Document Body Page Navigation Panel Document Outline

Union Health Service

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
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 OVERVIEW
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health 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--58

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

2
Union Health Service 2003 http:// www. unionhealth. org A Health Maintenance Organization
Serving: Chicago Area
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
761 Self Only 762 Self and Family

For changes in benefits
see page 7

RI 73-026
Authorized for distribution by the:
United States Office of Personnel Management
Retirement and Insurance Service http:// www. opm. gove/ insure 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative),
. To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is

protected, . To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and

. Where required by law.

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

. To communicate with your FEHB health plan when you or someone you have authorized to act on your
behalf asks for our assistance regarding a benefit or customer service issue. . To review, make a decision, or litigate your disputed claim.

. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
. For Government healthcare oversight activities (such as fraud and abuse investigations),
. For research studies that meet all privacy law requirements (such as for medical research or education), and
. To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
. See and get a copy of your personal medical information held by OPM.
. Amend any of your personal medical information created by OPM if you believe that it is wrong or if

information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information. 3.
3 Page 4 5
. 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

. Plan facilities ......................................................................................................................................... 8

What you must do to get covered care......................................................................................................... 8
. Primary care .......................................................................................................................................... 8

. Specialty care ........................................................................................................................................ 8
. Hospital care.......................................................................................................................................... 9

. Deductible ........................................................................................................................................... 11
. Coinsurance......................................................................................................................................... 11

When you lose benefits............................................................................................................................ .. 49
. When FEHB coverage ends................................................................................................................. 49

Long term care insurance is still available................................................................................................................... 52
Index ................................................................................................................................................................ 53
Summary of benefits.................................................................................................................................................... 54
Rates ................................................................................................................................................. Back Cover 6.
6 Page 7 8
2003 Union Health Service 4 Introduction
Introduction
This brochure describes the benefits of Union Health Service under our contract (CS 1571) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Union
Health Service administrative office is:
Union Health Service, 1634 West Polk Street, Chicago, Illinois 60612
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

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

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

. Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or
family member; "we" means Union Health Service
. 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 a comment or suggestion 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 email us at fehbwebcomments@ opm. gov. You may also

write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases you Federal 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. 7.
7 Page 8 9
2003 Union Health Service 5 Introduction
. 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 312/ 829-4224 ext. 3359 and explain the situation.
. If we do not resolve the issue:

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

employed or with OPM if you are retired. . You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain

FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10

2003 Union Health Service 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The plan is solely
responsible 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 services from Plan providers, you 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 because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How we pay providers
We employ individual physicians, own and operate our medical centers, and contract with hospitals to provide the benefits in this brochure. Most physicians are salaried employees. Other Plan providers accept a negotiated payment
from us. You will only be responsible for your copayments or coinsurance.
UHS is a Staff Model Group Practice Plan that employs most of our doctors. All doctors are either Board Certified or Eligible in their specialties and are affiliated with some of the area's finest hospitals.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
Union Health Service is a staff model not-for profit Health Maintenance Organization. Union Health Service is a state certified HMO. We were established in 1955.

If you want more information about us, call our Member Service Department at 312 829-4224 ext. 3379, or write to Union Health Service, 1634 West Polk Street, Chicago, IL 60612. You may also contact us by fax at 312/ 423-4380 or
visit our website at: www. unionhealth. org.
Service Area
To enroll with us, you must live in or work in our service area. This is where our providers practice. Our service area is: The Chicago Area located in Cook and DuPage, Kane, Will and Kendall counties, Illinois

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service
area unless the services have prior approval.
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 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 outside of the service area, you do not have to wait until Open Season to change plans. Contact your
employing or retirement office. 9.
9 Page 10 11
2003 Union Health Service 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change your benefits.
Program-wide changes
. We changed the address for sending disputed claims to OPM (Section 8)
. A Notice of the Office of Personal Management's Privacy Practices is included.
. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family

coverage. . Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend

their FEHB Program enrollment. . Program information on Medicare is revised.
. By law, the DoD/ Fehb Demonstration project ends on December 31, 2003.

Changes to this Plan
. Your share of the non-Postal premium will increase 10. 5 % for Self Only or 10.5 % for Self and Family.

. The copayment for prescription drugs will increase to $15 per prescription unit or refill from $10 per prescription
unit or refill.

