Document Body Page Navigation Panel Document Outline

Blue HMO SM

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
- How we pay providers
- Your Rights
- Service Area
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
- Identification cards
Where you get covered care
- Plan providers
- Plan facilities
What you must do to get
- How you choose a PCP
  - How you change your PCP
- Primary care
- Specialty care
- Hospital care
Circumstances beyond our
Services requiring our prior
Section 4. Your costs for covered services
- Copayment
- Deductible
- Coinsurance
Your catastrophic protection
Section 5. Benefits OVERVIEW
- Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5 (c). Services provided by a hospital or other facility, and ambulance services
- Section 5 (d). Emergency services/accidents
- Section 5 (e). Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
- Section 5 (g). Special features
- Flexible benefits
- 24 hour nurse line
- Centers of excellence
- Reciprocity benefit
  - Guest Membership Program
  - BlueCard Program
- Discount programs
  - Anthem Advantage
Section 5 (h). Dental benefits
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
- Deadline for filing your claim
- When we need more information
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health
- What is Medicare?
  - Medicare managed care
- TRICARE and CHAMPVA
Workers' Compensation
Medicaid
When other Government agencies
When others are responsible for
Section 10. Definitionsof terms we use in this brochure
- Calendar year
- Coinsurance
- Copayment
- Covered services
- Custodial care
- Experimental or investigational
- Group health coverage
- Medical necessity
- TRICARE and CHAMPVA
- Our allowance
- Predetermination
- Us/We
- You
Section 11. FEHB facts
- No pre-existing condition
- Where you can get information
- Types of coverage available for
- Children's Equity Act
- When benefits and
- When you retire
- When you lose benefits
Getting a Certificate of
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for Blue HMO - 2003
2003 Rate Information for Blue HMO

Pages 1--68

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

Blue HMO SM Formerly Health Maintenance Plan http:// www. anthem. com
2003 A Health Maintenance Organization

Serving: Most Of Ohio
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

This Plan has excellent accreditation from NCQA. See the 2003 Guide for more information on accreditation.
Enrollment codes for this Plan:
R51 Self Only R52 Self and Family

RI 73-031

For changes in benefits,
see pages 8 & 9. 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

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

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

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

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this NOTICE. You

may take back (" revoke") your written permission at any time, except if OPM has already acted based on your permission. 3.
3 Page 4 5
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202/ 606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 Blue HMO 3 Table of Contents
Table of Contents (Continued) 24 hour nurse line
Centers of excellence for transplants/ heart surgery
Reciprocity benefit
Discount programs
(h) Dental benefits............................................................................................................................... 40

2003 Blue HMO 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Blue HMO SM , under our contract (CS 1659) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by
Community Insurance Company, dba Anthem Blue Cross and Blue Shield*. The address for Blue HMO administrative office is:

Anthem Blue Cross and Blue Shield Blue HMO, Mail No. CE2-014
1351 William Howard Taft Road Cincinnati, Ohio 45206-1775

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 summarized on pages 8 and 9. Rates are shown at the end of this brochure.

*An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. . Registered marks Blue Cross and Blue Shield Association.

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 Blue HMO

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare
plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650. 7.
7 Page 8 9
2003 Blue HMO 5 Stop Health Care Fraud!
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how
to bill us to get it paid. Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 848-9276 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 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 Blue HMO 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 contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

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:
Disenrollment rates for 2001 Compliance with State and Federal licensing or certification requirements and the dates met. If noncompliant, the
reason for noncompliance. Accreditations by recognized accrediting agencies and the dates received
Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency, confidentially and transfer of medical record
Years in existence Profit status
Medical Records Transitional Care

If you want more information about us, call 800/ 228-4375, or write to Mail No. CE2-014, 1351 William Howard Taft Road, Cincinnati, Ohio 45206-1775. You may also contact us by fax at 513/ 872-3929 or visit our website at
www. anthem. com.
The Plan has a confidentiality Policy. This policy sets forth guidelines regarding a member's right to access and amend information in the Plan's possession. The Policy specifically addresses when a release, signed by a member, is
required before information may be disclosed by the Plan to parties such as a member's provider, spouse, or other family members. Through the contract under which the Plan is administering your benefits, the Plan is not required to
obtain your consent to the release of any information or records concerning claims for routine uses as may be reasonably necessary for the administration of your benefits. Please refer to our website www. anthem. com,
Frequently Asked Questions, for further details. 9.
9 Page 10 11
2003 Blue HMO 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:

Cincinnati Area: In Ohio --Adams, Brown, Butler, Clermont, Clinton, Hamilton, Highland and Warren Counties
Cleveland Area: In Ohio Ashtabula, Cuyahoga, Geauga, Lake, Lorain, Medina, and Summit Counties
Dayton Area: In Ohio --Butler, Champaign, Clark, Clinton, Darke, Greene, Logan, Miami, Montgomery, Preble, Shelby and Warren counties, and ZIP codes 43128 and 43142 in Fayette County

