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Group Health Cooperative of South Central Wisconsin

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Cover Page
Introductory Letter
Notice re. Privacy Practices
Table of Contents (Page 2)
Table of Contents (Page 3)
Stop Health Care Fraud!
Section 1. Facts about this HMO Plan
Section 2. How we change for 2003
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits-OVERVIEW
- Section 5 (a). Medical services and supplies
- Section 5 (b). Surgical and anesthesia services
- Section 5 (c). Hospital or 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
- Section 5 (h). Dental benefits
Section 6. General exclusionsthings we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long-Term Care Insurance Is Still Available!
Index
Notes
Summary of benefits for Group Health Cooperative - 2003
2003 Rate Information for GHC

Pages 1--56

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

Group Health Cooperative of South Central Wisconsin
http:// www. ghc-hmo. com
A Health Maintenance Organization

Serving: South Central Wisconsin

Enrollment codes for this Plan:
WJ1 Self Only
WJ2 Self and Family

RI 73-061

For changes in benefits
see page 8.

2003
Serving: South Central Wisconsin
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 the NCQA.
See the 2003 Guide for more
information on the NCQA.

EX CELL ENT 1.
1 Page 2 3

2002 Group Health Cooperative of South Central Wisconsin Table of Contents B 2002 Group Health Cooperative of South Central Wisconsin Table of Contents 2002 Group Health Cooperative of South Central Wisconsin Table of Contents
CON 131-64-4
Semptember 1993 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

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

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

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

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

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

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

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

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal
medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not
cover your personal medical information that was given to you or your personal representative, any information that
you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a
disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to
a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to
agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice. 3.
3 Page 4 5

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

4 2003 Group Health Cooperative of South Central Wisconsin Introduction
Introduction
This brochure describes the benefits of Group Health Cooperative of South Central Wisconsin under our contract
(CS 1828) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for the administrative offices is:

Group Health Cooperative of South Central Wisconsin
8202 Excelsior Drive
Madison, WI 53717

This brochure is the offical statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and
Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that
were available before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes
are summarized on page 8. Rates are shown at the end of this brochure.

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

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

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
5 2003 Group Health Cooperative of South Central Wisconsin
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Banefits (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 yor medical record or recommend services.
Avoid using health care providers who say that an item or service us bit usually covered, but they know how to bill us
to get it paid.
Carefully recview 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 608-828-4853 and explain the situation.
If we do not resolve the issue:

CALL-THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW, Room 6400
Washington, DC 20415

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self-support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or
with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHBP
benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan. 8.
8 Page 9 10

6 2003 Group Health Cooperative of South Central Wisconsin 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 and coinsurance 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.

Who provides your health care?
GHC is a Group-Practice Prepayment (GPP) plan. We select qualified, experienced doctors for our medical staff. The
group medical practice at GHC allows for in-house consultations, peer review, and regular staff audits of medical care so
that we can assure quality care for you and your family members.

The first and most important decision you must make is to select your primary care provider. Specialists who represent
every possible specialty area also serve GHC members. Your Primary Care Provider (PCP) makes any necessary
referrals, with the following exceptions: A woman may see her Plan gynecological provider for her annual routine
examination without a referral (certified nurse midwives are not covered providers under this Plan); Vision care; Dental
care; Mental Condition benefits; Substance Abuse benefits; and Chiropractic care.

GHC uses the facilities and services of four hospitals in the South Central Wisconsin area. Your primary care site
(clinic) determines the assigned hospital for your routine care. Most specialty care is referred to the University of
Wisconsin Hospital and Clinics in Madison. Babies are usually delivered at St. Marys Hospital in Madison.

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.

Years in existence: 26
Profit status: Non-Profit
Accreditation: Excellent rating from NCQA

If you want more information about us, call 608/ 828-4827, or write to the GHC Marketing Department, PO Box 44971,
Madison, WI 53744-4971. You may also contact us by fax at 608/ 828-9333 or visit our website at www. ghc-hmo. com. 9.
9 Page 10 11
7 2003 Group Health Cooperative of South Central Wisconsin 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:

In the state of Wisconsin, the entire counties of Columbia, Dane, Dodge, Green, Iowa, Jefferson, Rock, and Sauk.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside of our service area,
we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area
unless the services have prior 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. 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
8 2003 Group Health Cooperative of South Central Wisconsin 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 12.2% for Self Only or 12.9% for Self and Family.
The office visit copay has increased from $10 to $20.
The copay for emergency care received in the outpatient department of a hospital has increased from $25 to $50.
Under the Accidental Injury benefit, coverage has been eliminated for the replacement of sound natural teeth.
Eye refractions are now subject to the $20 office visit copay. 11.
11 Page 12 13

9 2003 Group Health Cooperative of South Central Wisconsin 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
608/ 260-3170 or write to us at Group Health Cooperative, PO Box
44971, Madison, WI 53744-4971. You may also request replacement
cards through our website at www. ghc-hmo. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments 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 GHC provider directory, which we
update periodically. The list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area
that we contract with to provide covered services to our members.
We list these in the provider directory, which we update periodically.
The list is also on our website.

