Pages 1--57

Serving: Southeastern Michigan
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
K31 Self Only K32 Self and Family

For changes in benefits
see page 7.

A Health Maintenance Organization

St. Clair and Shiawassee counties are no longer part of our service area. If you live in one of these 2 counties and do not work in
Genessee, Lapeer, Macomb, Oakland, or Wayne, you should choose another health plan during Open Season.

RI 73-075 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
3
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
4
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
5.
5 Page 6 7
2003 The Wellness Plan 2 Table of Contents
Tab le of C on t en t s
Introduction.................................................................................................................................................................................................. 4
Plain Language ................................................................................................................................................................................................ 4
Stop Health Care Fraud!.................................................................................................................................................................................. 4
Section 1. Facts about this HMO plan........................................................................................................................................................... 6
How we pay providers .................................................................................................................................................................. 6
Your Rights ................................................................................................................................................................................... 6
Service Area.................................................................................................................................................................................. 7
Section 2. How we change for 2003.............................................................................................................................................................. 7
Program-wide changes.................................................................................................................................................................. 7
Changes to this Plan...................................................................................................................................................................... 7
Section 3. How you get care ......................................................................................................................................................................... 8
Identification cards ....................................................................................................................................................................... 8
Where you get covered care ......................................................................................................................................................... 8
Plan providers......................................................................................................................................................................... 8
Plan facilities .......................................................................................................................................................................... 8
What you must do to get covered care ......................................................................................................................................... 8
Primary care............................................................................................................................................................................ 8
Specialty care.......................................................................................................................................................................... 8
Hospital care........................................................................................................................................................................... 9
Circumstances beyond our control............................................................................................................................................... 9
Services requiring our prior approval ........................................................................................................................................ 10
Section 4. Your costs for covered services.................................................................................................................................................. 11
Copayments .......................................................................................................................................................................... 11
Deductible............................................................................................................................................................................. 11
Coinsurance .......................................................................................................................................................................... 11
Your catastrophic protection out-of-pocket maximum ............................................................................................................. 11
Section 5. Benefits........................................................................................................................................................................................ 12
Overview ..................................................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals ........................................ 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................... 22
(c) Services provided by a hospital or other facility, and ambulance services ................................................................... 25
(d) Emergency services/ accidents......................................................................................................................................... 27
(e) Mental health and substance abuse benefits ................................................................................................................... 29
(f) Prescription drug benefits................................................................................................................................................ 31
(g) Special features ............................................................................................................................................................... 33 6.
6 Page 7 8
2003 The Wellness Plan 3 Table of Contents
Flexible benefits option
Services for the Deaf and Hearing Impaired
(h) Dental benefits ................................................................................................................................................................. 34
(i) Non-FEHB benefits available to Plan members............................................................................................................. 35
Section 6. General exclusions --things we don't cover .............................................................................................................................. 36
Section 7. Filing a claim for covered services ............................................................................................................................................ 37
Section 8. The disputed claims process....................................................................................................................................................... 38
Section 9. Coordinating benefits with other coverage ............................................................................................................................... 40
When you have other health coverage ....................................................................................................................................... 40
What is Medicare................................................................................................................................................................. 40
Medicare managed care plan ............................................................................................................................................. 43
TRICARE and CHAMPUS ................................................................................................................................................ 43
Workers' Compensation ...................................................................................................................................................... 43
Medicaid ............................................................................................................................................................................. 44
Other Government agencies................................................................................................................................................ 44
When others are responsible for injuries ............................................................................................................................ 44
Section 10. Definitions of terms we use in this brochure ............................................................................................................................ 45
Section 11. FEHB facts ................................................................................................................................................................................ 46
Coverage information ................................................................................................................................................................. 46
No pre-existing condition limitation.................................................................................................................................... 46
Where you get information about enrolling in the FEHB Program ................................................................................... 46
Types of coverage available for you and your family ........................................................................................................ 46
Children's Equity Act .......................................................................................................................................................... 46
When benefits and premiums start ...................................................................................................................................... 47
When you retire .................................................................................................................................................................... 47
When you lose benefits............................................................................................................................................................... 47