Akron-Canton Area: In Ohio --Ashland, Carroll, Harrison, Holmes, Medina, Portage, Stark, Summit, Tuscarawas, and Wayne Counties
Warren-Youngstown Area: In Ohio Belmont, Columbiana, Jefferson, Mahoning, and Trumbull Counties
Columbus Area: In Ohio --Athens, Coshocton, Crawford, Delaware, Fairfield, Franklin, Guernsey, Hocking, Knox, Licking, Madison, Marion, Morrow, Muskingham, Perry, Pickaway, Pike, Richland, Ross, Scioto, Union and
Washington Counties
Toledo-Defiance Area: In Ohio --Allen, Auglaize, Defiance, Erie, Fulton, Hancock, Hardin, Henry, Huron, Lucas, Mercer, Ottawa, Paulding, Putnam, Sandusky, Seneca, Williams, Wood, Wyandot and Van Wert Counties

Ordinarily, you must receive care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency or urgent care benefits. We will not pay for any other health care services out of our
service area unless the services have prior plan 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. Refer to Section 5( g) Special Features on page 39 for details regarding our reciprocity benefits. If you or a family member
move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 10.
10 Page 11 12
2003 Blue HMO 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5, Benefits. Also, we edited and clarified language throughout the brochure; any language change not
shown here is a clarification that does not change benefits.

Program-wide changes
A notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 9. 1% for Self Only or 29. 6% for Self and Family.
We changed our name for 2003. If you were already enrolled under Health Maintenance Plan (R5), you do nothing to enroll for 2003.

We no longer require referrals for participating specialty care providers; however, certain services may require precertification and/ or predetermination.
We have expanded our service and enrollment areas. ( Section 1 )
We changed the Preventive care, adult benefits by removing the age limits on routine mammograms; we will now cover one routine mammogram per calendar year regardless of age. ( Section 5( a) )

We changed the Family planning benefit to remove the 20% copay on Voluntary sterilization procedures. ( Sections 5( a) and 5( b) )
We changed the 50% copay on Intrauterine devices (IUDs) and Diaphragms when provided during an office visit, to 20%. ( Section 5( a) )
We changed the physical and occupational therapy benefit to 60 visits per calendar year with a $10 per visit copay. ( Section 5( a) )
We changed the speech therapy benefit to 20 visits per calendar year with a $10 per visit copay. ( Section 5( a) )
We changed the hearing benefits to remove the age limit on ear exams to determine the need for hearing correction. ( Section 5( a) )

We changed the copay for TMJ appliances from 50% to 20% and removed the $200 maximum. ( Section 5( a) )
We now cover 12 spinal manipulations, per calendar year, performed by a chiropractor or doctor of osteopathy with a $10 per visit copay. ( Section 5( a) )

We changed the organ/ tissue transplant benefit to exclude transplants in a non-designated organ transplant facility. ( Section 5( b) )
We changed the organ/ tissue transplant benefit to include coverage for travel expenses related to covered transplants outside of a 75-mile radius. ( Section 5( b) )
We changed the extended care/ skilled nursing care facility benefits from 0-30 days at 100% and days 31-180 at 50%, to 60 days covered in full. ( Section 5( c) )
We removed the 20% copay on infertility treatment services. ( Section 5( a) ) 11.
11 Page 12 13
2003 Blue HMO 9 Section 2
We changed the 50% copay for the first pair of lenses following cataract surgery to 20%. ( Section 5( a) )
We changed the 50% copay for orthopedic and prosthetic devices to 20%. ( Section 5( a) )

We changed the 50% copay for durable medical equipment (DME) to 20%. ( Section 5( a) )
We changed the 50% copay for breast prostheses and surgical bras and replacements to 20%. ( Section 5( b) )
We removed the 20% copay for ambulance services. ( Sections 5( c) and 5( d) )
The prescription drug copays for a 30-day supply will increase from : $8 copay for generic, $15 for formulary name brand and $25 for non-formulary name brand to $10 for generic, $20 for formulary name brand and $30 for

non-formulary name brand. ( Section 5( f) )
The prescription drug copays for a 90-day supply will increase from: $16 copay for generic, $30 for formulary name brand and $40 for non-formulary name brand to $20 for generic, $40 for formulary name brand and $60 for

non-formulary name brand. ( Section 5( f) )
We now cover Autologous tandem transplant for testicular and other germ cell tumors. ( Section 5( b) )
We removed the 20% copay for allergy serum and allergy injections. ( Section 5( a) ) 12.
12 Page 13 14

2003 Blue HMO 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800/ 228-
4375 or write to us at Blue HMO, 1351 William Howard Taft Road, CE2-014, Cincinnati, OH 45206. You may also request replacement
cards through our website at www. anthem. com.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www. anthem. com.

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. The list is also on our website at www. anthem. com.

It depends on the type of care you need. First, you and each family member must choose a primary care physician (PCP). This decision is
important since your primary care physician provides or arranges for most of your health care.

How you choose a PCP
1. Ask family and friends about their doctors. While you're at it, ask health care practitioners you respect, too. Personal

recommendations can mean a lot.
2. After you choose a PCP, make an appointment with your PCP, get to know your PCP and help your PCP get to know you. At your first
appointment, talk to your PCP about: What are your office hours?

Who will handle my care when you aren't available?
3. Pay attention. Does the physician explain things so you can understand? Are you comfortable talking with him or her? Is the
tone of the conversation friendly and respectful? Is the physician listening carefully to you?

What you must do to get covered care 13.
13 Page 14 15
2003 Blue HMO 11 Section 3
How you change your PCP
You are encouraged to develop a long-term relationship with one Physician, but you may change your PCP if you feel it is necessary.

Select your new Physician from the Plan's Provider Directory, then contact us to make the change. You can only change your PCP once in a
30-day period.
Timing a Physician change
If you notify us before the 15 th of the month, your new PCP choice is effective the first day of the following month

If you notify us on or after the 15 th of the month, your new PCP choice is effective on the first day of the second month
Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
Specialty care Your primary care physician will refer you to a specialist when necessary; however, we do not require referrals from your PCP for participating
specialty care providers. If specialists or consultants are required beyond those participating with us, your primary care doctor will make
arrangements for appropriate referrals. There are certain services that may require prior approval by us; see Section 3, page 13. It is always a good
idea for you to talk with your PCP before receiving care from any specialty care provider.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will work with you and the Plan to develop a treatment plan.
If you are seeing a specialist when you enroll with us, 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 us.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
Terminate our contract with your specialist for other than cause; or
Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or 14.
14 Page 15 16
2003 Blue HMO 12 Section 3
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 customer service department immediately at 800/ 228-4375. 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.

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. 15.
15 Page 16 17
2003 Blue HMO 13 Section 3
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. We

call this review and approval process precertification.
Your physician must obtain precertification for services such as, but not Limited to:

All inpatient admissions (except maternity)
Outpatient surgeries such as but not limited to: Plastic/ Reconstructive & Uvulopalatopharyngoplasty (UPPP)

Durable Medical Equipment Motorized Wheelchairs and Hospital/ Rocking/ Air Beds
Prosthetics Electronic or Externally Powered Prosthetics and custom made orthotics and braces
Newborn admissions that extend beyond the mother's discharge
Positron Emission Tomography (PET) & Single Photon Emission Computed Tomography (SPECT) scans

Home health services
Surgical treatment of morbid obesity

Precertification is a procedure that requires an approval to be obtained from us before incurring expenses for certain covered services.
when care is evaluated, the medical necessity will be determined. For admissions, the appropriate length of stay will also be determined. For
certain services you will be required to use the provider designated by our Health Care Management staff.

Medical necessity includes a review of both the service and the setting. When approved, a copy of the approval will be provided to you, the
physician, and the hospital or facility. The care will be covered according to your benefits for the number of days approved unless our concurrent
review determines that the number of days should be revised. As a result of concurrent review, additional days of inpatient care may be approved
which exceed the number of days originally authorized by our Health Care Management staff. With prior notice by us, the number of days originally
authorized by precertification may be reduced when it is determined that continued inpatient care is no longer medically necessary.

Your PCP and other network providers know which services require precertification and will obtain any required precertification. If a
request is denied, the provider may request a reconsideration to be completed within 3 days of the request. An expedited reconsideration
may be requested when the member's health requires an earlier decision.

For emergency admissions, precertification is not required; however, you must notify your Primary Care Physician of your admission within
24 hours or as soon as possible within a reasonable period or services after 24 hours could be denied.

Predetermination is the process of requesting approval of benefits before the service or supply is rendered. 16.
16 Page 17 18
2003 Blue HMO 14 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayment 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 We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: You pay 20% of our allowance for durable medical equipment.

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

out-of-pocket maximum, and you must continue to pay copayments and/ or coinsurance for these services:

Dental services
Prescription drugs

Be sure to keep accurate records of your copayments and/ or coinsurance since you are responsible for informing us when you reach the maximum. 17.
17 Page 18 19
2003 Blue HMO 15 Section 5
Section 5. Benefits OVERVIEW
(See pages 8 and 9 for how our benefits changed this year and page 63 for a benefits summary.)

Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 800/ 228-4375.

(a) Medical services and supplies provided by physicians and other health care professionals 16-23
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 ....................... 24-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 28-29
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services ........................................................................................................................................ 30-31
Medical emergency Ambulance

(e) Mental health and substance abuse benefits.................................................................................................... 32-33
(f) Prescription drug benefits ............................................................................................................................... 34-37
(g) Special features ............................................................................................................................................... 38-39 Flexible benefits option

24 hour nurse line
Reciprocity benefit
Centers of Excellence for transplants/ heart surgery
Discount programs
(h) Dental benefits ................................................................................................................................................ 40-42

Summary of benefits .............................................................................................................................................. 63-64 18.
18 Page 19 20
2003 Blue HMO 16 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 no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians, physicians assistants or nurses
In a primary care physician's office
In a specialty physician's office
Office medical consultations
Second surgical opinion

$10 per office visit

Professional services of physicians
In an urgent care center
$25 per visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility
At home

Nothing

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine mammograms
Pathology
X-rays
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Non-routine pap test

$10 per office visit; Nothing for Lab, X-ray and other diagnostic
tests 19.
19 Page 20 21
2003 Blue HMO 17 Section 5( a)
Preventive care, adults You pay
Routine screenings, such as:
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening starting at age 50
Colonoscopy once every 10 years starting at age 50
Double contrast barium enema (DCBE) once every 5-10 years starting at age 50

Prostate Specific Antigen (PSA test) one annually for men age 40 and older
Routine pap test
One routine mammogram, per calendar year, regardless of age

Fasting Lipoprotein profile (total cholesterol, LDL, HDL and triglycerides)

$10 per office visit; Nothing for Routine screenings

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, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccines annually
Pneumococcal vaccine, age 65 and over

$10 per office visit; Nothing for immunizations

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit; Nothing for immunizations

Well-child care charges for routine examinations, immunizations and care (through age 21)
Examinations, such as:
Eye exams through age 17 to determine the need for vision correction

Ear exams to determine the need for hearing correction
Examinations done on the day of immunizations (through age 21)

Nothing if you receive these services during your office visit,
otherwise, $10 per exam 20.
20 Page 21 22
2003 Blue HMO 18 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
One routine sonogram
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 13 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will 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 (including circumcision) 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)

Nothing

Not covered: Subsequent routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization See Section 5( b)
Surgically implanted contraceptives
Note: We cover oral and injectable contraceptives (such as Depo provera) under the prescription drug benefit

$10 per office visit; Nothing for Family planning services

Intrauterine devices (IUDs)
Diaphragms (when provided in a physician's office)
Note: See Section 5( f), Prescription drug benefit, for coverage when purchased through a retail pharmacy

$10 per office visit; 20% of our allowance for Birth control
devices

Not covered: Reversal of voluntary surgical sterilization All charges 21.
21 Page 22 23
2003 Blue HMO 19 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)

$10 per office visit

Diagnosis and treatment of infertility, such as:
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit

$10 per office visit; 50% of our allowance for Fertility drugs

Not covered: Assisted reproductive technology (ART) procedures, such as:
In vitro fertilization Embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer Services and supplies related to excluded ART procedures
Cost of donor sperm Cost of donor egg

All charges

Allergy care
Testing $10 per office visit; 20% of our allowance for Allergy testing

Allergy injections
Allergy serum
$10 per office visit; Nothing for Allergy injections and serum

Not covered: Provocative food testing and sublingual allergy desensitization All charges 22.
22 Page 23 24
2003 Blue HMO 20 Section 5( a)
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 27
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

$10 per office visit; Nothing for Treatment therapies

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit
Note: Approval is based on our medical policy. We may ask you or your physician to submit, through our predetermination process, for the

following:
A letter of medical necessity
Laboratory results, and
A growth chart

$10 per office visit; 50% of our allowance for Growth hormone
therapy (GHT)

Physical and occupational therapies
60 visits, per calendar year, for services by the following:
Qualified physical therapists
Qualified chiropractors (physical therapy only) and
Occupational therapists
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction.

$10 per visit

Not covered: Long-term rehabilitative therapy
Exercise programs Inpatient hospital stays for physical therapy purposes only
All charges

Speech therapy
20 visits, per calendar year $10 per visit 23.
23 Page 24 25
2003 Blue HMO 21 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
Hearing examinations to determine the need for hearing correction Nothing if you receive these services during your office visit;
otherwise $10 per exam

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

Vision services (testing, treatment, and supplies)
One routine eye exam with refraction per year
Note: See Preventive care, children for eye exams for children
$10 per office visit

First pair of lenses following cataract surgery $10 per office visit; 20% of our allowance for First pair of lenses
Not covered: Eyeglasses or contact lenses and examinations for them
Eye exercises and vision training Radial keratotomy and other refractive surgeries
Photo-Refractive keratectomy (PRK)

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 office 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 or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)

All charges

Orthopedic and prosthetic devices
Externally worn orthopedic and prosthetic devices such as:
Artificial limbs and eyes; stump hose
Braces, slings, splints and certain orthotics
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
Note: See Section 5( b) for coverage of the medical treatment of TMJ pain dysfunction syndrome

$10 per office visit; 20% of our allowance for Orthopedic and
prosthetic devices

Orthopedic and prosthetic devices -Continued on next page 24.
24 Page 25 26
2003 Blue HMO 22 Section 5( a)
Orthopedic and prosthetic devices -Continued You pay
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants

following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment information. See Section 5( b) for coverage of

the surgery to insert the device

Nothing

Not covered: Orthopedic shoes
Foot support devices, such as arch supports and corrective shoes, unless they are an integral part of a leg brace
All charges

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment of durable medical equipment prescribed by your Plan physician, such as

oxygen and oxygen equipment. Under this benefit, we also cover items such as:

Hospital beds Wheelchairs
Crutches Walkers
Blood glucose monitors; (when purchased at a participating medical supply provider)
Insulin pumps First pair of lenses following cataract removal
Medical supplies, such as surgical dressings and colostomy bags

$10 per office visit; 20% of our allowance for DME services
rendered in a physician's office or from a medical supplier

Not covered: Devices and equipment used for environmental control or to
enhance the environmental setting, such as air conditioners, humidifiers or air filters
Supplies that can be used by other family members such as: adhesive tape, band-aids, alcohol and cotton balls
Raised toilet seats Personal hygiene and convenience items

All charges 25.
25 Page 26 27
2003 Blue HMO 23 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (RN), licensed practical nurse (LPN), or home

health aide
Services include oxygen therapy, intravenous therapy and medications

Nothing

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
Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication

All charges

Chiropractic
Limited to:
12 Spinal manipulations, per calendar year, provided by the following:

Participating chiropractors
Doctors of Osteopathy

$10 per visit

Alternative treatments
No Benefits All charges

Not covered services such as:
Naturopathic services Hypnotherapy

Biofeedback Acupuncture

Note: Please contact the Plan at 800/ 228-4375 for further clarification

All charges

Educational classes and programs
Coverage is limited to:
Diabetes self-management
$10 per office visit

Smoking cessation (one smoking cessation program per member, per lifetime)
Note: See Section 5( e) for individual or group counseling coverage
Nothing up to $100; All charges thereafter

Not covered: Second and subsequent smoking cessation programs
Services or supplies primarily for educational, vocational, or training purposes, except as otherwise specified herein
All charges 26.
26 Page 27 28
2003 Blue HMO 24 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

medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

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

with the facility (i. e. hospital, surgical center, etc).
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3

to be sure which services require precertification and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Operative procedures

Treatment of fractures, including casting Treatment of burns
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 or Body Mass Index (BMI) of 40 or greater.
For which physician monitored and sanctioned non-surgical treatment has been unsuccessful
For eligible members, age 18 or over
Note: Approval will be based on our medical policy through our predetermination process

Insertion of internal prosthetic devices, such as pacemakers and artificial joints. See Section 5( a), Orthopedic and prosthetic
devices, for device coverage information.
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for

a pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing

Surgical procedures -Continued on next page 27.
27 Page 28 29
2003 Blue HMO 25 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization (e. g., Tubal ligation, Vasectomy) Nothing

Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care in Section 5( a)
Non-surgical treatment of morbid obesity as set-forth by our predetermination process

All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm

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

Nothing

Breast prostheses and surgical bras and replacements (see Section 5( a) 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

20% of our allowance

Not covered: Cosmetic surgery any surgical procedure connected with or
incidental to treatment that is primarily intended to improve appearance as set-forth by our predetermination process
Surgeries related to sex transformation, or the reversal thereof

All charges 28.
28 Page 29 30
2003 Blue HMO 26 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, such as:
Excision of exostoses of the jaws and hard palate. (If pathology exists, generally done to prepare the mouth for dentures.)

Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth
External (extra-oral) incision and drainage of cellulitis
Incision of accessory sinuses, salivary glands or ducts
Reduction of dislocations and excision of the temporomandibular joints (TMJ)

Surgery for correction of accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth
Treatment of fractures of facial bones
Correction of orthognanthic when severe handicapping malocclusion is present

Other surgical procedures that do not involve the teeth or their supporting structures
Note: See Section 5( a), Orthopedic and prosthetic devices, for appliance cost

Nothing

Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involved in the treatment of temporomandibular joint (TMJ) pain dysfunction or syndrome

All charges 29.
29 Page 30 31
2003 Blue HMO 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to: Cornea

Heart Heart/ lung
Kidney Kidney/ Pancreas
Liver Lung: Single Double
Pancreas Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute
lymphoctyic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advance non-Hodgkin's lymphoma; advance
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors Intestinal transplants (small intestine) and the small intestine with
the liver or small intestine with multiple organs such as the liver, stomach, and pancreas
Autologous tandem transplant for testicular and other germ cell tumors
Travel expenses related to covered transplants outside a 75 mile radius, subject to Plan's procedures.
Blue Quality Centers for Transplant (BQCT) (See page 38 for a description of BQCT)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient
Note: All transplants are subject to the Plan's medical policy through case management. When you or your provider become aware that a
transplant is needed, you should contact us.
Note: See Section 5( f), Prescription drug benefits, for related drug coverage

Nothing

Not covered: Implants of artificial organs
Transplants not listed as covered Transplants performed in a non-designated organ transplant
facility except as authorized by the Plan.

All charges

Anesthesia
Professional services provided in: Hospital (inpatient)

Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office

Nothing

Not covered: Professional services provided in a dentist's office. See Section 5( h) for dental benefits. All charges 30.
30 Page 31 32
2003 Blue HMO 28 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.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

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

Any costs associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 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 Meals and special diets
Nursery charges
Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate

Note: Please see Section 3, page 13 for services that require prior approval

Nothing

Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medications 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

Nothing

Inpatient hospital -Continued on next page 31.
31 Page 32 33
2003 Blue HMO 29 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered: Custodial care

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care Inpatient hospital stays for physical therapy purposes only
Inpatient hospital stays when the patient checks out Against Medical Advice (A. M. A.)
Non-covered facilities; such as schools

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medications

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced 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.
Note: Please see Section 3, page 13 for services that require prior approval

Nothing

Extended care benefits/ skilled nursing care facility benefits
Extended care/ skilled nursing facility benefits:

Up to 60 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
necessary as determined by a Plan doctor and approved by the Plan.

Nothing

Not covered: Custodial care, domiciliary or convalescent care All charges
Hospice Care
Home Health Care provided by Hospice nurses Nothing

Not covered: Independent nursing, homemaker services and hospice services provided in a hospice facility All charges

Ambulance
Local professional ambulance service when medically appropriate Nothing 32.
32 Page 33 34
2003 Blue HMO 30 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 and are payable only when we determine they are

medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

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, you must contact your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the

local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are our member so they can notify us. You or a family
member must notify your primary care doctor within 24 hours, unless it was not reasonably possible to do so. It is your responsibility to ensure that your primary care doctor has been timely notified.

If you need to be hospitalized, we must be notified within 24 hours or on the first working day following your admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized
in a non-Plan facility and our 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 you believe delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by us, any follow-up care recommended by non-Plan providers must be approved by us or provided by Plan providers.

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, we must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us 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.

To be covered by us, any follow-up care recommended by non-Plan providers must be approved by us or provided by Plan providers. 33.
33 Page 34 35
2003 Blue HMO 31 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center or in the outpatient urgent care department of a hospital, including doctors' services $25 per visit
Emergency care as an outpatient at a hospital, including doctors' services $50 per visit; if visit results in an inpatient
admission, you pay nothing

Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center or in the outpatient urgent care department of a hospital, including doctors' services $25 per visit

Emergency care as an outpatient at a hospital, including doctors' services $50 per visit; if visit results in an inpatient
admission, you pay nothing

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 land and air ambulance service when medically appropriate

See Section 5( c) for non-emergency service
Nothing 34.
34 Page 35 36
2003 Blue HMO 32 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.
We have no deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

Benefit Description You pay
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 illnesses or conditions

Professional services, including medication management, individual therapy or group therapy by providers such as psychiatrists,
psychologists, or clinical social workers provided in:
Office

$10 per office visit

Professional services by providers such as psychiatrists, psychologists, or clinical social workers provided in the office for treatment of tobacco
cessation
Nothing

Professional services, including medication management, individual therapy or group therapy by providers such as psychiatrists,
psychologists, or clinical social workers provided in:
Hospital (inpatient) Hospital outpatient department

Nothing

Mental health and substance abuse benefits -Continued on next page 35.
35 Page 36 37
2003 Blue HMO 33 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, full-day hospitalization or facility based intensive

outpatient treatment

Nothing

Not covered: Services we have not approved
Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through
relatively short-term treatment Psychological testing when not medically necessary to determine
the appropriate treatment of a short-term psychiatric condition Services for marital counseling or personal growth
Inpatient hospital stays when the patient checks out Against Medical Advice (A. M. A.)
Service, drugs, or supplies related to weight loss or treatment of obesity, except for surgical treatment of morbid obesity

The same exclusions contained in this brochure that apply to other benefits apply to these mental health and substance abuse benefits, unless the
services are included in a treatment plan that we approve.
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 obtain a treatment plan and follow all of the following authorization processes:
If you feel you need mental health or substance abuse services, you or your PCP should call Magellan Behavioral Health at 800/ 788-4003.
Magellan will work with you to determine your needs and begin the treatment planning process. Referrals for any necessary services will
also be handled by Magellan. Your mental health and substance abuse services must be provided by
Plan providers.

Limitation We may limit your benefits if you do not obtain a treatment plan. 36.
36 Page 37 38

2003 Blue HMO 34 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 page 36.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are

medically necessary.
We have no calendar year deductible.
Prior authorization is the process required to dispense certain drugs when the use of a drug is defined or limited by your medical condition.

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

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 licensed dentist must write the prescription.

Where you can obtain them. You may fill the prescription at an Anthem Rx Network Plan pharmacy or by mail for maintenance medication.
We use a formulary. Prescription drugs are prescribed by Plan doctors and dispensed in accordance with our prescription drug formulary. All prescription drugs on the formulary have been
approved by the Food and Drug Administration (FDA). The formulary consists of medications that have been rigorously reviewed and selected by a committee of practicing doctors and clinical
pharmacists for their safety, quality and effectiveness. Coverage will be provided for both formulary and non-formulary medications when prescribed by a Plan doctor. However, when non-formulary
drugs are dispensed a higher copay will apply.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This

list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug listing, call 800/ 228-4375 or visit our website at
www. anthemprescription. com.
These are the dispensing limitations. Prescriptions filled by a retail pharmacy or through a mail order pharmacy have a limitation on days supply and different levels of copayments based on the

days supply. You may obtain a 30-day supply or one commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin) at a Plan pharmacy or up to a 90-day supply through our
mail order program. Remind your doctor to write for the maximum days supply. Any continuous therapy medication presently covered by us within the limits of applicable State and Federal laws,
can be dispensed through the mail order program. Your prescriptions will be filled using FDA dispensing guidelines.

Your prescription claims' history and patient profile information will be used by us to administer your pharmacy program and to identify possible drug interactions, duplications or other adverse
events that may occur. This profile allows us to determine if you are trying to refill your prescription too soon, which could cause your claim to be rejected and could require you to file
again at a later date. 37.
37 Page 38 39
2003 Blue HMO 35 Section 5( f)
If you receive a name brand drug, whether by mail order or from a Plan pharmacy, the copayment for the name brand applies regardless of whether:
A generic equivalent is unavailable The prescription order specifies "Dispense as Written"
You choose the name brand drug instead of a generic drug
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 will still have to pay the name brand copay.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive name brand drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original name brand product. Generics cost less than the equivalent name brand 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 name brand drugs.

You can save money by using generic drugs. However, you and your physician have the option to request a name brand if a generic option is available. Using the most cost-effective medication
saves money.
When you have to file a claim. Typically you will not have to file a claim for prescription drugs; however, if you have had to pay for a prescription due to some unforeseen circumstance, please

contact us at 800/ 228-4375.
Prescription drug benefits begin on the next page 38.
38 Page 39 40
2003 Blue HMO 36 Section 5( f)
Benefit Description You pay
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 requires a physician's prescription for their purchase

FDA-approved prescription drugs, injectable drugs (such as depo provera) and devices for birth control
Insulin
Disposable needles and syringes needed to inject covered prescribed medications are covered at the name brand copayment.

Diabetic supplies including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, glucose
monitors and acetone test tablets are covered at the name brand copayment.

Drugs for the treatment of impotence, such as Viagra: we require proof of medical necessity prior to approving benefits. Then, this
Plan will cover a maximum of six tablets per month, subject to the following guidelines. The patient:

Must be a male over age 18
Is being treated for erectile dysfunction (ED) regardless of the cause, and

Is not on medication containing nitrates
Smoking cessation prescription drugs and medications

Note: Intravenous fluids and medications for home use, implantable drugs, and some injectable drugs, such as Depo Provera, may also be

covered under Medical and Surgical Benefits. See Section 5( a)

Up to a 30-day supply at a Plan pharmacy
$10 copay for generic drugs
$20 copay for formulary name brand drugs

$30 copay for non-formulary name brand drugs

Up to a 90-day supply through the mail order program
$20 copay for generic drugs
$40 copay for formulary name brand drugs

$60 copay for non-formulary name brand drugs

Note: If there is no generic equivalent available, you will still
have to pay the name brand copay

Immuno-Suppressive Agent
Fertility drugs
Human growth hormones

50% of our allowance

Covered Medications and Supplies Continued on next page 39.
39 Page 40 41
2003 Blue HMO 37 Section 5( f)
Covered medications and supplies (Continued) You pay
Not covered: Drugs and supplies for cosmetic purposes

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines Drugs available without a prescription or for which there is a
nonprescription equivalent available Drugs obtained at a Non-network pharmacy except for out-of-area
emergencies Drugs to enhance athletic performance
Drugs for weight loss purposes (except when authorized by the Plan doctor, through the predetermination process, for treatment of morbid
obesity) Replacement prescriptions such as lost, stolen or spilled
Drugs in connection with camp, travel, school or insurance exams Personal hygiene and convenience items

All Charges 40.
40 Page 41 42

2003 Blue HMO 38 Section 5( g)
Section 5 (g). Special features
Feature Description

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

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

24 hour nurse line The Plan now offers Tel-a-Nurse. This free, 24-hour phone service is you link to non-emergency health information. Simply call the toll-free
number day or night to speak to a registered nurse. So, the next time you have a health question or want some help making a health

care decision, call:
888/ 220-3891
800/ 877-8044 (TDD for those with hearing impairments)
You also have access, through the internet www. myhealth. com to receive customized health information.

Centers of excellence We use the Blue Quality Centers for Transplant Network (BQCT) as our transplant network. The network consists of leading medical
facilities throughout the nation. For a list of transplant hospitals near you, call 800/ 824-0581.

We utilize a network of institutions that have met stringent clinical standards for the following heart services:

Coronary artery bypass graft (CABG)
Percutaneous transluminal coronary angioplasty (PTCA)
Heart valve procedures
Other major cardiovascular procedures

You can refer to our provider directory for further information concerning our transplant and heart surgery centers of excellence.

Special features Continued on next page 41.
41 Page 42 43
2003 Blue HMO 39 Section 5( g)
Section 5 (g). Special features (Continued)
Feature Description

Reciprocity benefit Guest Membership Program
We offer guest memberships at affiliated HMO plans through the Guest Membership Program. Whenever you or a family member is

away from our service area for more than 90 days, you may become a guest member at an affiliated HMO near your destination. Reasons to
consider a guest membership include extended out-of-town business, children away at school, dependent children in another state, or a
winter "snowbird" residency in the South. To determine if a guest membership is available at your destination, call 800/ 355-6414.

BlueCard Program
With the BlueCard Program, Plan members have access to benefits when traveling outside the plan's service area for urgent care and
emergency room services. To find a nearby health care provider, members can simply call BlueCard Access at 800/ 810-BLUE (2583)

Discount programs Anthem Advantage
You can receive negotiated savings on selected health and wellness services and programs simply by being an eligible Anthem Blue Cross

and Blue Shield Blue HMO member. To obtain information about these programs please call us at 800/ 228-4375 or visit our website at
www. anthem. com. Companies participating in the Anthem Advantage program include:

Beltone" free hearing exams and discounts on hearing aids
Complementary Blue SM discounts on vitamins, herbs, sports nutrition products, books, videotapes and educational resources to

help you become smoke-free
GlobalFit discounts at participating fitness clubs
Vision One discounts on frames, contacts, bifocals
House of Healing soothe your body, mind and soul with discounts on products to help you rev up or chill out

Amazon. com discounts on Anthem recommended books
CVS discounts on personal care and over the counter medications

SafeTech (a div. Of Troxel) preferred pricing on bicycle and inline skating helmets
Safe Beginnings" discounts on child-proofing and family safety products
FTD. com discounts on some internet orders 42.
42 Page 43 44
2003 Blue HMO 40 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of

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

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

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair within three days of an accident (but not replace) sound natural teeth.

The need for these services must result from an accidental injury.
Nothing

Dental benefits
See benefit chart on the following page. 43.
43 Page 44 45
2003 Blue HMO 41 Section 5( h)
We cover the following dental services when you use a participating Plan dentist and we have indicated when copayments apply. This benefit description does not list exclusions. Contact us for specific exclusions at 800/ 228-
4375 or 513/ 872-8242 (in the local dialing area).

Dental Benefits
Service You pay

DIAGNOSTIC
X-rays including bite wings and panoramic; oral examinations and treatment plan; vitality test; and

oral cancer exam

Nothing

PREVENTIVE
Prophylaxis; annual topical application of fluoride to children age 12, preventive dental instructions
Nothing

RESTORATIVE (Fillings)
Amalgam one surface
Amalgam two surfaces
Amalgam three surfaces (Build up per tooth)
Plastic or composite single surface
Plastic or composite two surfaces

80% of our allowance

ORAL SURGERY (Including preoperative and postoperative treatments under local anesthetics)
Extraction (simple)
Alveolectomy per quadrant
Impaction (soft tissue)
Impaction (complete bony)

80% of our allowance

PROSTHODONTICS
Complete upper or lower denture
Cast chrome partial upper or lower
Acrylic partial upper or lower (with clasps)
Repair broken denture
Denture adjustment
Reline upper or lower complete denture or partial (office)

Reline upper or lower complete denture or partial (laboratory)
Space maintainers (for primary teeth)

80% of our allowance

Dental Benefits -Continued on next page 44.
44 Page 45 46
2003 Blue HMO 42 Section 5( h)
Dental Benefits (Continued)
Service You pay

PROSTHODONTICS -Continued
Stainless steel crown (for primary teeth)
Bridge abutments or pontics

80% of our allowance

PERIODONTICS (Under local anesthetics)
Examination, treatment plan
Periodontal, root planing and curettage
Hemisection
Gingivectomy or gingivoplasty
Osseous surgery (per quadrant)
Equilibration (entire mouth)

80% of our allowance

ENDODONTICS (Under local anesthetics)
Pulpotomy (including restoration)
Root canal filling one canal
Each additional canal
Apicoectomy, performed as separate surgical procedure

80% of our allowance

ORTHODONTICS (Braces)
Initial Consultation
Diagnosis and treatment plan
(Limited to one, two-year course of phase II treatment per eligible child up to age 19)

80% of our allowance

Missed appointments without 24 hours prior notification $10.00
ACCIDENTAL INJURY BENEFIT
Restorative services and supplies necessary to promptly repair within three days of accident (but not

replace) sound natural teeth.
(The need for these services must result from an accidental injury)

Nothing

Not covered: All other dental services not shown as covered All charges 45.
45 Page 46 47
2003 Blue HMO 43 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;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies for court ordered testing or care, unless Medically Necessary;
Services, drugs, or supplies received from a member of your immediate family (parent, child, spouse, sister, brother, or corresponding in-laws);

Services for completion of claim forms or charges for medical records or reports;
Missed or canceled appointments;
Mileage costs or other travel expenses, except as authorized by the plan;
Services, or supplies at a health spa or similar facility;
Services, drugs, or supplies for research studies or screening examinations, except as specified elsewhere in the brochure; or

Services, drugs, or supplies you receive without charge while in active military service 46.
46 Page 47 48
2003 Blue HMO 44 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 or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 800/ 228-4375.

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

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

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

Receipts, if you paid for your services
Submit your claims to: Anthem Blue HMO PO Box 37180
Louisville, KY 40233-7180

Prescription drugs When you must file a claim for prescription drugs that you had to pay for, submit the original itemized Pharmacy receipt that comes
with the prescription and the completed Prescription Drug Claim Form.
Submit your claims to: Anthem Prescription Management LLC PO Box 145433
Cincinnati, OH 45250-5433

Other supplies or services When you must file a dental claim, such as out-of-network care, submit a completed Standard ADA (American Dental Association) Claim Form.

Submit your claims to: Health Management Systems 555 Middle Creek Parkway
Colorado Springs, CO 80921-3634 47.
47 Page 48 49
2003 Blue HMO 45 Section 7
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. 48.
48 Page 49 50
2003 Blue HMO 46 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: Blue HMO, Mail No. CE2-014,
1351 William Howard Taft Road, Cincinnati, OH 45206-1775; 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 II, 1900 E Street, NW, Washington, D. C. 20415-3620. 49.
49 Page 50 51
2003 Blue HMO 47 Section 8
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 800/ 228-4375 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 II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 50.
50 Page 51 52
2003 Blue HMO 48 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 health
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.
What is Medicare? Medicare is a Health Insurance Program for: People 65 years of age and older.