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care. If you need assistance, please call the GHC
Member Services Department at 608/ 828-4853.

Primary care Your primary care physician can be a family practitioner, an internist
or a pediatrician. (You may also select from affiliated nurse
practitioners or physicians assistants.) Your primary care physician
will provide most of your health care, or give you a referral to see
a specialist.

If you want to change primary care physicians or if your primary
care physician leaves the Plan, call us. We will help you select a
new one. 12.
12 Page 13 14
10 2003 Group Health Cooperative of South Central Wisconsin Section 3
Specialty care Your primary care physician will refer you to a specialist for needed
care. When you receive a referral from your primary care physician,
you must return to the primary care physician after the consultation,
unless your primary care physician authorized a certain number of
visits without additional referrals. The primary care physician must
provide or authorize all follow-up care. Do not go to the specialist for
return visits unless your primary care physician gives you a referral.
However, you may see plan mental health and/ or substance abuse,
vision care, dental care or chiropractic providers without a referral,
and a woman may see her Plan gynecological provider for her annual
routine examination without a referral.

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

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

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

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

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

you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.

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

Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility. 13.
13 Page 14 15
11 2003 Group Health Cooperative of South Central Wisconsin Section 3
If you are in the hospital when your enrollment in our Plan begins,
call our Care Management department immediately at 608/ 257-5294
x4514. 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 92nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the benefits of the hospitalized
person.

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

Services requiring our Your primary care physician has authority to refer you for most prior approval 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 prior approval. Your
physician must obtain prior approval for all services that require
prior authorization, such as, but not limited to:

Hospital care;
Referring you to a specialist;
Recommending follow-up care;
All surgical procedures;
All physical, speech and occupational therapy;
Infertility;
Breast reduction mammoplasty;
Plastic surgery;
Transplant of any organ;
All outpatient surgery; and
Growth hormone therapy (GHT).

GHC will not guarantee payment for services that require prior
authorization and were not prior authorized unless emergent in
nature. 14.
14 Page 15 16
12 2003 Group Health Cooperative of South Central Wisconsin Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider,
facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician, you pay a
copayment of $20 per office visit.

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

Coinsurance Coinsurance is the percentage of our negotiated fee that you must
pay for your care.

Example: In our Plan, you pay 20% of our allowance for insulin
pumps, and 50% of our allowance for sexual dysfunction drugs and for
preventive dental care services if a non-participating dentist is used.

Your catastrophic protection We do not have a catastrophic protection out-of-pocket maximum. out-of-pocket maximum 15.
15 Page 16 17

13 2003 Group Health Cooperative of South Central Wisconsin Section 5
Section 5. Benefits-OVERVIEW (See page 8 for how our benefits changed this year and page 51 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims filing advice or more information about our benefits, contact us at
608/ 828-4853 or at our website at www. ghc-hmo. com.

(a) Medical services and supplies provided by physicians and other health care professionals.................................... 14 21
Diagnostic and treatment services Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and occupational therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................ 22 24
Surgical procedures Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and maxillofacial surgery

(c) Services provided by a hospital or other facility, and ambulance services .............................................................. 25 26
Inpatient hospital Hospice care
Outpatient hospital or ambulatory Ambulance
surgical center
Extended care benefits/ skilled nursing care
facility benefits

(d) Emergency services/ accidents .................................................................................................................................. 27 28
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................ 29 30
(f) Prescription drug benefits.......................................................................................................................................... 31 32
(g) Special features .............................................................................................................................................................. 33
Services for deaf and hearing impaired
Centers of excellence for transplants/ heart surgery/ etc.

(h) Dental benefits ................................................................................................................................................................ 34
Summary of benefits ............................................................................................................................................................ 52 16.
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14 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
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Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and 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.