When FEHB coverage ends................................................................................................................................................. 47
Spouse equity coverage........................................................................................................................................................ 47
Temporary Continuation of Coverage (TCC) ..................................................................................................................... 47
Converting to individual coverage ...................................................................................................................................... 48
Getting a Certificate of Group Health Plan Coverage ........................................................................................................ 48
Long-term care insurance is still available ................................................................................................................................................... 49
Index............................................................................................................................................................................................................... 50
Summary of benefits...................................................................................................................................................................................... 52
Rates................................................................................................................................................................................................. Back cover 7.
7 Page 8 9
2003 The Wellness Plan 4 Introduction/ Plain Language/ Advisory
I n t rod u ct ion
This brochure describes the benefits of The Wellness Plan under our contract (CS1900) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for administrative offices is:

The Wellness Plan
2875 W. Grand Boulevard
Detroit, MI 48202

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

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 7. Rates are shown at the end of this brochure.

Plain Lan gu age
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 The Wellness Plan (TWP).

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

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate
Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC
20415-3650.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program
premium.

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

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. 8.
8 Page 9 10
2003 The Wellness Plan 5 Introduction/ Plain Language/ Advisory
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 875-WELL (9355) and explain the situation.
If we do not resolve the issue:

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

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415 9.
9 Page 10 11
2003 The Wellness Plan 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

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

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about networks,
our providers, facilities, and us. 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.

We are Federally Qualified and licensed by the State of Michigan to operate as an HMO.
We have been in existences since 1972
We are a non-profit HMO with URAC accreditation (also known as the American Accreditation Healthcare Commission).
If you want more information about us, call 800 875-WELL (9355), or write to The Wellness Plan, 2875 W. Grand Blvd, Detroit, MI
48202. You may also contact us by fax at 313-202-8670 or visit our website at www. wellplan. com.

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 includes
the following Michigan counties: Genessee, Lapeer, Macomb, Oakland, and Wayne.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only
for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
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
2003 The Wellness Plan 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

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

Program information on TRICARE and CHAMPUS 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 8.3% for Self only or 7.7% for Self and Family. Our 2003 service area no longer includes St. Clair, and Shiawasee counties. If you don't live or work in one of the remaining

counties in our service area, you should switch to a new health plan during Open Season. (Section 1)
Your physician is responsible for obtaining prior authorization before prescribing drugs that are not on our performance drug list. (Section 5( f)). 11.
11 Page 12 13
2003 The Wellness Plan 8 Section 3
S ect ion 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, and your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800-875-WELL (9355) or write to
us at 2875 W. Grand Blvd., Detroit, MI 48202.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www. wellplan. com/ providersearch wizard and includes Primary
Care Physicians, Specialists, Pharmacies, Urgent Care and Vision Providers.

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

It depends on the type of care you need. First, you and each family 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. You will need to let us know which Primary Care Physician you select for each member of your family. If you notify us by

the 10 th of the month, your change will be effective the first of the following month.

Primary care Your primary care physician can be a family practitioner, internist, or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see
a specialist.
If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may obtain gynecology, mammogram screening, mental health, and vision services 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 work with the specialists and the
Plan 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

What you must do to get covered care 12.
12 Page 13 14
2003 The Wellness Plan 9 Section 3
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. Contact us or, if we
drop out of the Program, contact your new plan.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer Service department immediately at 800-875-WELL (9355). If you are new to the FEHB
Program, we may arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

C ircu m st an ces b eyond ou r con t rol 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. 13.
13 Page 14 15
2003 The Wellness Plan 10 Section 3
Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain
prior authorization for the following services:

Growth Hormone Therapy
Elective Surgery
Organ Tissue Transplants
Elective Hospital Admission
DME (Durable Medical Equipment)
Orthotic and Prosthectic Devices
Certain Prescriptions

Your Physician obtains this authorization by calling The Wellness Plan.

Services requiring our prior approval 14.
14 Page 15 16
2003 The Wellness Plan 11 Section 4
S ect ion 4. Y ou r cos t s f or covered s ervices
You must share the cost of some services. You are responsible for:
Co-payments A co-payment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per
office visit.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. We do not have a deductible.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. We do not have coinsurance.