. The Plans service area has expanded into Kane, Will and Kendall counties, Illinois (See page 6). 10.
10 Page 11 12
2003 Union Health Service 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call our Member
Service Department at 312 829-4224 ext. 3379 or write to us at 1634 West Polk Street; Chicago, Illinois 60612.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and deductibles. You will not have to file claims.
. Plan providers Plan providers are physicians and other health care professionals in our
group that we employ to provide covered services to our members. We credential Plan providers in accordance with state and national standards.

We list Plan providers in the provider directory, which we update periodically.
. 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 the provider directory, which we update periodically.

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care. The UHS Physicians Directory lists all primary
care physicians and specialists. The UHS Member Service Department can assist you if you have questions.

. Primary care Your primary care physician can be a family practitioner, internist,
pediatrician, or obstetrician/ gynecologist (OB-GYNE). Your primary care physician will provide 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 physician leaves the Plan, call us. 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 additional 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, a
woman may see her Plan OB-GYNE without a referral.
Here are other things you should know about specialty care: 11.
11 Page 12 13
2003 Union Health Service 9 Section 3
. If you need to see a participating 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 number of visits without additional referrals. Your primary care physician will use our criteria when creating your
treatment plan.
. 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. Contact us.

. 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)
Program and 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 us, or if we drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

. Hospital care 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 you are in the hospital when your enrollment in our Plan begins, call our Medical Management Department immediately at 312 829-4224
ext. 3210. 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:
. You are discharged, not merely moved to an alternative care center; or
. The day your benefits from your former plan run out; or
. The 92 nd day after you become a member of this Plan, whichever
happens first. 12.
12 Page 13 14
2003 Union Health Service 10 Section 3
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may 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 internal prior approval services. For external 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.
Our Medical Director must approve your referral to an outside specialist before you receive treatment. When you receive a referral from your
primary care physician to an outside specialist, you must return to the primary care physician after the consultation. Your primary care
physician must provide or authorize all follow-up care. On outside referrals, your primary care physician will give specific instructions to
the specialist as to what services are authorized. If the specialist suggests additional services or visits, you must check with your primary care
physician for approval and authorization. Do not go to the outside specialist unless your primary care physician has arranged for and the
Plan has issued an authorization for the referral in advance. 13.
13 Page 14 15
2003 Union Health Service 11 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 $10 per office visit.

. 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. UHS has a deductible for orthopedic and

prosthetic devices and durable medical equipment, see page 19, otherwise we do not have a deductible.

NOTE: If you change plans during open season, you do not have to start a new deductible under you 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 negotiated fee that you must pay for
your care. Coinsurance doesn't begin until you meet your deductible.

In our Plan, you pay 20% of our allowance for orthopedic and prosthetic devices and for durable medical equipment.

Your catastrophic protection Your out-of-pocket expenses for benefits covered under this Plan are out-of-pocket maximum for limited to the stated copayments and deductibles required for a few
deductibles, coinsurance and benefits. Copayments
Be sure to keep accurate records of your copayment since you are responsible for informing us when you reach the maximum. 14.
14 Page 15 16
2003 Union Health Service 12 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and page 54 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain advice, or more information about our benefits, contact our Member Service Department at 312 829-4224 ext. 3379.
(a) Medical services and supplies provided by physicians and other health care professionals.. 13-20
. Diagnostic and treatment services
. Lab, X-ray, and other diagnostic tests
. Preventive care, adult
. Preventive care, children
. Maternity care
. Family planning
. Infertility services
. Allergy care
. Treatment Therapies
. Physical and Occupational therapies
. Speech Therapy

. Hearing services (testing, treatment, and
supplies) . Vision services (testing, treatment, and

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ........................ 21-24
. Surgical procedures
. Reconstructive surgery
. Oral and maxillofacial surgery
. Organ/ tissue transplants
. Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services...................................................... 25-27
. Inpatient hospital
. Outpatient hospital or ambulatory surgical

center

. Extended care benefits/ skilled nursing care
facility benefits . Hospice care

. Ambulance

(d) Emergency services/ accidents ......................................................................................................................... 28-29 . Medical emergency . Ambulance

(e) Mental health and substance abuse benefits .................................................................................................... 30-31
(f) Prescription drug benefits................................................................................................................................ 32-33
(g) Special features..................................................................................................................................................... 34 . Not for Profit Organization . 24 hour emergency line . High risk pregnancies

. Centers of excellence for transplants/ heart surgery/ etc . Translation Services . Urgent Care
. Continuity of Care . Staff Model
(h) Dental benefits...................................................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members ................................................................................................... 36

Summary of benefits.................................................................................................................................................... 54 15.
15 Page 16 17
2003 Union Health Service 13 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things 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.
. We have deductibles for prosthetic and orthopedic devices and durable medical equipment
. Be sure to read Section 4, Your costs for covered service, for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including Medicare.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible
Diagnostic and treatment services
Professional services of physicians
. In physician's office

. In an urgent care center
. Office medical consultations

. Second surgical opinion

$10 per visit

Professional services of physicians .
During a hospital stay .
In a skilled nursing facility Nothing

At home $10 per visit

Diagnostic and treatment services --Continued on next page 16.
16 Page 17 18
2003 Union Health Service 14 Section 5( a)
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. Cat Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

Nothing

Preventive care, adult
Routine screenings, such as:
. Total Blood Cholesterol once every three years, ages 19 through 64

. Colorectal Cancer Screening, including

-Fecal occult blood test

Nothing

-Sigmoidoscopy, screening every five years starting at age 50
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $10 per visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$10 per visit

Routine mammogram covered for women age 35 and older, as follows:
. 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 two consecutive calendar years

Nothing.

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All Charges
Routine immunizations, limited to:
. 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

$10 per visit 17.
17 Page 18 19
2003 Union Health Service 15 Section 5( a)
Preventive care, children You pay
. Childhood immunizations recommended by the American Academy
of Pediatrics $10 per visit

. Well-child care charges for routine examinations, immunizations and
care (up to age 22)

. Examinations, such as:

-Eye exams through age 17 to determine the need for vision correction.

-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations (up to age 22)

$10 per visit

Maternity care
Complete maternity (obstetrical) care, such as:
. Prenatal care

. Delivery
. Postnatal care

Note: Here are some things to keep in mind:
. You do not need prior approval for your normal delivery; see page
26 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 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.
. We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$10 per visit

Not covered: Routine sonograms to determine fetal age, size or sex All charges 18.
18 Page 19 20
2003 Union Health Service 16 Section 5( a)
Family planning You pay
A range of voluntary family planning services, such as;
. Voluntary sterilization (See Surgical procedures Section5 (b))

. Surgically implanted contraceptives
. Injectable contraceptive drugs
. Intrauterine devices (IUDs)
. Diaphragms

NOTE: We cover oral contraceptives under the prescription drug benefit

$10 per visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
. Artificial insemination:

-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
. Fertility drugs are covered as mandated by the State of Illinois.

. Other assisted reproductive technology (ART) procedures that enable a
woman with otherwise untreatable infertility to become pregnant through artificial conception procedures such as in vitro fertilization

and embryo transfers including medical examinations in accordance with the limitations specified in the State of Illinois mandated benefits.

Note: The State of Illinois has limitations on the number of ART procedures.

$10 per visit

Not covered:
. Cost of donor sperm

. Assisted reproductive technology (ART) procedures, such as:

-in vitro fertilization
-embryo transfer and GIFT
. Services and supplies related to excluded ART procedures

All charges.

Allergy care
Testing and treatment $10 per visit 19.
19 Page 20 21
2003 Union Health Service 17 Section 5( a)
Allergy serum
Allergy injection
Nothing

Not covered: provocative food testing and sublingual allergy desensitization All charges.
Treatment therapies You pay
. Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 23.
. Respiratory and inhalation therapy

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

. Growth hormone therapy (GHT)

Note: We will only cover GHT when the treatment is authorized by the Medical Director. We will ask your primary care physician to
submit information that establishes that the GHT is medically necessary. Authorization must be given before you begin GHT
treatment; otherwise, we will only cover GHT services from the date of approval. If you do not ask or if we determine GHT is not medically
necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Growth Hormone therapy is covered under the plan's medical benefits.

$10 per visit

Physical and Occupational therapies
. 60 treatments per condition for the services of each of the
following:

-licensed physical therapists;
-occupational therapists.
Note: We only cover short-term therapy to restore bodily function when there has been a total or partial loss of bodily function due to

illness or injury. Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved
functioning in other activities of daily living.
. Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 30 sessions.

$10 per visit

Not covered:
. long-term rehabilitative therapy

. exercise programs

All charges. 20.
20 Page 21 22
2003 Union Health Service 18 Section 5( a)
Speech therapy You Pay
. 60 treatments per condition upon approval of the Plan's Medical
Director.
$10 per visit

Not covered:
. therapy that will not result in improvement to your condition within
60 visits

All charges

Hearing services (testing, treatment, and supplies) You Pay
. Hearing testing only when necessitated by accidental injury
. Hearing testing for children through age 17 (see Preventive care,
children)

$10 per visit

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

Vision services (testing, treatment, and supplies)
In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, you may obtain one annual eye

refraction (which includes the written lens prescription).
$10 per visit

. Eye exam to determine the need for vision correction for children
through age 17 (see preventive care)

. Annual eye refractions

$10 per visit

Not covered:
. Eyeglasses or contact lenses.

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

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per visit

Not covered:
. 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, flat feet, bunions or spurs; and of any
instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges. 21.
21 Page 22 23
2003 Union Health Service 19 Section 5( a)
Orthopedic and prosthetic devices You pay
. Artificial limbs and eyes; stump hose
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5( b) for coverage of the surgery to insert the

device.
. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

20% of charges after you pay the calendar year deductible.
$100 deductible per member per calendar year (maximum $300
family deductible).

Not covered:
. 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

All charges.

Durable medical equipment (DME)
Purchase or rental (up to the purchase price), at our option, including repair and adjustment, of durable medical equipment prescribed by your

Plan physician as medically necessary, such as oxygen and dialysis equipment. Under this benefit, we also cover:

. Hospital beds;
. Wheelchairs
. Crutches
. Walkers;
. Blood glucose monitors; and
. Insulin pumps.

Note: Call our Medical Management Department at 312 829-4224 ext. 3210 as soon as your Plan physician prescribes this equipment. We will

arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service
when you call.

20% of charges after you pay the calendar year deductible.
$100 deductible per member per calendar year (maximum $300
family deductible).

Not covered: . Motorized wheel chairs
. Equipment that is not medically necessary
All charges. 22.
22 Page 23 24
2003 Union Health Service 20 Section 5( a)
Home health services You Pay
. Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), or home health aide.

. Services include oxygen therapy, intravenous therapy and
medications.

. Home health care is provided for homebound members at their home
when prescribed by a Plan physician.

Note: Our Medical Management Department will monitor all home health care.

$10 per visit

Not covered: . Nursing care requested by, or for the convenience of, the patient or
the patient's family; . Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Alternative treatments
No benefit for services such as: . Acupuncture

. Naturopathic services
. Hypnotherapy
. Biofeedback

All charges.

Chiropractic
Your UHS Orthopedic physician may refer you for a chiropractic consultation or chiropractic care.

Note: You must receive prior approval from the Plan's Medical Director to receive chiropractic services. The Plan's medical director will review your
chiropractor's treatment plan after your receive your consultation. (See section 3 for services requiring prior approval)

$10 per visit 23.
23 Page 24 25
2003 Union Health Service 21 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

. Plan physicians must provide or arrange your care.
. We only have deductibles for prosthetic and orthopedic devices and durable medical equipment
. 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 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 .
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information and services requiring our prior

approval shown in Section 3 to be sure which services require precertification or prior approval.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible
Surgical procedures
A comprehensive range of services and operative procedures, such as:
. Treatment of fractures, including casting
. Normal pre-and post-operative care by the surgeon
. Correction of amblyopia and strabismus
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and cysts
. Correction of congenital anomalies (see reconstructive surgery)
. Surgical treatment of morbid obesity --a condition in which an

individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible

members must be age 18 or over. Surgery for morbid obesity should be performed only as a last resort, when the member's
health is endangered and more conservative medical measures, including prescription drugs such as appetite suppressants, have
not been successful.
. Insertion of internal prosthetic devices such as pacemakers and
artificial joints. See 5( a) Orthopedic and prosthetic devices for device coverage information.

$10 per visit; nothing for hospital visits

Surgical procedures continued on next page. 24.
24 Page 25 26
2003 Union Health Service 22 Section 5( b)
Surgical procedures (Continued) You pay
. Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
. Treatment of burns
$10 per visit

Not covered: . Reversal of voluntary sterilization
. Routine treatment of conditions of the foot; see Foot care.
All charges.

Reconstructive surgery
. Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if:

-the condition produced a major effect on the member's appearance and

-the condition can reasonably be expected to be corrected by such surgery
. Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft

palate; birth marks; webbed fingers; or webbed toes.

$10 per visit; nothing for hospital visits

. All stages of breast reconstruction surgery following a mastectomy,
such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices)

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.

$10 per visit; nothing for hospital visits

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

All charges 25.
25 Page 26 27
2003 Union Health Service 23 Section 5( b)
Oral and maxillofacial surgery You Pay
Oral surgical procedures, limited to: . Reduction of fractures of the jaws or facial bones;

. Surgical correction of cleft lip, cleft palate;
. Removal of stones from salivary ducts;
. Excision of leukoplakia or malignancies;
. Excision of cysts and incision of abcesses when done as independent

procedures; and . Other surgical procedures that do not involve the teeth or their

supporting structures.

$10 per visit; nothing for hospital visits

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

. Shortening of the mandible or maxillae for cosmetic purposes,
correction of malocclusion, and any other dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction

syndrome.

All charges.

Organ/ tissue transplants
Limited to: .
Cornea .
Heart .
Kidney .
Liver .
Allogeneic (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 (autologous bone marrow transplants limited to non-random clinical trials)

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

Limited Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by the Plan's Medical Director in accordance with the Plan's protocols.

Note: Transplants must be approved by the Medical Director. We will refer you to a specific treatment location. We cover related medical and
hospital expenses of the donor when we cover the recipient.

$10 per visit; nothing for hospital visits.

Not covered: . Donor screening tests and donor search expenses, except those
performed for the actual donor . Implants of artificial organs

. Transplants not listed as covered

All charges 26.
26 Page 27 28
2003 Union Health Service 24 Section 5( b)
Anesthesia You pay
Professional services provided in
. Hospital (inpatient)
. Hospital outpatient department
. Skilled nursing facility
. Ambulatory surgical center
. Office

Nothing 27.
27 Page 28 29
2003 Union Health Service 25 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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 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

Sections 5( a) or (b). .
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 (services requiring our approval) to be sure

which services require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as . Ward, semiprivate, or intensive care accommodations;

. General nursing care; and
. Meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

Inpatient hospital continued on next page. 28.
28 Page 29 30
2003 Union Health Service 26 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: . Operating, recovery, maternity, and other treatment rooms
. Prescribed drugs and medicines
. Diagnostic laboratory tests and X-rays
. Administration of blood and blood products
. Blood or blood plasma, if not donated or replaced
. Dressings, splints, casts, and sterile tray services
. Medical supplies and equipment, including oxygen
. Anesthetics, including nurse anesthetist services
. Take-home items
. Medical supplies, appliances, medical equipment, and any covered

items billed by a hospital for use at home (Note: calendar year deductible applies to durable medical equipment and prosthetic

and orthopedic devices.)

Nothing

Not covered: . Custodial care, rest cures, domiciliary or convalescent care
. Non-covered facilities
. Personal comfort items, such as telephone, television, barber

services, guest meals and beds . Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
. Operating, recovery, and other treatment rooms
. Prescribed drugs and medicines
. Diagnostic laboratory tests, X-rays, and pathology services
. Administration of blood, blood plasma, and other biologicals
. 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.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges 29.
29 Page 30 31
2003 Union Health Service 27 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
We provide a comprehensive range of benefits for up to 60 days per calendar year when full time nursing care is necessary and

confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

. Bed, board and general nursing
. Drugs, biologicals, supplies, and equipment ordinarily
provided or arranged by the skilled nursing facility (SNF) when prescribed by a Plan doctor and managed by our Medical

Management Department.

Nothing

Not covered: custodial care All charges
Hospice care
We cover supportive and palliative care for a terminally ill member in the home or hospice facility. Services include inpatient and outpatient

care, and 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

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
. Local professional ambulance service when approved by the Plan
and medically appropriate Nothing 30.
30 Page 31 32
2003 Union Health Service 28 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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.

I M
P O
R T
A N
T
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 the Plan
24-hour emergency number at once at 312/ 829-4224. The Plan has doctors on call around the clock, seven days a week. 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. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a
family member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within
that time, If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges
covered in full.
Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

Emergencies outside our service area: Benefits are available for any 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 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a
Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full. 31.
31 Page 32 33
2003 Union Health Service 29 Section 5( d)
Benefit Description You pay
Emergency within our service area
. Emergency care at a doctor's office

. Emergency care at a Plan urgent care center
$10 per visit

. Emergency care at a non-Plan urgent care center
. Emergency care as an outpatient at a hospital, including doctors'
services

$25 per visit

We waive the copay if you are admitted to the hospital.
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital, including

doctors' services

$25 per visit

We waive the copay if you are admitted to the hospital.
Not covered:
. 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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance when approved by the Plan and medically appropriate
See 5( c) for non-emergency service.