Benefit Description You pay
Diagnostic and treatment services

Professional services of physicians $20 per office visit
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion
At home

Professional services of physicians Nothing
During a hospital stay
In a skilled nursing facility 17.
17 Page 18 19
15 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as: Nothing if you receive these
tests during your office
Blood tests visit; otherwise, $20 per
Urinalysis per day for lab and/ or
Non-routine pap tests radiology visits.
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Preventive care, adult You pay
Routine screenings, such as: $20 per office visit
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Routine Prostate Specific Antigen (PSA) test one annually for men age 40
and older

Routine pap test
Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period.
From age 40 through 64, one every calendar year

Physical exams required for travel, or for attending school or camp

Not covered: Physical exams required for obtaining or continuing All charges.
employment, obtaining or continuing insurance, or other third-party requests.

Routine immunizations, limited to: $20 per office visit
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Pneumococcal vaccine, age 65 and over 18.
18 Page 19 20
16 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy Nothing to age 5; $20 per
of Pediatrics office visit age 5 and older
Well-child care charges for routine examinations, immunizations and care
(up to age 22)
Examinations, such as:
Eye exams through age 17 to determine the need for vision correction
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (up to age 22)

Maternity care You pay
Complete maternity (obstetrical) care, such as: $20 for the initial maternity
Prenatal care office visit; nothing for all
Delivery other maternity related
Postnatal care office visits.

Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant under
a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
Circumcision is covered as a surgery benefit, not as a Maternity benefit.
See Section 5( b).

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning You pay
A broad range of voluntary family planning services, limited to: $20 per office visit
Voluntary sterilization (see surgical procedures Section 5( b))
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

Not covered: Reversal of voluntary surgical sterilization, genetic counseling All charges. 19.
19 Page 20 21
17 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Infertility services You pay
Diagnosis and treatment of infertility, such as: $20 per office visit
Artificial insemination:
Intracervical insemination (ICI)
Fertility drugs
Note: We only cover the oral fertility drug (clomiphene citrate) under the
prescription drug benefit.

Not covered: All charges.
Artificial insemination:
Intravaginal insemination (IVI)
Intrauterine insemination (IUI)
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
Injectable and oral fertility drugs, except for Clomiphene citrate

Allergy care You pay
Testing and treatment $20 per office visit
Allergy injection

Allergy serum Nothing
Not covered: Provocative food testing and sublingual All charges.
allergy desensitization

Treatment therapies You pay
Chemotherapy and radiation therapy $20 per office visit
Note: High dose chemotherapy in association with autologous bone marrow
transplants is limited to those transplants listed under Organ/ Tissue
Transplants on page 24.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment.
Call your primary care physician for preauthorization. If we determine that
GHT is not medically necessary, we will not cover the GHT or related
services and supplies. See Services requiring our prior approval in Section 3. 20.
20 Page 21 22
18 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Physical and occupational therapies You pay
60 consecutive days per condition for the services of each of the following: $20 per initial visit per
qualified physical therapists; and condition; nothing during
occupational therapists. inpatient admission
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.

One follow-up visit six months after the date of your last physical or $20 per visit
occupational therapy treatment.

Cardiac rehabilitation following a heart transplant, bypass surgery, a $20 for the initial visit
myocardial infarction, unstable angina pectoris, or angioplasty is provided
for up to 36 sessions.

Not covered: All charges.
Long-term rehabilitative therapy
Exercise programs (except in therapy programs listed above)

Speech therapy You pay
60 consecutive days per condition for the services of qualified $20 per initial office visit
speech therapists. per condition; nothing during
inpatient admission

Hearing services (testing, treatment, and supplies) You pay
Hearing testing Nothing to age 5; $20 per
office visit for age 5 and older

Not covered: Hearing aids, testing and examinations for them All charges.
Vision services (testing, treatment, and supplies) You pay
Annual vision examinations Nothing to age 5; $20 per
office visit for age 5 and older

Annual eye refractions $20 per office visit

Lenses following intraocular surgery (such as for cataract removal) or $20 per office visit
for Keratoconus when there is a change in visual acuity requiring a
new prescription 21.
21 Page 22 23
19 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Vision services (testing, treatment, and supplies) You pay
(Continued)

Not covered: All charges.
Eyeglasses or contact lenses, except as above
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot care You pay
Routine foot care when you are under active treatment for a metabolic or $20 per office visit
peripheral vascular disease, such as diabetes.

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

Not covered: All charges.
Cutting, trimming or removal of corns, calluses, or the free edge of toenails,
and similar routine treatment of conditions of the foot, except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability, imbalance or subluxation of the foot (unless the treatment is by
open cutting surgery)

Orthopedic and prosthetic devices You pay
Artificial limbs and eyes, stump hose $20 per office visit
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy.
Note: See Section 5 (b) for coverage of the surgery to insert the device.
Braces
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome

Not covered: All charges.
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices
Cost of a cochlear implanted device
Prosthetic replacements, unless the item is no longer useful and has exceeded
its reasonable lifetime under normal use; or the member's condition has
changed so as to make the original equipment inappropriate. 22.
22 Page 23 24
20 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable $20 per office visit
medical equipment prescribed by your Plan physician, such as oxygen and
dialysis equipment. Under this benefit, we also cover:
hospital beds;
standard wheelchairs;
crutches;
walkers; and
blood glucose monitors

insulin infusion pumps. 20% copay
Note: Call us at 608/ 257-5294 as soon as your Plan physician prescribes
any of the above equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Not covered: All charges.
Motorized wheel chairs
DME replacements, unless the item is no longer useful and has exceeded its
reasonable lifetime under normal use; or the member's condition has
changed so as to make the original equipment inappropriate.

Home health services You pay
Home health care ordered by a Plan physician and provided by a registered Nothing
nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Not covered: All charges.
Nursing care requested by, or for the convenience of, the patient or the
patient's family;
Home care primarily for personal assistance that does not include a medical
component and is not diagnostic, therapeutic, or rehabilitative 23.
23 Page 24 25
21 2003 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Chiropractic You pay
Chiropractic services, but only related to a specific injury. $20 per office visit

Not covered: All charges.
Chiropractic services for chronic problems or for maintenance.

Alternative treatments You pay
Not covered: All charges.
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback

Educational classes and programs You pay
Coverage may include: Some fees required contact
Smoking Cessation GHC Health Education
Diabetes self-management Department at 608/ 257-9705
Nutrition for fees and schedules
Weight Management
Stress Management
Prenatal
First aid
Fitness programs 24.
24 Page 25 26
22 2003 Group Health Cooperative of South Central Wisconsin Section 5 (b)
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Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine
they are medically necessary.
Plan physicians must provide or arrange your care.
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 PLAN DOCTOR MUST GET PRIOR APPROVAL OF SOME
SURGICAL PROCEDURES. Please refer to the prior approval information
shown in Section 3 to be sure which services require prior approval and
identify which surgeries require prior approval.

Benefit Description You pay
Surgical procedures

A comprehensive range of services such as: $20 per office visit;
Operative procedures nothing for hospital visit
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an individual
weighs 100 pounds or 100% over his or her normal weight according to
current underwriting standards; eligible members must be age 18 or over
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for a pacemaker
and Surgery benefits for insertion of the pacemaker.

Not covered: All charges.
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care 25.
25 Page 26 27
23 2003 Group Health Cooperative of South Central Wisconsin Section 5 (b)
Reconstructive surgery You pay
Surgery to correct a functional defect $20 per office visit;
Surgery to correct a condition caused by injury or illness if: nothing for hospital visit
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate;
birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements
(see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.

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

Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: $20 per office visit;
Reduction of fractures of the jaws or facial bones; nothing for hospital visit
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures;
Other surgical procedures that do not involve the teeth or their
supporting structures; and
Surgical removal of fully impacted teeth.

Dental treatment of Temporomandibular joint (TMJ) syndrome is limited $20 per office visit
to a maximum Plan payment of $1250 per person per calendar year.

Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone) 26.
26 Page 27 28
24 2003 Group Health Cooperative of South Central Wisconsin Section 5 (b)
Organ/ tissue transplants You pay
Limited to: $20 per office visit
Cornea for evaluation;
Heart nothing in hospital
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single/ Double
Pancreas
Allogenic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or
small intestine with multiple organs such as the liver, stomach, and pancreas
National Transplant Program (NTP) UW Hospital & Clinics

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

Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.

Not covered: All charges
Donor screening tests and donor search expenses, except those performed
for the actual donor
Implants of artificial organs
Transplants not listed as covered

Anesthesia You pay
Professional services provided in Nothing
Hospital (inpatient)

Professional services provided in $20 per visit
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 27.
27 Page 28 29
25 2003 Group Health Cooperative of South Central Wisconsin Section 5 (c)
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Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care.
Any costs associated with the professional charge (i. e., physicians, etc.) are
covered in Section 5 (a) or (b).

Benefit Description You pay
Inpatient hospital

Room and board, such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home

Not covered: All charges.
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care 28.
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26 2003 Group Health Cooperative of South Central Wisconsin Section 5 (c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
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.

Not covered: Blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care You pay
facility benefits

We provide a comprehensive range of benefits for up to a 100 days per Nothing
calendar year when full-time skilled nursing care is necessary and confinement
in a skilled nursing facility is medically appropriate as determined by a Plan
doctor and approved by the Plan.

Not covered: Custodial care All charges
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered in Nothing
the home. Services include outpatient care and family counseling; these
services are provided under the direction of a Plan doctor who certifies that
the patient is in the terminal stage of an illness, with a life expectancy of six
months or less.

Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
Local professional ambulance service when medically appropriate Nothing

Not covered: Ambulance services to home following an inpatient stay All charges 29.
29 Page 30 31
27 2003 Group Health Cooperative of South Central Wisconsin Section 5 (d)
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Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
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.

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the nearest emergency
system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell
emergency room personnel that you are a GHC Plan member so they can notify us. You or a family member
must also notify us within 48 hours. It is your responsibility to make certain that the Plan has been notified.

If you need to be hospitalized in a non-Plan facility, you or a family member must notify the Plan within 48
hours or on the first working day following your admission, unless it is not reasonably possible to do so. If a
GHC plan doctor believes that you will receive better care in a Plan hospital, we will transfer you when it is
medically feasible and we will pay all ambulance charges for the transfer.

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

Any follow up care recommended by non-plan providers in such a medical emergency must be approved by
GHC or provided by GHC 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, you or a family member must notify the Plan within 48 hours or on the first
working day following your admission, unless it is not reasonably possible to do so. If a GHC Plan doctor
believes you will receive better care in a Plan hospital, we will transfer you when it is medically feasible and we
will pay all ambulance charges for that transfer.

Any follow-up care recommended by non-plan providers in such a medical emergency must be approved by
GHC or provided by GHC plan providers. 30.
30 Page 31 32
28 2003 Group Health Cooperative of South Central Wisconsin Section 5 (d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $20 per visit
Emergency care at an urgent care center

Emergency care as an inpatient at a hospital, including doctors' services Nothing
Emergency care as an outpatient at a hospital, including doctors' services $50 per visit, waived if
admitted as an inpatient.

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office $20 per visit
Emergency care at an urgent care center

Not covered: All charges.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area

Ambulance
Professional ambulance service, as well as air ambulance, when Nothing
medically appropriate.

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

Not covered: Ambulance services to home following an inpatient stay All charges. 31.
31 Page 32 33
29 2003 Group Health Cooperative of South Central Wisconsin Section 5 (e)
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Section 5 (e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve,
cost sharing and limitations for Plan mental health and substance abuse benefits
will be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in
this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

Benefit Description You pay
Mental health and substance abuse benefits

All diagnostic and treatment services recommended by a Plan provider and Your cost sharing
contained in a treatment plan that we approve. The treatment plan may include responsibilities are no
services, drugs and supplies described elsewhere in this brochure. greater than for other
illnesses or conditions.
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.

Professional services, including individual or group therapy by providers $20 per office visit
such as psychiatrists, psychologists, or clinical-social workers.
Medication management

Diagnostic tests Nothing if you receive
these services during your
office visit; otherwise,
$20 per day for such lab
and/ or radiology tests.

Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial hospitalization,
full-day hospitalization, facility based intensive outpatient treatment.

Mental health and substance abuse benefits continued on next page Mental health and substance abuse benefits continued on next page 32.
32 Page 33 34
30 2003 Group Health Cooperative of South Central Wisconsin Section 5 (e)
Mental health and substance abuse benefits (continued) You Pay
Not covered: Services we have not approved. All charges.
NOTE: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order us to
pay or provide one clinically appropriate treatment plan in favor of another.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of our network authorization processes.
Patients may make their own appointments for mental health and/ or substance
abuse services as follows:

Outpatient Mental Health GHC Mental Health Department
Telephone: 608-441-3290 or 800-608-4327; after hours 608-257-9700

Inpatient Mental Health UW Hospital & Clinics
Substance Abuse Outpatient and Inpatient Services
Gateway Recovery Services, Inc.
608/ 278-8200 (Madison, WI)
608/ 877-1855 (Stoughton, WI)

Limitation We may limit your benefits if you do not obtain a treatment plan. 33.
33 Page 34 35
31 2003 Group Health Cooperative of South Central Wisconsin Section 5 (f)
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Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are
medically necessary.

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

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician, referral doctor, or
licensed dentist must write the prescription.

Where you can obtain them. You must fill the prescription at a
plan pharmacy.

We use a formulary. A drug formulary is a list of prescription medications
representing the current judgment of medical practitioners for the treatment of
disease. Not all medications will be listed in the formulary, particularly when
there are several similar medications available. The formulary will include the
drugs covered by the plan's benefit. Your physician/ practitioner may request
coverage for non-formulary drugs when clinically necessary.

There are dispensing limitations. We furnish up to a 34-day supply of the
prescribed drug, or one commercially prepared unit (such as one vial of
opthalmic drops, one inhaler, or one bottle of insulin). There are certain drugs
that we will cover up to a 100 day supply. You pay $6 copay for each generic and
$12 copay for each name brand prescription, for up to a 34-day supply.
If coverage has been approved for a non-formulary drug, you pay the applicable
generic or name brand copayment. For non-formulary drugs when coverage has
not been approved, the copayment is equal to the plan-calculated total
prescription cost.

Why use generic drugs? Generic drugs offer a safe and economic way to meet
your prescription drug needs. The generic name of a drug is its chemical name;
the name brand is the name under which the manufacturer advertises and sells a
drug. Under federal law, generic and name brand drugs must meet the same
standards for safety, purity, strength, and effectiveness. A generic prescription
costs you less and helps moderate the costs of providing healthcare.

When you have to file a claim. Generally you will not need to file a claim.
An exception would be a drug prescribed in an emergency or urgent situation
when you are out of the area. Forward such claims to GHC Claims Department,
PO Box 44971, Madison, WI 53744-4971. Be sure to include your member
number and an explanation of why you are submitting the claim.

Prescription drug benefits begin on the next page. Prescription drug benefits begin on the next page. 34.
34 Page 35 36
32 2003 Group Health Cooperative of South Central Wisconsin Section 5 (f)
Benefit Description You pay
Covered medications and supplies

We cover the following medications and supplies prescribed by a Plan physician, A $6 copay for generic drugs
referral doctor, or licensed dentist, and obtained from a Plan pharmacy. A $12 copay for
Drugs and medicines that by Federal law of the United States require a name brand drugs
physician's prescription for their purchase, except those listed as Not covered. Note: if there is no generic
Insulin equivalent available, you will
Diabetic supplies, including insulin syringes, needles, injection pens, glucose still have to pay the
test tablets and test tape, Bendict's solution or equivalent and acetone name brand copay.
test tablets
Contraceptive drugs and devices
Smoking cessation drugs when participating in the Plan's behavior
modification program
Prenatal vitamins during pregnancy
Disposable needles and syringes for the administration of covered medications
Oral fertility drug, Clomiphene citrate, limited to a lifetime maximum of
one year

Drugs for sexual dysfunction are subject to dosage limits. 50%
Contact plan for details.

Not covered: All Charges
Drugs and supplies for cosmetic purposes
Non-formulary drugs
Drugs to enhance athletic performance
Fertility drugs, including drugs to maintain pregnancy (except Clomiphene
citrate see covered medications)
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins, nutrients, and food supplements even if a physician prescribes or
administers them (except prenatal vitamins see covered medications)
Non-prescription medications
Drugs for which there is a nonprescription equivalent available
Medical supplies such as dressings and antiseptics
Smoking cessation drugs (except when participating in the Plan's behavior
modification program)
Weight loss drugs, appetite suppressants, weight loss programs or classes,
except when medically necessary for the treatment of morbid obesity 35.
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33 2003 Group Health Cooperative of South Central Wisconsin Section 5 (g)
Section 5 (g). Special features
Feature Description

Services for deaf and Hearing impaired interpreter for non-emergency services can be reached at this hearing impaired TDD line: 608/ 257-7391.

Center of excellence Our local center of excellence is associated with the University of Wisconsin Hospital and Clinics in Madison, Wisconsin. 36.
36 Page 37 38
34 2003 Group Health Cooperative of South Central Wisconsin Section 5 (h)
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Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
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.

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair but not Nothing up to $1500 per
replace sound natural teeth. The need for these services must result from an accident, all charges above
accidental injury. You must be seen within 48 hours of the accident; however, $1500 per accident
treatment may be delayed due to your medical condition. Damage to teeth
caused by chewing or biting does not constitute an accidental injury.

Dental benefits
Service You pay

Prophylaxis or cleaning (one every six months) Nothing if you use a GHC
Topical applications of fluoride through age fifteen (one every six months) Plan dentist; 50% of charges
if you use a non-participating
dentist.

Not covered: all other dental services (i. e., fillings, extractions, crowns, All charges.
orthodontics, etc.) 37.
37 Page 38 39
35 2003 Group Health Cooperative of South Central Wisconsin 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 you receive without charge while in active military service. 38.
38 Page 39 40
36 2003 Group Health Cooperative of South Central Wisconsin 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, hospital and drug 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 608/ 828-4853.

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

Covered member's name and ID number;
Name and address of the physician or facility that provided the
service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any
primary payer such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.

Submit your claims to: Group Health Cooperative, Claims
Department, PO Box 44971, Madison, WI 53744-4971.

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. 39.
39 Page 40 41
37 2003 Group Health Cooperative of South Central Wisconsin 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: Group Health Cooperative Member Services, PO Box 44971, Madison, WI
53744-4971; 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, Health Benefits Contracts
Division 3, 1900 E Street NW, Washington, DC 20415-3630.

Step 4 continued on next page 40.
40 Page 41 42
38 2003 Group Health Cooperative of South Central Wisconsin Section 8
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.

6 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
608/ 828-4853 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited
treatment too, or
You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 41.
41 Page 42 43
39 2003 Group Health Cooperative of South Central Wisconsin
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.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant)

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay
for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a federal
employee on January 1, 1983, or since automatically qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.

If you are eligible for Medicare, you may have choices in how you
get your health care. Medicare + Choice plan is the term used to
describe the various health plan choices available to Medicare
beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have. 42.
42 Page 43 44
40 2003 Group Health Cooperative of South Central Wisconsin Section 9
Section 9. Coordinating benefits with other coverage (continued)
The Original Medicare Plan The Original Medicare Plan is available everywhere in the
(Part A or Part B) United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits
now. You may go to any doctor, specialist or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare, like
prescription drugs.

When you are enrolled in Original Medicare along with this plan,
you still need to follow the rules in this brochure for us to cover your
care. Your care must continue to be authorized by your Plan primary
care physician.

You probably will never have to file a claim form when you have
both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claim will be coordinated
automatically and we will then provide secondary benefits for
covered charges. You will not need to do anything. To find out if you
need to do something to file your claim, call us at 608/ 251-4138.

We do not waive any costs if the Original Medicare Plan is your
primary payer.

(Primary payer chart begins on next page.) 43.
43 Page 44 45
41 2003 Group Health Cooperative of South Central Wisconsin
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you or your covered spouse are age 65 or over and Then the primary payer is
Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability),

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

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

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge
who retired under Section 7447 of title 26, U. S. C.
(or if your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)

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

B. When you or a covered family member have Medicare based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits solely
because of ESRD,

2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision,

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 44.
44 Page 45 46

42 2003 Group Health Cooperative of South Central Wisconsin
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get
your benefits from another type of Medicare + Choice plan a
Medicare managed care plan. These are health care choices (like
HMOs) in some areas of the country. In most Medicare managed
care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide all the
benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-
633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options
are available to you:

This Plan and another plan's Medicare managed care plan:
You may enroll in another plan's Medicare managed care plan and
also remain enrolled in our FEHB plan. We will still provide benefits
when your Medicare managed care plan is primary, even out of the
managed care plan's network and/ or service area (if you use our
Plan providers), but we will not waive any of our copayments
or coinsurance. If you enroll in a Medicare managed care plan, tell us.
We will need to know whether you are in the Original Medicare Plan
or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed
care plan: If you are an annuitant or former spouse, you can suspend
your FEHB coverage to enroll in a Medicare managed care plan,
eliminating your FEHB premium. (OPM does not contribute to your
Medicare managed care plan premium.) For information on
suspending your FEHB enrollment, contact your retirement office.
If you later want to re-enroll in the FEHB Program, generally you
may do so only at the next open season unless you involuntarily lose
coverage or move out of the Medicare managed care plan's
service area.

If you do not enroll in If you do not have one or both parts of Medicare, you can still be
Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll
in Medicare Part B, and if you can't get premium-free Part A, we
will not ask you to enroll in it. 45.
45 Page 46 47
43 2003 Group Health Cooperative of South Central Wisconsin
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. CHAMPVA provides health coverage to
disabled Veterans and their eligible dependents. If TRICARE or
CHAMPVA and this Plan cover you, we pay first. See your
TRICARE or CHAMPVA Health Benefits Advisor if you have
questions about TRICARE coverage.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:
If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in one of these programs, eliminating your
FEHB premium. (OPM does not contribute to any applicable plan
premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the
FEHB Program, generally you may do so only at the next Open
Season unless you involuntarily lost coverage under the program.

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

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

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar
State-sponsored program of medical assistance: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to
enroll in one of these State programs, eliminating your FEHB
premium. For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the
FEHB Program, generally you may do so only at the next Open
Season unless you voluntarily lost coverage under the State program.

When other government agencies We do not cover services and supplies when a local, state, are responsible for your care or federal government agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is
called subrogation. If you need more information, contact us for our
subrogation procedures. 46.
46 Page 47 48
44 2003 Group Health Cooperative of South Central Wisconsin Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care means care that is primarily for the purpose of meeting personal needs and which could be provided by persons
without professional skill or training. For example, custodial care
includes help in walking, getting in or out of bed, bathing, dressing,
eating, preparing special diets, and taking medicine. Custodial care
that lasts 90 days or more is known as Long-term care.

Experimental or We use the following criteria to determine if a service or procedure investigational services is considered experimental or investigational:

1. The technology involved must have final approval from the
appropriate government regulatory bodies;
2. The scientific evidence must allow conclusions to be drawn based
on health outcomes;
3. The technology involved must improve the health outcome of
the member;
4. The technology involved must be as good for a patient as any of
the already established alternatives; and
5. Possible harm from the procedure (including long term effects)
must be well understood and not outweigh the benefits.

Contact us if you would like more information about the criteria
used in deciding whether a service or procedure is experimental
or investigational.

Medically necessary Medically necessary means a service or supply that is determined by the GHC medical director to be required for the treatment or
evaluation of a medical condition, is consistent with the diagnosis,
and which could not have been omitted under generally accepted
medical standards or provided in a less intensive setting.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.

Us/ we Us and we refer to Group Health Cooperative of South Central Wisconsin.
Yo u You refers to the enrollee and each covered family member. 47.
47 Page 48 49

45 2003 Group Health Cooperative of South Central Wisconsin Section 11
Section 11. FEHB facts
No preexisting condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal
FEHB Program Employees Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your
FEHB coverage. These materials will tell you:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment begins.

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

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

If you have a Self Only enrollment, you may change to a Self and
Family enrollment if you marry, give birth, or add a child to your
family. You may change your enrollment 31 days before to 60 days
after that event. The Self and Family enrollment begins on the first
day of the pay period in which the child is born or becomes an
eligible family member. When you change to Self and Family
because you marry, the change is effective on the first day of the pay
period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until
you marry.

Your employing or retirement office will not notify you when a
family member is no longer eligible to receive health benefits, nor
will we. Please tell us immediately when you add or remove family
members from your coverage for any reason, including divorce, or
when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by
another FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be
enrolled for Self and Family coverage in the Federal Employees 48.
48 Page 49 50
46 2003 Group Health Cooperative of South Central Wisconsin Section 11
Health Benefits (FEHB) Program; if you are an employee subject to
a court or administrative order requiring you to provide health
benefits for your child (ren).

If this law applies to you, you must enroll for Self and Family
coverage in a health plan that provides full benefits in the area where
your children live or provide documentation to your employing office
that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you
involuntarily as follows:

If you have no FEHB coverag, your employing office will enroll
you for Self and Family coverage in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option.
If you have a Self Only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing
office will change your enrollment to Self and Family in the same
option of the same plan; or
if your are enrolled in an HMO that does not serve the area where
the children live, your employing office will change your
enrollment to Self and Family in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at
least one child identified in the order who is still eligible under the
FEHB Program, you cannot cancel your enrollment, change to Self
Only, or change to a plan that doesn't serve the area in which your
children live, unless your provide documentation that you have other
coverage for the children. If the court/ administrative order is still
ineffect when you retire, and you have at least one child still eligible
for FEHB coverage, you must continue your FEHB coverage into
retirement (if eligible) and cannot make any changes after retirement.
Contact your employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this Plan during Open Season, your coverage begins on the first day
of your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any
other time during the year, your employing office will tell you the
effective date of coverage.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the
last five years of your Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such
as temporary continuation of coverage (TCC).

When you lose benefits When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage. 49.
49 Page 50 51

47 2003 Group Health Cooperative of South Central Wisconsin Section 11
Spouse equity If you are divorced from a Federal employee or annuitant, you may
coverage not continue to get benefits under your former spouse's enrollment.
This is the case even when the court has ordered your former spouse
to supply health coverage to you. But, you may be eligible for your
own FEHB coverage under the spouse equity law or Temporary
Continuation of Coverage (TCC). If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees, or other information about your coverage
choices. You can also download the guide from OPM's website,
www. opm. gov/ insure.

Temporary Continuation If you leave Federal service, or if you lose coverage because you no
of Coverage (TCC) longer qualify as a family member, you may be eligible for
Temporary Continuation of Coverage (TCC). For example, you can
receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent
child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law ends (if you
canceled your coverage or did not pay your premium, you
cannot convert);
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse
equity law.

If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member
who is losing coverage, the employing or retirement office will not
notify you. You must apply in writing to us within 31 days after you
are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB
Program; however, you will not have to answer questions about your
health, and we will not impose a waiting period or limit your
coverage due to pre-existing conditions. 50.
50 Page 51 52