Your catastrophic protection out-of-pocket maximum We do not have a catastrophic protection out-of-pocket maximum. 15.
15 Page 16 17
2003 The Wellness Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 52 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 800 875-WELL (9355) or at our website at
www. wellplan. com.

(a) Medical services and supplies provided by physicians and other health care professionals ............................................................ 13-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

Speech therapy Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies) Foot care
Orthopedic and prosthetic devices Durable medical equipment (DME)
Home health services Chiropractic
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals...................................................... 22-24
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................................................... 25-26

Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(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
Flexible benefits option

Services for the deaf and hearing impaired
(h) Dental benefits ....................................................................................................................................................................................... 34
(i) Non-FEHB benefits available to Plan members .................................................................................................................................. 35
Summary of benefits...................................................................................................................................................................................... 52 16.
16 Page 17 18
2003 The Wellness Plan 13 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible
Be sure to read Section 4, Your costs for covered services, or valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office Medical Consultants
Second surgical opinion

$10 per office visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility

Nothing

At home Nothing 17.
17 Page 18 19
2003 The Wellness Plan 14 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during
your office visit; otherwise, $10 per office
visit.

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

$10 per office visit

Routine P r os tate S pecif ic A ntigen ( P S A ) tes t one annually f or m en age 40
and older
$10 per office visit

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

$10 per office visit

Routine mammogram covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period
From age 40 and over, one every calendar year
Note: You do not need a referral from your primary care physician
when you use a participating facility for your routine mammogram

Nothing if you receive these services during
your office visit; otherwise, $10 per office
visit.

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, such as:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

Nothing if you receive these services
during your office visit or at an in network
facility. 18.
18 Page 19 20
2003 The Wellness Plan 15 Section 5( a)
Preventive care children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if you receive these services during your office visit or at an in network
facility.

Well-child care charges for routine examinations, immunizations and care (through 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
(through age 22)

$10 per office visit

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

Nothing

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefits.

$10 per office visit 19.
19 Page 20 21
2003 The Wellness Plan 16 Section 5( a)
Not covered:
reversal of voluntary surgical sterilization,
genetic counseling

All charges.

Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI) intracervical insemination (ICI)

intrauterine insemination (IUI) Fertility drugs

Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Nothing

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization embryo transfer, gamete GIFT and zygote ZIFT

Zygote transfer Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 20.
20 Page 21 22
2003 The Wellness Plan 17 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 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 800/ 875-WELL (9355) for preauthorization. We will ask you to

submit information that establishes that the GHT is medically
necessary. Ask us to authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date you submit
the information. If you do not ask or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Nothing

Physical and occupational therapies
60 visits per condition per year for the services of each of the following:
qualified physical therapists and occupational therapists.

Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 18 sessions.

Nothing

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
60 visits per condition per year for the services of a qualified speech
therapist
Nothing

Not covered:
long term rehabilitative therapy
exercise programs

All charges. 21.
21 Page 22 23
2003 The Wellness Plan 18 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)
Hearing Aids
Note: We will cover one hearing aid every 36 consecutive months as
appropriate

$10 per office visit

Not covered:
all other hearing testing
hearing aids ordered prior to effective date of coverage
batteries
unauthorized services
replacement or repair of hearing aids due to theft, misuse, misplacement, or damage

All charges.

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
Nothing

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)
Annual eye refractions
Dialated Retinal exams for diabetics

Nothing

Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges. 22.
22 Page 23 24
2003 The Wellness Plan 19 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

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

$10 per office visit

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

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

treatment is by open cutting surgery)

All charges.

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See 5( b)
for coverage of the surgery to insert the device.

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

Note: Call us at 800 875-WELL (9355) as soon as your Plan physician
prescribes this equipment. We will make arrangements with a health
care provider for the equipment at discounted rates. We will tell you
more about this service when you call us.