Nothing 32.
32 Page 33 34
2003 Union Health Service 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

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.
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.

. All benefits are subject to the definitions, limitations, and exclusions in this brochure.

. 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 Medicare.

. YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF THESE SERVICES.
See the instructions after the benefits section below.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year
deductible

Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

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

Your cost sharing responsibilities are no
greater than for other illness or conditions.

. Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers

. Medication management

$10 per visit

Mental health and substance abuse benefits -Continued on next page 33.
33 Page 34 35
2003 Union Health Service 31 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
. Diagnostic tests when ordered by a Plan doctor Nothing

. Services provided by a hospital or other facility
. Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing.

Not covered:
. Services we have not approved.
. Psychiatric evaluation or therapy on court order or as a condition of

parole or probation, unless determined by a Plan doctor to be necessary and appropriate

. Services rendered or billed by a school or a member of its staff
. Psychotherapy or psychoanalysis credited toward furthering

education, training, or earning a degree . Intelligence, IQ, aptitude, ability, or interest testing not necessary to

determine the appropriate treatment of a psychiatric condition.

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.

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
YOU MUST GET PRECERTIFICATION OF SOME PROCEDURES. Please refer to Section 3 for information on which services require precertification or prior
approval.
The Plan emergency number, (312) 829-4224, can be accessed 24-hours a day 7 days a week.

Referrals will be written by the Plan Primary Care Physicians to network mental health and substance abuse providers
Upon initial consultation an authorized treatment plan will be determined and structured .
Inpatient services will be precertified through the Plan's case managers Review and discharge planning are all through the Plan case managers

Limitation We may limit your benefits if you do not obtain a treatment plan 34.
34 Page 35 36
2003 Union Health Service 32 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

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.

. 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 Medicare.

I M
P O
R T
A N
T
There are important features you should be aware of. These include:
. Who can write your prescription. A Plan physician or Plan licensed dentist must write the
prescription.

. Where you can obtain them. You must fill the prescription at a Plan pharmacy. The Plan
pharmacy can fill some maintenance medications by mail.

. These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day
supply or 100 unit supply, whichever is less; 240 milliliters of liquid (8oz.); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i. e., one inhaler, one vial

ophthalmic medication or insulin).
Certain maintenance prescriptions can be mail ordered according to Food and Drug Administration Guidelines and you can obtain these by mail from the Plan pharmacy. Contact the Plan pharmacy

at 312 829-4224 ext. 3260 to make arrangements.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is

available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

Sexual dysfunction drugs have dispensing limitations. Contact the Plan pharmacy for details.
. Why use generic drugs. Generic drugs are lower-priced drugs in which the therapeutic ingredient
is chemically equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product.

Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand-name drugs.
. When you have to file a claim. You will not have to file a claim unless you receive covered
prescription drugs during an out of area emergency. See Section 7 for information on how to file your claim 35.
35 Page 36 37
2003 Union Health Service 33 Section 5( f)
Benefit Description You pay After the calendar year deductible
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program: . Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as Not covered.
. Insulin
. Disposable needles and syringes for the administration of covered

medications . Drugs for sexual dysfunction when medically necessary (contact the

Plan Pharmacy for limits) . Contraceptive drugs and devices
. Intravenous fluids and medication for home use, implantable drugs,
and some injectable drugs are covered under Medical and Surgical benefits

. Fertility drugs are covered under infertility benefits, see page 16

$15 per prescription unit or refill

Not covered:
. Drugs and supplies for cosmetic purposes

. Vitamins and nutritional substances that can be purchased without a
prescription

. Drugs available without a prescription or for which there is a
nonprescription equivalent available

. Drugs obtained at a non-Plan pharmacy except for out of area
emergencies

. Drugs to enhance athletic performance

. Medical supplies such as dressings and antiseptics

All Charges 36.
36 Page 37 38
2003 Union Health Service 34 Section 5( g)
Section 5 (g). Special Features
Feature Description
Not for Profit Organization UHS is a not-for-profit organization managed by a Board composed of members representing Unions, physicians, and community leaders.

24 hour emergency line Emergencies -24 hours a day, 7 days a week, you may call 1-312-829-4224.

High risk pregnancies Affiliated with Major Medical Centers
Centers of excellence for transplants/ heart
surgery/ etc

Affiliated with Major Medial Centers and guided by National Transplant Program

Translation Services Extensive translation skills among staff and physicians
Urgent Care UHS offers urgent care/ extended clinic hours at our main facility on weekends.

Continuity of Care Union Health Service has low physician and employee turnover

Staff Model Because of our staff model status, most physicians are employees who work for UHS at our locations. For example: podiatry, ophthalmology, optometry, cardiology, allergy, gastroenterology, and
dentists are all some of the many specialties that work at our main medical facility. 37.
37 Page 38 39
2003 Union Health Service 35 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

. Plan dentists must provide or arrange your care.
. 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 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 Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must

result from an accidental injury.
$10 per visit

Dental benefits
We have no other FEHB dental benefits. (Please refer to Non-FEHB benefits available to Plan members) 38.
38 Page 39 40
2003 Union Health Service 36 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
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 out-of-pocket
maximums.
Vision care . One annual refraction (which includes the written lens prescription) may be obtained from a UHS optometrist. The services are available by appointment at the UHS Eye Care Center

312 829-4224 ext. 3320 located at the UHS Main Facility, 1634 West Polk Street, Chicago, IL 60612
. UHS Plan members receive special package prices and discounts on eyeglasses, frames, lenses,
contact lenses and optical accessories at all For Eyes Optical store locations. . For further information about our Vision Benefits please contact our Member Service Department

at 312 829-4224 ext. 3379

Dental Care . Dental Services are available to UHS Plan members. The services are available by appointment at UHS Dental Office 312 829-4224 ext. 3308 located at the UHS Main Facility, 1634 West Polk
Street, Chicago, IL 60612 . Annual Office No Charge
. Annual Oral Examination and diagnosis.. No Charge
. Annual Fluoride Treatment... No Charge

(dependent under age 19) . Other dental services are available at reduced cost with an additional 20% discount. Payment is

required at the time of service. The benefits are available only at the UHS Dental Office
For further information about our Dental Benefits, please contact our Marketing Department at 312 829-4224 ext. 3222

Benefits on this page are not part of the FEHB contract 39.
39 Page 40 41
2003 Union Health Service 37 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.
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;

. 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

. Services, drugs, or supplies related to sex transformations; or
. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
. Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2003 Union Health Service 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.
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 312 829-4224 ext. 3304.

When you must file a claim --such as for services you receive outside of the Plan's service area submit the hospital bill or the claim on the
HCFA-1500 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: Union Health Service Insurance Department 1634 West Polk Street
Chicago, Illinois 60612

Prescription drugs . Submit out-of-area and emergency prescription drug reimbursement claims to:
Submit your claims to: Union Health Service Pharmacy 1634 West Polk Street
Chicago, IL 60612

Other supplies or services . All other claims for supplies or services should be sent to the following department for review and processing 41.
41 Page 42 43
2003 Union Health Service 39 Section 7
Submit your claims to: Union Health Service Insurance Department 1634 West Polk Street
Chicago, Illinois 60612

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. 42.
42 Page 43 44
2003 Union Health Service 40 Section 8
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: UHS Medical Director, 1634 West Polk Street, Chicago, IL 60612; 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 physicians' 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:
. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
. 120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630. 43.
43 Page 44 45
2003 Union Health Service 41 Section 8
The Disputed Claims process (Continued)
Send OPM the following information: .
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

. Copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms; .
Copies of all letters you sent to us about the claim; .
Copies of all letters we sent to you about the claim; and .
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 312 829-4224 ext. 3359 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
. If we expedite our review and maintain our denial, we will inform OPM so that they can give your
claim expedited treatment too, or

. You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time. 44.
44 Page 45 46
2003 Union Health Service 42 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays heatlh care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance. If we are the secondary payer, we may be entitled to receive payment from your primary plan.

We will always provide you with the benefits described in this brochure. Remember: even if you do not file a claim with your other plan, you must still tell us that you have
double coverage.

. What is Medicare? Medicare is a Health Insurance Program for:
. People 65 years of age and older.
. Some people with disabilities, under 65 years of age.
. People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
. Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse
worked for at least 10 years in Medicare covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or

since automatically qualifies) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for information.

. Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your retirement check.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available to Medicare beneficiaries.
The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan you have.

. The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,

or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or precertified as required 45.
45 Page 46 47
2003 Union Health Service 43 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
. When we are the primary payer, we process the claim first.
. When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find

out if you need to do something to file your claim, call us at 312 829-4224 ext. 3304.

We waive some costs if the Original Medicare is your primary payer We will waive some out-of-pocket costs as follows:
. Deductible for inpatient hospitalization
. The balance of what Medicare does not pay for physician services

In the following cases, we do not waive any out-of-pocket costs: . Medical services and supplies provided by physicians and other
health care professionals who do not follow all of our rules, and guidelines;
. Care received from out-of-plan providers. 46.
46 Page 47 48
2003 Union Health Service 44 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely because of a disability), .

2) Are an annuitant, .
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB .

b) The position is not excluded from FEHB
Ask your employing office which of these applies to you.

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), .
5) Are enrolled in Part B only, regardless of your employment status, . (for Part B
services)

.
(for other services)

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

.
(except for claims related to Workers'

Compensation.)
B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD, .
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD, .
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, .
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or .
b) Are an active employee .

c) Are a former spouse of an annuitant .
d) Are a former spouse of an active employee .

. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from a Medicare managed care plan. These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to

doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans provide all the benefits the original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan, 47.
47 Page 48 49

2003 Union Health Service 45 Section 9
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. We do not have a Medicare Managed Care Plan; however, we do have a Medicare Health
Care Prepayment Plan (HCPP). For more information on our Medicare HCPP, call us at 312/ 829/ 4224 ext. 3379.

If you enroll in a Medicare managed care plan, the following options are available to you: This Plan and another Plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary, even
out of the managed care plan's network and/ or service area (if you use our Plan providers), but we will not waive any of our copayments, coinsurance, or deductibles. If
you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care plan so we can correctly
coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium). For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the Medicare managed care plan's service area.
. If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under the
Medicare Part A or Part B FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.

Workers' Compensation We do not cover services that: .
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they

must provide; or
. OWCP or a similar agency pays for through a third party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your eligible care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in a one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may 48.
48 Page 49 50
2003 Union Health Service 46 Section 9
do so only at the next Open Season unless you involuntarily lose coverage under the State program.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care for for injuries injuries or illness caused by another person, you must reimburse us for any expenses we
paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 49.
49 Page 50 51
2003 Union Health Service 47 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Treatment or services that are designed mainly to help the patient with daily living activities. Custodial care that lasts 90 days or more is
sometimes known as Long term care

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 11.

Experimental or If a medical treatment, procedure, drug, device, or biological product is investigational services FDA approved, the Plan will use this as a basis for providing coverage.
If it lacks FDA's approval, the Plan will make a policy decision based on specific statements from specialty societies or medical organizations such
as the American Cancer Society, the American College of Surgeons, and the American Medical Society

Group health coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or other health care services or supplies.

Medically necessary A Medically Necessary service is a service that is (1) consistent with the Enrollee's condition, disease, ailment or injury, (2) appropriate with
regard to standards of good medical practice, (3) not solely for the convenience of the Enrollee or provider, and (4) the most appropriate
supply or level of service which can be safely rendered to the Enrollee. When specifically applied to an inpatient, it further means that the
Enrollee's medical symptoms or condition require that the diagnosis or treatment cannot be effectively, safely and economically provided to the
Enrollee in an outpatient setting.
Your Primary Care Physician, in accordance with the above standards adopted by Union Health Service, will determine when a service is
medically necessary.

Us/ We Us and we refer to Union Health Service
You You refers to the enrollee and each covered family member. 50.
50 Page 51 52

2003 Union Health Service 48 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about: your FEHB coverage. These
materials tell you:
. When you may change your enrollment;
. How you can cover your family members;
. What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;

. When your enrollment ends; and

. When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your

employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's equity Act of 2000. This law mandates that you be enrolled
for Self and Family coverage in the Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or 51.
51 Page 52 53
2003 Union Health Service 49 Section 11
administrative order requiring you to provide health benefits for your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows: . If you have no FEHB coverage, your employing office will
enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,
. If you have a Self Only enrollment in a fee-for-service plan or in
an HMO that serves the area where your children live, your employing office will change your enrollment to Self and

Family in the same option of the same plan; or . If you are enrolled in an HMO that does not serve the area
where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield
Service Plan's Basic Option. As long as the court/ administrative order is in effect, and you have at
least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel you