac units day for 3 days; maximum
general nursing care; and of $ 600 per person per
meals and special diets. hospitalization.
Note: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Nothing except the $ 200
Prescribed drugs and medicines inpatient copayment per day
Diagnostic laboratory tests and X-rays for 3 days; maximum of $ 600
Administration of blood and blood products per person per hospitalization.
Blood and blood derivatives
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services

Medical supplies, appliances, medical equipment, and any covered According to the benefit of the items billed by a hospital for use at home specific item you take home, i. e. ,
hospital bed, pharmacy items, etc.
Not covered: All charges
Custodial care, rest cures, domiciliary or convalescent care
Non-covered facilities, such as nursing home, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care 30.
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2003 Group Health Cooperative of Puget Sound 27 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Outpatient surgery is subject
Prescribed drugs and medicines administered at the facility to a $ 75 copayment per
Diagnostic laboratory tests, X-rays, and pathology services procedure or visit.
Administration of blood, blood plasma, and other biologicals
Blood and blood derivatives
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Rehabilitative therapies
Physical therapy, occupational therapy, speech therapy -Two months per Nothing after the $ 200 inpatient
condition per calendar year for the services of each of the following in a copayment per day for 3
certified rehabilitation facility: days; maximum of $ 600 per

qualified physical therapists person per hospitalization.
qualified speech therapists; and
qualified occupational therapists

Not covered: Long-term rehabilitative therapy All charges
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility ( SNF) benefit: When full-time skilled nursing Nothing
care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and authorized
by the Plan you will receive up to 60 days per calendar year.

Not covered: All charges
custodial care;
rest cures;
domiciliary or convalescent care
personal comfort items, such as telephone and television 31.
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2003 Group Health Cooperative of Puget Sound 28 Section 5( c)
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered in Nothing
the home or a hospice facility. Services could include:

inpatient and outpatient care
drugs
biologicals
medical appliances and supplies that are used primarily for the relief of pain and symptom management

family counseling
These services are provided under the direction of a Plan doctor who
certifies that the patient is in the terminal stages of illness, with a life
expectancy of approximately six months or less.

Not covered: Independent nursing, homemaker services All charges
Ambulance
Ground and air ambulance transportation to a Plan facility, Plan 20% of charges designated facility, or non-Plan designated facility, when medically
appropriate and ordered or authorized by a Plan doctor. 32.
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Section 5 (d). Emergency services/ accidents
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.
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.

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life
or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are
emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are
medical emergencies what they all have in common is the need for quick action. .

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor . In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system ( e. g. , the 911

telephone system) or go to the nearest hospital emergency room. Remember, it is your responsibility to notify the Plan.
If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 24 hours by calling the Plan notifi-
cation line at 1-888/ 457-9516, unless it was not reasonably possible to do so. If you are hospitalized in a non-Plan facility
and a Plan doctor believes that better care can be provided in a Plan hospital, you will be transferred when medically
feasible with ambulance charges covered in full. If you have questions about acute illnesses other than emergencies, you
should call your primary care physician.

Benefits are available for care received from non-Plan providers in a medical emergency only if the delay in reaching a
Plan provider would have resulted in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.

If you are admitted to an in-Plan hospital or designated facility directly from the emergency room, we will waive the in-
Plan copayment.

Emergencies outside our service area: Benefits are available for medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 24 hours or on the first working day following your
admission, unless it was not reasonably possible to do so. If you are hospitalized in a non-Plan facility and a Plan doctor
believes that better care can be provided in a Plan hospital, you will be transferred when medically feasible with ambu-
lance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers. 33.
33 Page 34 35
2003 Group Health Cooperative of Puget Sound 30 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency or urgent care at a Plan doctor s office $ 15 copay
Emergency or urgent care at a Plan urgent care center $ 15 copay
Emergency care at a Plan or a Plan designated emergency department $ 75 copay
Emergency care at a non-plan facility, including doctors services $ 125 copay per member per visit

Not covered: Elective care or non-emergency care All charges except at Plan
doctor's office or Plan
urgent care center

Emergency outside our service area
Emergency care or urgent care at a doctor s office $ 125 copay per member
Emergency care or urgent care at an urgent care center per visit
Emergency care at a hospital, including doctors services

Not covered: All charges.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Ambulance
Professional ambulance service which include both ground and air 20% of charges
ambulance transportation when medically appropriate and approved
by the Plan.

See Section 5( c) for non-emergency service.

Not covered: Cabulance All charges. 34.
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Section 5 (e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than
for similar benefits for other illnesses and conditions.

to treat your condition.
Plan doctor must provide or arrange your care.
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 cover-age,

including with Medicare.

Benefit Description You pay
Mental health and substance abuse benefits
Cost sharing and limitations for benefits that we cover ( for
example, visit/ day limits, copayments, and out-of-pocket
maximums) for mental health and substance abuse are
based on the cost sharing and limits for similar benefits
under our Plan medical, hospital, prescription drug,
diagnostic testing, and surgical benefits.

For example:
The same $ 15 copayment that applies when you visit a specialist for a physical illness or disease

applies to a visit to a mental health or substance
abuse provider for a therapy session.

The same $ 15 copay for generic formulary drugs or $ 25 copay for brand name formulary drugs and a $ 50

copay for non formulary drugs when prescribed by a
Plan doctor, to treat a mental health or substance
abuse condition as you would for a prescription to
treat a physical illness or disease.

The same $ 200 inpatient copayment per day for 3 days; maximum of $ 600 per person per

hospitalization as you would for a physical illness
or disease.

A $ 25 copayment per day for partial hospitalization;
no day limit

A $ 15 copayment for each office visit
Nothing for diagnostic tests

We will cover all diagnostic and treatment services
for the treatment of mental health and substance
abuse conditions that are clinically necessary and
recommended by the member s primary physician
and approved by the Plan Medical Director or
designee.

Examples of mental health inpatient and
outpatient treatment can include:

Diagnosis evaluation
Diagnostic tests
Consultation services
Psychiatric treatment ( individual, family and group therapy) by providers such as psychiatrists,

psychologists, or clinical social workers
Hospitalization ( including professional services)
Services in approved alternative care settings such as partial hospitalization

Medication management visits
Examples of substance abuse inpatient and
outpatient treatment can include:

Diagnosis, treatment and counseling for alcoholism and drug addiction

Diagnostic tests
Detoxification
Hospitalization ( including inpatient professional services)

Medication management visits
Alcohol and drug education
Services in approved alternative care settings such as intensive outpatient treatment

Mental health and substance abuse benefits -continued on next page 35.
35 Page 36 37
2003 Group Health Cooperative of Puget Sound 32 Section 5( e)
Not covered by the Plan: The same exclusions that
apply to other benefits apply to these mental health
and substance abuse benefits.

Examples of mental health inpatient and outpatient
treatment that the Plan excludes are:

Psychiatric evaluation or therapy that is court ordered as a condition of parole or probation

unless determined by a Plan provider to be
necessary and appropriate

Psychological testing that is not medically necessary

Services that are custodial in nature
Assessment and treatment services that are primarily vocational and academic in nature

(i. e., educational testing)
Services provided under a Federal, state, or local government program

Services rendered or billed by a school or a member of its staff
Continued services if you do not substantially follow your treatment plan
Treatment not authorized by a Plan provider, provided by the Plan, or specifically contracted
for by the Plan
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.

Mental health and substance abuse benefits You Pay (Continued)
All charges. 36.
36 Page 37 38
2003 Group Health Cooperative of Puget Sound 33 Section 5( f)
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Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

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.
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.

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or referral doctor must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan pharmacy.
We use a formulary. Prescriptions written by Plan physicians are dispensed in accordance with the Plan's drug formulary. A drug formulary is a list of preferred pharmaceutical products that our pharmacists and physicians,

have developed to assure that you receive quality prescription drugs at a reasonable price. Non-formulary drugs
will be covered only if based on medical necessity and if prescribed by a plan doctor. For information about
specific formulary drugs, please call Customer Service at 1-888/ 901-4636.

A generic equivalent to a brand name drug will be dispensed if it is available. If your physician believes that a
name brand product is medically necessary, or if there is no generic equivalent available, your physician may
prescribe a name brand drug. You pay a higher copay when a brand name drug is prescribed.

These are the dispensing limitations. Prescription drugs prescribed by Plan doctors and filled at Plan pharma-cies will be dispensed for up to a 30-day supply. You will be required to pay a copay for each 30-day supply. If

your prescription is written for more than a 30-day supply, such as a 90 day supply, you are responsible for three
copays, one for each 30-day supply.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which a manufacturer

advertises and sells that drug. They must contain the same active ingredients and must be equivalent in strength
and dosage to the original brand-name product. Under federal law, generic and name brand drugs must meet the
same standards for safety, purity, strength, and effectiveness. Generic drugs cost you and your plan less money
than a name-brand drug.

Prescription drug benefits begin on the next page. 37.
37 Page 38 39
2003 Group Health Cooperative of Puget Sound 34 Section 5( f)
Mail Order Drug Program
Prescription medications mailed to your home by the Group Health mail order pharmacy. ( Mail order issues up to a 90 day supply)

Limited benefits:
Drugs to aid in tobacco cessation. Participation in the Plan s Free and Clear Program is required in order to receive coverage for one

course of nicotine replacement therapy per calendar year.

Sexual dysfunction drugs; dosage limits set by the Plan. Contact Customer Service at 1-888/ 901-4636 for details.

Benefit Description You pay
Covered medications and supplies
A $ 15 copay for generic
formulary drugs and a $ 25
copay for brand name formulary
drugs, per prescription unit or
refill for up to a 30-day supply
or 100-unit supply, whichever is
less; or one commercially
prepared unit ( i. e. , one inhaler,
one vial ophthalmic medication
or insulin) .

A $ 50 copay for non-formulary
drugs when prescribed by a Plan
doctor.

Nothing for Allergy serum

We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

Drugs ( including injectibles) for which a prescription is required by Federal law

Insulin
Diabetic supplies, including needles, syringes, lancets, urine and blood glucose testing reagents; a copay charge applies per item per each 30-day supply

Oral, injectable, and implanted contraceptive drugs and devices
Compound dermatological preparations
Disposable needles and syringes for the administration of covered prescribed medications

Allergy serum
Intravenous fluids and medication for home use are covered under ( Section
5( a) Treatment Therapies )

$ 10 copay for generic formulary
drugs or a $ 20 copay for brand
name formulary drugs, for each
30-day supply.

A $ 45 copay for non-formulary
drugs when prescribed by a Plan
doctor, for each 30-day supply.

$ 15 copay for generic formulary
drugs or a $ 25 copay for brand
name formulary drugs per 30-
day supply.

A $ 50 copay for non-formulary
drugs when prescribed by a Plan

doctor.

50% copayment

Covered medications and supplies continued on the next page. 38.
38 Page 39 40
2003 Group Health Cooperative of Puget Sound 35 Section 5( f)
Not covered: All Charges.
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non-Plan pharmacy; except when due to an out of area emergency
Vitamins and nutritional substances, including dietary formulas and special diets, except for the treatment of phenylketonuria (PKU);
total parenteral; and enteral nutrition therapy
Oral nutritional supplements
Medical supplies such as dressings, antiseptics, etc
Experimental drugs, devices and biological products
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Replacement of lost or stolen drugs, medicines or devices.

Covered medications and supplies (Continued) You Pay 39.
39 Page 40 41
2003 Group Health Cooperative of Puget Sound 36 Section 5( g)
Section 5 (g). Special Features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

Consulting Nurse Service For urgent care information and after hours care between 5: 30 PM and 8: 30 AM call toll-free 1-800/ 297-6877 for Western WA or 1-800/ 497-2210 for
Eastern WA and Idaho.

Services for deaf and Members who are hearing or speech-impaired may use the following number hearing impaired to access a Group Health Facility, staff member, or Group Health provider.
Washington: 711 or 1-800/ 833-6388
Idaho: 711 or 1-800/ 377-3529

Reciprocity benefit Plan members who temporarily reside or are traveling outside the service area of this Plan may have access to care with Kaiser Permanente Plans. If
you need services when out of the area, and are in the service area of a
Kaiser Permanente Plan, you may obtain care from any Kaiser Permanente
provider, medical office, or medical center, applicable copays will apply. If
you plan to travel and wish to obtain more information about the benefits
available to you, please call our Customer Service Center at 1-888/ 901-4636.

Travel benefit If you are traveling, and are outside the Plans service area by more than 100 miles, certain health services, i. e. , follow-up care and continuing care, are
covered. You pay a $ 25 copay per follow-up or continuing care visit, up to a
maximum Plan copayment of $ 1,200 per person per calendar year. You must
pay the provider at the time you receive the services. If the services are
covered under this benefit, you will be reimbursed the reasonable charges for
the care, up to a maximum of $ 1,200 per person per calendar year, and the
$ 25 copay per visit will be deducted from the payment you receive from the
Plan.

Submit a claim to the Plan for the services on a HCFA Form 1500, with
necessary supporting documentation, i. e. , itemized bills and receipts, along
with an explanation of the services, and the identification information
from your ID card. Send the claims to Group Health Cooperative, Claims
Administration, P. O. Box 34585, Seattle, WA 98124-1585. 40.
40 Page 41 42

2003 Group Health Cooperative of Puget Sound 37 Section 5( h)
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Dental benefits continued on the next page.

Section 5 (h). Dental benefits
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.

You are not required to receive your care from specified dental providers.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of

the patient. See Section 5 ( c) for inpatient hospital benefits. We do not cover the
dental procedure unless it is described below.

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.
The following is a summary of the Plan s dental benefits. Please call the Plan s member Services Department at 1-206/ 522-2300 or 1-800/ 554-1907 or you may visit our website

at www. deltadentalwa. com for more information on additional exclusions and limitations.
Benefits are provided only for services included in the list of covered dental services and no charges will be paid in excess of the reasonable and customary charge. No dental

benefit will be paid for any dental service or supply which is incomplete or temporary.

The Dental program will pay a percentage of the reasonable and customary charge for dental services listed below and will
reimburse any dentist, dental hygienist ( under the supervision of a dentist) , or denturist, that you select. You pay an annual
deductible of $ 50 per member and $ 150 per family, per year up to $ 1,000 maximum benefit, per member per year as well
as any amounts over Plan payment. You are not required to receive your care from specified dental providers.

Important: Benefits are provided only for services included in the list of covered dental services and no charge will be
paid in excess of the reasonable and customary charge. No dental benefit will be paid for any dental service or supply
which is incomplete or temporary.

Dental Benefits
Service You Pay
Preventive Care Nothing after the deductible
Prophylaxis ( cleaning and polishing of teeth) not more than once in any five month period

Routine oral examinations, except for orthodontics
Fluoride treatment for children under age 16
Dental X-rays, except for orthodontics
Bacteriologic cultures and biopsies of tissue
Emergency palliative treatment for relief of dental pain
Space maintainers, except for orthodontics 41.
41 Page 42 43
2003 Group Health Cooperative of Puget Sound 38 Section 5( h)
Dental Benefits (continued) You Pay
Basic Dental Care 50% of reasonable and
Endodontic treatment as follows: root canal therapy, pulpotomy, customary charges after the apicoectomy, and retrograde fillings deductible

Simple extractions
Oral surgery
Basic periodontal services, limited to occlusal adjustment when performed with a covered root scaling

Study models
Crown build-up on non-vital teeth
Pin retention of fillings
Fillings ( restorations) using amalgam, silicate, acrylic synthetic porcelain and composite fill materials to restore teeth broken down by decay or

injury; on posterior teeth, an allowance will only be made for an
amalgam filling

Recementing inlays, onlays, and crowns
Recementing bridges
Repairs to full and partial dentures and bridges
General anesthetics and analgesics

Injectable antibiotics

Major dental care 70% of reasonable and
Major periodontal treatment of the gums and supporting structure customary charges after the of the teeth deductible

Bridges and dentures
Crowns and gold restorations

Replacement of damaged appliances

Not covered: Other dental services not shown as covered. All charges 42.
42 Page 43 44

2003 Group Health Cooperative of Puget Sound 39 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
Vision Hardware (See Centers)
Federal employees and their dependents are eligible
for a 10% vision hardware discount at Group Health
Cooperative See Centers. The discount applies to
the cost of one or more pairs of prescription
eyeglasses or one pair of contact lenses per year if
these items are purchased through a See Center.
Fitting and evaluation fees are not included in the
discount.

Take Care Stores
Take Care stores sell self--care and wellness
products such as back support cushions, blood
pressure monitors, and allergy-control bedding. There
are four Take Care Stores ( located at Group
Health Capitol Hill, Group Health Northgate
Medical Center, Group Health Eastside Hospital,
and Group Health Olympia Medical Center) , or you
can order directly online from the Take Care website
www. take-care. com.

Hear Centers
Our Hear Centers offer a full range of the latest
hearing aid technology from the world s leading
manufacturers, as well as custom noise plugs, swim
molds, assistive listening devices, other accessories
and batteries. There are four Hear Centers ( located
in Redmond, Seattle, Tacoma, and Olympia) .

Smoking Cessation
Group Health continues to pave the way in smoking
cessation benefits with our nationally recognized
Free & Clear program. . Any currently enrolled
Group Health member may participate in the Free
& Clear program. . Participants pay extra for any
pharmaceuticals used. To learn more, call Free &
Clear at 1-800-462-5327.

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection
out-of-pocket maximums.

Weight Management Program
Group Health s Weight Management program offers a
total lifestyle plan. It teaches positive behaviors that
promote health, and helps improve overall well-being
through weight management. For more information, call
206-527-6920 in Seattle or 1-888-874-7783 toll free.

MyGroupHealth
MyGroupHealth is an online health center available
to all members. MyGroupHealth provides access to
valuable health risk assessment tools, doctor profiles
and selection, medical center locations and programs,
and 22,000 pages of reliable health care information.
Visit MyGroupHealth at www. ghc. org.

SilverSneakers (FOR WESTERN WASHINGTON
MEMBERS ONLY)

As a member of the FEHB Medicare Managed Care
Plan, your member ID card entitles you to participate in
our popular SilverSneakers program. With over twenty
health and fitness facilities to choose from throughout
the Puget Sound area, you choose what you want to do:
relax in a sauna, improve your posture and flexibility
in a SilverSneakers class, or tone your body with
weight training, circuit training, or aerobics. 43.
43 Page 44 45
2003 Group Health Cooperative of Puget Sound 40 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition and we agree, as discussed under What Services Require Our Prior Approval on page 12.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies ( see Emergency Benefits) ;
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Procedures, services, drugs, or 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;

Procedures, services, drugs, or supplies related to sex transformations;
Procedures, services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or

Services, drugs, or supplies you receive without charge while in active military service. 44.
44 Page 45 46
2003 Group Health Cooperative of Puget Sound 41 Section 7
Section 7. Filing a claim for covered services
When you see Plan providers, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will

file on the UB-92 form. For claims questions and assistance, call us at
1-888/ 901-4636.

When you must file a claim such as for services you receive outside of
the Plan's service area submit it on the HCFA-1500 or a claim form that
includes the information shown below. Bills and receipts should be
itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Group Health Cooperative, Claims
Administration, P. O. Box 34585, Seattle WA 98124-1585

Prescription drugs Outpatient drugs and medicines obtained at non-Plan pharmacies are not covered; except when due to an out of area emergency.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the
service, unless timely filing was prevented by administrative operations of
Government or legal incapacity, provided the claim was submitted as soon
as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 45.
45 Page 46 47
2003 Group Health Cooperative of Puget Sound 42 Section 8
The Disputed Claims Process continued on next page

Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Group Health Cooperative, Appeals Department, P. O. Box 34593, Seattle
WA 98124; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as providers' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of
our request go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
<