$10 per office visit
Nothing for the device

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

replacement or repair due to misuse, damage, theft or misplacement

All charges 23.
23 Page 24 25
2003 The Wellness Plan 20 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 800 875-WELL, (9355) as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider to
rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

$10 per office visit
Nothing for the device

Not covered:
Motorized wheel chairs (except for quadriplegics) Personal Comfort and convenience items

Replacement or repair due to misuse, damage, theft or misplacement

All charges.

Home health services
Home health care ordered by a Plan physician and provided by a registered 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.
Nothing

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

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

All charges.

Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: We limit Chiropractic care to 18 visits per member per year,
You must obtain a referral from your Primary Care Physician.

$10 per office visit

Not covered:
Unauthorized care Visits in excess of 18 per calendar year All charges. 24.
24 Page 25 26
2003 The Wellness Plan 21 Section 5( a)
Alternative treatments You pay
No benefit. We do not cover services such as but not limited to::
acupuncture naturopathic services

hypnotherapy biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

Smoking Cessation
Contact our Smoking Cessation Resource Center at 1-866-223-0321( toll
free). Registered Nurses are available to answer your questions and assist
you with obtaining counseling and nicotine replacement therapy. The
nurse may refer you to a contracted Smoking Cessation Program or you may obtain a referral from your Primary Care Physician. Please see the

prescription drug benefits for information on co pays for prescription
smoking cessation drugs.

Diabetes self-management
The Diabetic Care Network (DCN) will assist you in managing your
diabetes. Please contact us at 800-875-WELL, (9355). DCN will educate you about the disease and how to prevent complications. DCN

will send you informative literature and reminders by mail. DCN staff
may periodically call you to check on your progress,

Nothing 25.
25 Page 26 27
2003 The Wellness Plan 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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A N
T

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

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

surgical center, etc.).
YOUR PHYSICIAN MUST GET PRIOR APPROVAL OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure

which services require precertification and identify which surgeries require precertification.

I M
P O
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A N
T

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

Normal pre-and post-operative care by the surgeon 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 5( a) Orthopedic and prosthetic devices for device coverage information.

Voluntary sterilization 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.

$10 per office visit
Nothing when surgery is performed in a hospital

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

All charges. 26.
26 Page 27 28
2003 The Wellness Plan 23 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

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

$10 per office visit
Nothing when surgery is performed in a
hospital

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

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

$10 per office visit
Nothing when surgery is performed in a
hospital

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

See above.

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit
Nothing when surgery is performed in a hospital

Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures

(such as the periodontal membrane, gingiva, and alveolar bone)

All charges. 27.
27 Page 28 29
2003 The Wellness Plan 24 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and

peripheral stem cell support) for the following conditions: acute
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
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.

Nothing

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

Implants of artificial organs
Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in
Hospital (inpatient) Hospital outpatient department

Skilled nursing facility Ambulatory surgical center

Nothing

Professional services provided in
Office
$10 per office visit 28.
28 Page 29 30
2003 The Wellness Plan 25 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including

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

(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I M
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations; general nursing care; and

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

Nothing

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

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:
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

All charges. 29.
29 Page 30 31
2003 The Wellness Plan 26 Section 5( c)
Ou t p at ie n t h os p it al or am b u lat or y s u rgical c en t er You pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
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.

Nothing

Ext en d ed care b en ef it s /s k illed n u rs in g care f acilit y b en ef it s
Skilled nursing facility (SNF):
We cover a comprehensive range of benefits for up to 730 days per
confinement when fulltime skilled nursing care is necessary and
confinement in a SNF is medically appropriate as determined by a Plan
doctor and approved by the Plan.

Nothing

Not covered: custodial care, rest cures, domicillary, or convalescent
care.
All charges.

Hospice care
We cover supportive and palliative care for terminally ill members in
the home and hospice facility. Services may be inpatient and/ or out
patient and include family counseling. These services are provided
under the direction of a plan doctor who certifies that the patient is in
the terminal stages of illness with a life expectancy of approximately six
months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate All charges. 30.
30 Page 31 32
2003 The Wellness Plan 27 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

H er e ar e s ome impor tant things to keep in mind about thes e benef its :
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We do not have a calendar year deductible.
Be s ur e to r ead S ection 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
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A N
T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or

sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what
they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area
If you are in an emergency situation, please call your Primary Care Physician. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system (e. g. the 911 telephone system) or got to the nearest hospital
emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us. You or a
family member should notify the Plan within 48 hours or the first working day following your admission, unless it was not reasonably possible to do so. It is your responsibility to ensure that we are timely notified. If you are hospitalized in a non-Plan

facilities and we believe care can better be provided in a Plan hospital, we will transfer you when medically feasible
with any ambulance charges covered in full. We only cover medical emergency services from non-plan providers if delay in
reaching a Plan Provider would result in death, disability or significant jeopardy to your condition.

Emergencies outside our service area:
If you are out of area and in an emergency situation please contact the local emergency system (e. g. the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan
member so they can notify us. You or a family member should notify the Plan within 48 hours or the first working day following your admission, unless it was not reasonably possible to do so. It is your responsibility to ensure that we are

timely notified. If you are hospitalized in non-affiliated hospital and to the extent that it is deemed both practical and
medically permissible, TWP will arrange for the transfer of the member to a TWP affiliated hospital. 31.
31 Page 32 33
2003 The Wellness Plan 28 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services
$50 per urgent care center or hospital
emergency room visit

Note: We waive the $50 copay if you are
admitted to the hospital

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

Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per urgent care center or hospital emergency room visit
Note: We waive the $50.00 co pay if you
are admitted to the hospital

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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.

Air Ambulance

Nothing

Not covered: non-emergency ambulance transport All charges. 32.
32 Page 33 34
2003 The Wellness Plan 29 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We do not have a 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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

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

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

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

Medication management

$10 per vis it

Mental health and substance abuse benefits -continued on next page 33.
33 Page 34 35
2003 The Wellness Plan 30 Section 5( e)
Mental health and substance abuse benefits (continued) Y ou p ay
Diagnostic tests Nothing, if you received during your
office visit; otherwise $10 per office visit

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

Nothing

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
You do not need a referral for behavioral health services. You may contact the Plan
provider directly. The provider that you select will develop a treatment plan that you
must follow if you expect us to cover your treatment.

If you need behavioral services anywhere in our service area contact Comp Care at
1-800-435-5348.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2003 The Wellness Plan 31 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
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A N
T

Here are s om e im p ort an t t h in gs t o k eep in m in d ab ou t t h es e b en ef it s :
We cover pr es cr ibed dr ugs and medications , as des cr ibed in the char t beginning on the next page.
A ll benef its ar e s ubject to the def initions , limitations and exclus ions in this br ochur e and ar e payable only w hen w e deter mine they ar e m edically neces s ar y.

We do not have a calendar year deductible.
Cer tain dr ugs r equir e our pr ior appr oval. Y our phys ician s hould r eques t pr ior appr oval f r om us by completing a pr ior author ization r eques t f or m .

Be s ur e to r ead S ection 4, Your costs for covered services, f or valuable inf or m ation about how cos t s har ing w or ks . A ls o r ead S ection 9 about coor dinating benef its w ith other cover age, including w ith Medicar e.

I M
P O
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A N
T

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

Where you can obtain them or You must fill the prescription at a plan pharmacy.
We use a formulary. We call it the Wellness Plan Performance Drug List. The list includes classes of widely used drug products that we prefer. You may obtain a copy of the Wellness Plan Clinical Formulary

and Prescribing Guidelines by calling us. The drugs selected have been carefully reviewed and provide
excellent choices from the standpoint of safety and cost effectiveness. We cover non -formulary drugs when
your Plan doctor prescribes them, as long as the drugs are medically necessary and appropriate. Your Plan
doctor is responsible for requesting prior authorization from our Pharmacy Department.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from our formulary list. This list of name

brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a copy
of our formulary, call 800 875-WELL (9355).

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan Pharmacy will be dispensed for up to a 35-day supply or 100-unit doses, whichever is greater, or one

commercially prepared unit. You pay a $5.00 copay per prescription unit or refill.
The Plan Pharmacy will dispense a generic equivalent, if it is available, unless your physician specifically
requires a brand name. If you receive a brand drug when a Federally approved generic drug is available, and
your Physician has not specified Dispense As Written (DAW) for the brand name drug, you will to pay the
difference in price between the name brand drug and the generic in addition to the copay.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of the 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 and us less than a name
brand prescription.

When you have to file a claim. Please keep a copy of your pharmacy receipt and send it to our Customer Service Department for processing. If you need additional assistance you may phone them at 800 875-9355. 35.
35 Page 36 37
2003 The Wellness Plan 32 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase except those

listed as Not covered.
Insulin (up to 3 vials per co pay) Disposable needles and syringes for the administration of covered

medications
Drugs for sexual dysfunction (Contact us for dosage limits and prior authorization)

Contraceptive drugs and devices Infertility drugs
Diabetic supplies, including glucose test tablets and test tapes, Benedicts solution, or equivalent, acetone test tablets, glucose monitors
and meters

$ 5 per prescription unit or refill

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
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
Nonprescription medicines
Medical Supplies such as dressings and antiseptics
Smoking Cessation drugs if you are not in a program

All charges. 36.
36 Page 37 38
2003 The Wellness Plan 33 Section 5( g)
S ect ion 5 ( g) . S p ecial f eat u res
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

Services for deaf and hearing impaired Hearing impaired members may contact The Wellness Plan at 313-874-8256. 37.
37 Page 38 39
2003 The Wellness Plan 34 Section 5 (h)
S ect ion 5 ( h ) . D en t al b en ef it s
I M
P O
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A N
T

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

Plan dentists must provide or arrange your care.
We do not have a calendar year deductible.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient

hospital benefits. We do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

I M
P O
R T
A N
T

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

Nothing

Dental benefits
We have no other dental benefits. 38.
38 Page 39 40
2003 The Wellness Plan 35 Section 5 (i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums.

The Wellness Plan offers a discount dental program for all enrollees. The program is offered through Dental Preferred Provider Origination (DPPO) and extends discounts ranging from 20% -50% depending on the reason for the visit.
The Wellness Plan will provide members with a discount fee schedule and a list of participating dental providers. In
addition, we offer the following Wellness Programs designed to keep you well Stress Management, Smoking
Cessation, Diabetes Education, Weight Control, Childbirth, and Hypertension Education. Call 800-875-WELL (9355). 39.
39 Page 40 41
2003 The Wellness Plan 36 Section 6
S ect ion 6. Gen eral exclu s ion s --t h in gs w e d on '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. 40.
40 Page 41 42
2003 The Wellness Plan 37 Section 7
S ect ion 7. Filin g a claim f or covered s ervices
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 co-payment, You will only need to file a claim
when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 800-875-9355.

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: The Wellness Plan Attn.: Customer Service Department
2875 W. Grand Blvd.
Detroit, MI 48202

Prescription drugs You do not have to file claims. Simply use your Plan identification card at Plan Pharmacies and pay the appropriate co pay.
Submit your claims to: Same address as above

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. 41.
41 Page 42 43
2003 The Wellness Plan 38 Section 8
S ect ion 8. Th e d is p u t ed claim s p roces s
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 The Wellness Plan, 2875 W. Grand Boulevard, Detroit, MI 48202, Attn.: Customer Services Department; 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. 42.
42 Page 43 44
2003 The Wellness Plan 39 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons
beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against
OPM in Federal court by December 31 of the third year after the year, in which you received the disputed services, drugs, or
supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not
be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 800 875-WELL
(9355) 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. 43.
43 Page 44 45
2003 The Wellness Plan 40 Section 9
S ect ion 9. C oord in at in g b en ef it s w it h ot h er coverage
Wh en you h ave ot h er h ealt h 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.

Wh at is Med icare? 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 is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.

The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP and you will still pay applicable co payments.

Th e Origin al Med icare Plan ( Part A or Part B) 44.
44 Page 45 46
2003 The Wellness Plan 41 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most
cases, your claim will be coordinated automatically and we will then provide secondary
benefits for covered charges. You will not need to do anything. To find out if you need to do
something to file your claim, call us at 800/ 875-WELL (9355).

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

(Primary payer chart begins on next page.) 45.
45 Page 46 47
2003 The Wellness Plan 42 Section 9
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.

P r im ar y P aye r C h ar t
Th en t h e p rim ary p ayer is A . Wh en eit h er you --or you r covered s p ou s e --are age 65 or over an d

Origin al Med icare Th is P lan
1) A r e an active employee w ith the F eder al gover nment ( including w hen you or a f amily member ar e eligible f or Medicar e s olely becaus e of a dis ability) , 4

2) Are an annuitant, 4

4
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

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), 4

5) Are enrolled in Part B only, regardless of your employment status, 4 (for Part B services) 4 (for other services)
4
1) ( except f or claims r elated to Wor ker s ' Com pens ation.) B. When you --or
a covered family member --have Medicare based on end stage

renal disease (ESRD) and Are within the first 30 months of

eligibility to receive Part A benefits solely because of ESRD, 4 Have
completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,

4

2) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, 4
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 4

b) Are an active employee, or 4
c) Are a former spouse of an annuitant, or 4
d) Are a former spouse of an active employee 4 46.
46 Page 47 48
2003 The Wellness Plan 43 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits 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. 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 have one or both Parts of Medicare, you can still be 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.

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

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

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

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

If you do not enroll in Medicare Part A or Part B 47.
47 Page 48 49
2003 The Wellness Plan 44 Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in a one of these State programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may

do so only at the next Open Season unless you involuntarily lose coverage under the State
program.

Wh en ot h er Govern m en t agen cies We do not cover services and supplies when a local, State, or Federal Government are responsible for your care agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care for injuries 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. 48.
48 Page 49 50
2003 The Wellness Plan 45 Section 10
S ect ion 10. D ef in it ion s of t erm s w e u s e in t h is b roch u re
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Unskilled care that can be provided by an individual who does not have medical training. Examples of custodial care would be help with walking and getting out of bed and
assistance with daily living activities such as feeding, dressing and personal hygiene.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. We do not have
a deductible. See page 11.
Any drug, device, supply, treatment procedure, or equipment that:
a . Hasn't yet been approved by the Food and Drug Administration (FDA) and can not be
lawfully marketed without such approval;
b. Is the subject of a current investigational new drug or new device application on file with the FDA;

c Is part of a Phase 1 or Phase II clinical trial;
d. Hasn't been demonstrated to be a safe or effective treatment in comparison to
conventional alternatives.
e Is described as experimental, investigational, or research by informed consent or patient
information documents; f. Is being delivered or should be delivered subject to approval and supervision by an

Institutional Review Board based on Federal regulations; and
g. Most experts agree further study is needed.

Medical necessity Services and Supplies furnished to you that: Are medically required and medically appropriate for the diagnosis and treatment of
your illness or injury; or
Are consistent with professionally recognized standards of health care; and Do not involve costs that are excessive in comparisons with alternative services

thatwould effectively treat your condition, illness or injury

Us/ We Us and we refer to The Wellness Plan
You You refers to the enrollee and each covered family member.

Experimental or investigational services 49.
49 Page 50 51
2003 The Wellness Plan 46 Section 11
S ect ion 11. FEHB f act s
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure . Also, your employing or about enrolling in the retirement office can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your
enrollment status without information from your employing or retirement office.

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

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

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

be enrolled in or covered as a family member by another FEHB plan.

C h il d r en ' s Eq u it y A c t OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a
court or 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: 50.
50 Page 51 52
2003 The Wellness Plan 47 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option;
if you have a Self only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment

to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue

Cross and Blue Shield Service 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 you provide documentation that you have other coverage
for the children. If the court/ administrative order is still in effect 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 you employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start 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.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage 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 of coverage (TCC) If you leave Federal service, or if you lose coverage because you no 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. 51.
51 Page 52 53
2003 The Wellness Plan 48 Section 11
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.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you

have been enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans. For more information,
get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. See also the FEHB web site ( www. opm. gov/ insure/ health); refer to the
"TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any TCC eligibility as one

condition for guaranteed access to individual health coverage under HIPAA, and have
information about Federal and State agencies you can contact for more information. 52.
52 Page 53 54
2003 The Wellness Plan 49 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe