Pages 1--63

Enrollment codes for this Plan:
Arizona
A31 Self Only
A32 Self and Family

California
CY1 Self Only
CY2 Self and Family

Nevada
K91 Self Only
K92 Self and Family

Oklahoma
2N1 Self Only
2N2 Self and Family

Oregon
7Z1 Self Only
7Z2 Self and Family

Texas
GF1 Self Only
GF2 Self and Family

Washington
WB1 Self Only
WB2 Self and Family

2003
These plans have Excellent or Commendable
Accreditation from the NCQA. See the 2003
Guide for more information on NCQA.

For changes in benefits
see page
9

RI 73-105 1.
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Blank Page 2.
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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 3.
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Blank Page 4.
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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.

Notice of the Office of Personnel Management s
Privacy Practices 5.
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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. 6.
6 Page 7 8
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Plan facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Coinsurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Your catastrophic protection out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Health Improvement Programs PacifiCare Perks SM Program

Eye Glasses and Hearing Aids Centers of Excellence
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
( i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 6. General exclusions things we don t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Table of Contents

2003 PacifiCare Health Plans 2 Table of Contents 7.
7 Page 8 9
Table of Contents
2003 PacifiCare Health Plans 3 Table of Contents
Section 8. The disputed claims process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Workers Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Section 11. FEHB facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Where you get information about enrolling in the FEHB Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Children s Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 When FEHB coverage ends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Getting a Certificate of Group Health Plan Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Long Term Care Insurance is still Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back Cover 8.
8 Page 9 10
This brochure describes the benefits of PacifiCare Health Plans under our contract ( CS 1937) with the Office of Personnel
Management ( OPM) , as authorized by the Federal Employees Health Benefits law. The address for administrative offices is:

PacifiCare Health Plans
5995 Plaza Drive
Cypress, CA 90630

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

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; ; we means PacifiCare.

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 the 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.

2003 PacifiCare Health Plans Introduction/ Plain Language/ Advisory 4

Introduction 9.
9 Page 10 11
2003 PacifiCare Health Plans Introduction/ Plain Language/ Advisory 5
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits ( EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1/ 800-531-3341 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 10.
10 Page 11 12
2003 PacifiCare Health Plans Section 1 6
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.

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

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

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

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

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM s FEHB website ( www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.

PacifiCare Health Systems has been in existence since 1975. We were founded by the Lutheran Hospital Society now called UniHealth America. We began operating as a Federally qualified Health Maintenance Organization ( HMO) in 1978.

PacifiCare is a for profit organization.
If you want more information about us, call 1( 800) 531-3341, or write to 5995 Plaza Drive MS CY 20-303, Cypress, CA 90630.
You may also contact us by fax at ( 714) 226-3575 or visit our website at www. pacificare. com.

Section 1. Facts about this HMO plan 11.
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2003 PacifiCare Health Plans Section 1 7
Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice.
Our service areas are:
ARIZONA
Serving: Maricopa and Pima counties and Apache Junction identified by the following zip codes:
85217, 85219, 85278 and 85220

CALIFORNIA
Serving Northern and Southern California:
Alameda, Contra Costa, Fresno, Kern, Los Angeles ( except Catalina Island) , Marin, Orange, Sacramento, San Diego, San Francisco,
San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Ventura, Yolo, and portions of the
following counties as defined by zip codes:

El Dorado: 95682, 95726
Placer: 95602-04, 95626, 95631, 95648, 95650, 95658, 95661, 95663, 95668, 95677, 95678, 95681, 95703,
95713, 95717, 95722, 95736, 95746, 95747, 95765

Riverside: 91718-20, 91752, 91760, 92201-03, 92210, 92211, 92220, 92223, 92230, 92234-36,
92239-41, 92253-55, 92258, 92260-64, 92270, 92272, 92274-76, 92282, 92292, 92302-03, 92313, 92320,
92330-31, 92343-44, 92348, 92353, 92355, 92360, 92362, 92367, 92369-70, 92379-81, 92383, 92387-88,
92390, 92395, 92396, 92500-99

San Bernardino: 91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758-59, 91761-64, 91784, 91785-816, 92252, 92256, 92277,
92278, 92284, 92285, 92286, 92301, 92305, 92307-08, 92310-18, 92321, 92322, 92324-27, 92329, 92333-37, 92339-42, 92345-47,
92350, 92352, 92354, 92356-59, 92365, 92368, 92369, 92371-78, 92382, 92385, 92386, 92391-94, 92397-99, 92400-99

NEVADA
Serving Clark County Nevada identified by the following cities and zip codes:
Blue Diamond, Boulder City, Bunkerville, Cal/ Nev/ Ari, Henderson, Jean, Indian Springs, Las Vegas, Logandale, Mesquite, Moapa,
Mt. Charleston North Las Vegas, Nellis AFB, Overton and Searchlight.

Clark: 88901-88905, 89004-89007, 89009, 89011-12, 89014-16, 89018, 89019, 89021, 89024-27, 89030-33, 89036, 89039-40,
89046, 89052, 89070, 89100-89135, 89137-39, 89141-56, 89158-60, 89163, 89164, 89170, 89177, 89180, 89185, 89191, 89193,
89195 and 89199

OKLAHOMA
Serving Central and Northeastern Oklahoma:
The counties of: Canadian, Cleveland, Creek, Oklahoma, Pottawatomie, Rogers, Tulsa and Wagoner.
And portions of the following counties identified by zip code:

Muskogee: 74436
Osage: 74002, 74035, 74054, 74060
Washington: 74061, 74082

OREGON
Serving Metropolitan Portland, Salem, Corvalis, Eugene and Southwest Washington:
Multnomah, Washington, Clackamas, Marion, Polk, Linn, Benton, Lane, Yamhill and Columbia, and Clark
county in Washington. 12.
12 Page 13 14
2003 PacifiCare Health Plans Section 1 8
TEXAS
Serving San Antonio and Dallas/ Ft. Worth:
Atascosa, Bandera, Bexar, Collin, Comal, Dallas, Denton, Ellis, Guadalupe, Hood, Hunt, Johnson, Kaufmann, Kendall, Rockwall,
Tarrant, and Wise.

WASHINGTON
Serving the Puget Sound area and most of Western Washington.
Grays Harbor, King, Lewis, Mason, Pierce, Snohomish and Thurston.

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. 13.
13 Page 14 15
Section 2. How we change for 2003
2003 PacifiCare Health Plans Section 2 9
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not
change benefits.

Program-wide changes
A Notice of the Office of Personnel Management s Privacy Practices is included. A section on the Children s Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Code A3 Your share of the non-Postal premium will increase by 12% for Self Only or 5.6% for Self and Family Code CY Your share of the non-Postal premium will increase by 13.1% for Self Only or 12.2% for Self and Family
Code GF Your share of the non-Postal premium will increase by 43.7% for Self Only or 87.7% for Self and Family Code K9 Your share of the non-Postal premium will increase by 5.4% for Self Only or 9.5% for Self and Family
Code WB Your share of the non-Postal premium will increase by 15.1% for Self Only or decrease by 15.4% for Self and Family Code 2N Your share of the non-Postal premium will increase by 52.2% for Self Only or 86.7% for Self and Family
Code 7Z Your share of the non-Postal premium will decrease by 23.6% for Self Only or 25.2% for Self and Family You now pay a $ 20 copayment for office visits to specialists.
Prescription drugs You now pay $ 10 for generic drugs and $ 20 for brand name drugs. Maternity care You now pay a single $ 20 copay for the entire pregnancy.
Mental Health and Substance Abuse You now pay a $ 20 copayment for office visits to Behavioral Health specialists. Lab, X-ray and other diagnostic tests You now pay a $ 20 copayment for all complex radiology exams, such as, MRI,
Ultrasound, CT Scans, PET Scans and SPECT Scans.
Emergency Services You now pay a $ 75 copayment per visit to an Emergency Room. We no longer waive this copayment if you are admitted to the hospital.

Emergency Services You now pay a $ 10 copayment for emergency care provided in an urgent care center and a $ 20 copayment for emergency care provided in a specialist office.
Out-of-pocket maximum Your catastrophic protection out of pocket maximum has increased to $ 2,000 per person or $ 6,000 per family enrollment.
Service Area reductions We no longer provide service in the following areas: California Imperial County and City of Blythe
Oklahoma Logan County
If you are enrolled in the PacifiCare of Nevada health plan ( K9) , effective January 1, 2003, we will no longer offer reimbursement of copayments for providers or pharmacy services to those members that are enrolled in the Federal Employees

Health Benefits Program and the Secure Horizons Medicare managed care plan. 14.
14 Page 15 16
2003 PacifiCare Health Plans Section 3 10
Identification cards We will send you an identification ( ID) card. You should carry your ID card with you at all times. You must show it whenever you receive services from a
Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your
ID card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits enrollment confirmation ( for annuitants) , or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1( 800) 531-3341
or write to us at PacifiCare Health Plan, 5995 Plaza Drive, MS CY20-303,
Cypress, CA 90630. You may also request replacement cards through our
website at www. pacificare. com.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments and/ or coinsurance, and you will not have to file claims unless you
receive out of area emergency services.

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, which you can also access at www. pacificare. com.

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

What you must do to get It depends on the type of care you need. First, you and each family member covered care 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
may select a primary care doctor by completing the Primary Care Doctor
Selection form inside your enrollment packet.

Primary care Your primary care physician can be a family practitioner, internist, General Practitioner or pediatrician for children under 18 years of age. 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.

Section 3. How you get care 15.
15 Page 16 17
2003 PacifiCare Health Plans Section 3 11
However, women may see an OB/ Gyn within their primary medical group once
every twelve months for the well-woman exam, without a referral. If you are
enrolled in Plans PacifiCare of Washington ( WB) or PacifiCare of Texas ( GF) ,
you may also see any Woman s Healthcare provider within the network for
maternity care, reproductive health services, gynecological care and general
examinations 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 coordinate
with your specialist and PacifiCare to develop a treatment plan that allows
you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating
our treatment plan ( the physician may have to get an authorization or
approval beforehand) .

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

Generally, we will not pay for you to see a specialist who does not participate
with our Plan.

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

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

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

reduce our service area and you enroll in another FEHB Plan.
You may be able to continue seeing your specialist for up to 90 days after you
receive notice of the change. Contact us or, if we drop out of the Program,
contact your new plan.

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1( 800) 531-3341. If you are new
to the FEHB Program, we will arrange for you to receive care. 16.
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2003 PacifiCare Health Plans Section 3 12
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:

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

Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may our control have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to refer you for most services. For prior approval 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 the approval process precertification. Your physician must obtain
approval for some services such as:

Cardiovascular bypass surgery
Septoplasty
Cholecystectomy
Hysterectomy
Arthroplasty
MRIs and CTs
Growth Hormone Treatment ( GHT)
PacifiCare Health Plans may determine medical necessity by using
preauthorization programs and criteria. Our criteria are written guidelines
established by us to determine medical necessity and/ or coverage for certain
procedure and treatments. Our criteria are based on research of scientific
literature, collaboration with physician specialists and compliance with federal
and national regulatory agency guidelines. Criteria are approved by the
PacifiCare Health Care Standards and Education Committee and are reviewed
and revised on a regular basis. Criteria are available for review by the
member s participating physician, the member or the member s representative.
If you do not receive prior approval you may be responsible for charges.
Always return to your primary care physician for prior approval. 17.
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Section 4. Your costs for covered services
2003 PacifiCare Health Plans Section 4 13
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility or pharmacy when you receive services.
Example: When you see your primary care physician you pay a copayment of
$ 10 per office visit and when you go in the hospital, you pay nothing per
admission.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage that you must pay for your care.

After your copayments total $ 2,000 per person or $ 6,000 per family enrollment
in any calendar year, you do not have to pay any more for covered services.
However, copayments for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay
copayments for these services:

Prescription Drugs Dental Services
Chiropractic Services
Be sure to keep accurate records of your copayments since you are responsible
for informing us when you reach the maximum.

Your Catastrophic Protection out-of-pocket maximum for
copayments 18.
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2003 PacifiCare Health Plans Section 5 14
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning
of each subsection. For more information about our benefits, contact us at 1( 800) 531-3341 or at our website at www. pacificare. com.

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 -22
Diagnostic and treatment services Speech Therapy Lab, X-ray, and other diagnostic tests Hearing services ( testing, treatment, and supplies)
Preventive care, adult Vision services ( testing, treatment, and supplies) Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices Family planning Durable medical equipment ( DME)
Infertility services Home health services Allergy care Chiropractic
Treatment therapies Educational classes and programs Physical and occupational therapies

( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 -26
Surgical procedures Oral and maxillofacial surgery Reconstructive surgery Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 -28

Inpatient hospital Extended care benefits/ skilled nursing care Outpatient hospital or ambulatory Ambulance
facility benefits surgical center Hospice care
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 -30
Accidental injury Medical emergency Ambulance
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 -32
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 -35
( g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Health Improvement Programs PacifiCare Perks SM Programs Eye Glasses and Hearing Aid Centers of Excellence

( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 -38
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Section 5. Benefits OVERVIEW ( See page 9 for how our benefits changed this year and page 56 for a benefits summary. ) 19.
19 Page 20 21
Section 5 ( a) Medical services and supplies provided by physicians
and other health care professionals

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

are medically necessary.
Plan physicians must provide or arrange your care. Be sure to read Section 4, Your costs for covered services for valuable information

about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

Professional services of physicians $ 10 per primary care physician ( PCP)
In a physician s office office visit, Nothing for inpatient services. In an urgent care center $ 20 per specialist office visit

During a hospital stay In a skilled nursing facility
Office medical consultations Second surgical opinion

At home doctors house calls or visits by nurses and health aides $ 10 per visit

Tests, such as: Nothing if you receive these services
Blood tests during your office visit. Urinalysis

Non-routine pap tests Pathology
X-rays Non-routine Mammograms

CAT Scans $ 20 copayment per exam PET Scans
SPECT Scans MRI
Ultrasound Electrocardiogram and EEG

Benefit Description You Pay after the calendar year deductible
Diagnostic and treatment services

Lab, X-ray and other diagnostic tests
Complex radiology diagnostic exams 20.
20 Page 21 22
2003 PacifiCare Health Plans Section 5 ( a) 16
Routine screenings, such as: Nothing if you receive these services during
Total Blood Cholesterol once every three years your office visit; ; Otherwise, Colorectal Cancer Screening, including $ 10 per PCP office visit

Fecal occult blood test $ $ 20 per specialist office visit
Sigmoidoscopy, , screening every five years starting at age 5

Prostate Specific Antigen ( PSA test) one annually for men age 40 and older $ $ 10 per PCP office visit
$ 20 per specialist office visit

Routine pap test $ 10 per PCP office visit,
$ 20 per specialist office visit

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

Routine mammogram covered for women age 35 and older, , as follows: Nothing if you receive these services
From age 35 through 39, one during this five year period during your office visit; otherwise, From age 40 through 64, one every calendar year $ 20 per office visit

At age 65 and older, one every two consecutive calendar years
Not covered: Physical exams required for obtaining or continuing All charges.
employment or insurance, attending schools or camp, or travel.
Immunizations for travel

Routine immunizations limited to: Nothing if you receive these services
Tetanus-diphtheria ( Td) booster once every 10 years, , ages 19 and during your office visit; otherwise, over ( except as provided for under Childhood immunizations) . $ 10 per PCP office visit,

Influenza vaccines, annually, Pneumococcal vaccine, age 65 and over $ 20 per specialist visit

Childhood immunizations recommended by the American Academy Nothing if you receive these services of Pediatrics and the ACIP during your office visit; otherwise;
$ 10 per PCP office visit,
$ 20 per specialist office visit

Examinations, such as: $ 10 per PCP office visit, Eye exams to determine the need for vision correction. $ 20 per specialist office visit
Ear exams to determine the need for hearing correction.
Examinations done on the day of immunizations ( up to age 22 years) .
Well-child care charges for routine examinations, immunizations and care ( up to age 22 years) .

Preventive care, adult
Preventive care, children
You Pay 21.
21 Page 22 23
2003 PacifiCare Health Plans Section 5 ( a) 17
Complete maternity ( obstetrical) care, such as: A single $ 20 copay for the entire
Prenatal care pregnancy. Delivery

Postnatal care Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 27 for other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother s maternity stay. We will cover other care of an infant

who requires non-routine treatment only if we cover the infant under a Self
and Family enrollment. Note: Circumcisions for newborns are covered under
surgical benefit not maternity benefits. See section 5 ( b) .

We pay hospitalization and surgeon services ( delivery) the same as for illness and injury. See Hospital benefits ( Section 5c) and Surgery

benefits ( Section 5b) .

Not covered: Routine sonograms and genetic testing to determine fetal sex. All charges.

A broad range of family services such as: $ 10 per PCP office visit, $ 20 per specialist
Voluntary sterilization ( See Surgical procedures Section 5 ( b) office visit. Nothing for hospital visits or Surgically implanted contraceptives Outpatient Surgical Center.

Injectable contraceptive drugs ( such as Depo-Provera) Intrauterine devices ( IUDs)
Diaphragms
Note: we cover oral contraceptives under the prescription drug benefit.
Not covered: Reversal of voluntary surgical sterilization All charges.
Genetic counseling, unless part of authorized genetic testing.

Diagnosis and treatment of infertility, such as: 50% of all charges
Artificial insemination: intravaginal insemination ( ( IVI)

intracervical insemination ( ( ICI)
intrauterine insemination ( ( IUI)
Injectable fertility drugs

Note: We cover oral fertility drugs under the prescription drug benefit.

Maternity care
Family planning
Infertility services

You Pay 22.
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2003 PacifiCare Health Plans Section 5 ( a) 18
Not covered: All charges.
Assisted reproductive technology ( ART) procedures, such as: in vitro fertilization

embryo transfer gamate GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures Cost of donor sperm

Cost of donor egg

Testing and treatment $ 10 per PCP office visit,
Allergy injection $ 20 per specialist office visit

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

Chemotherapy and radiation therapy $ 10 per PCP office visit, $ 20 per specialist office visit
Note: High dose chemotherapy in association with autologous
bone marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.

Respiratory and inhalation therapy Dialysis hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy Growth hormone therapy ( GHT)

Note: We will only cover GHT when we preauthorize the treatment.
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.

Not covered: All charges.
Other treatment services not listed as covered.

Infertility services ( Continued)
Allergy care
Treatment therapies

You Pay 23.
23 Page 24 25
Physical therapy, occupational therapy $ 10 per PCP office visit,
Unlimited visits for the services of each of the following: $ 20 per specialist visit qualified physical therapists; ;

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

Cardiac rehabilitation following a heart transplant, bypass surgery or $ 10 per PCP outpatient visit, a myocardial infarction is provided with no day limit. $ 20 per specialist visit

Pulmonary Rehabilitation
Not covered: All charges.
long-term rehabilitative therapy exercise programs

Unlimited visits for the services of: $ 10 per PCP office visit copay,
Qualified speech therapists $ 20 per specialist visit Note: All therapies are subject to medical necessity

First hearing aid and testing only when necessitated by accidental injury $ 10 per PCP office visit, Hearing testing ( see Preventive care) $ 20 per specialist visit
Not covered: All charges.
all other hearing testing all other hearing aids

One pair of eyeglasses or contact lenses to correct an impairment directly $ 10 per PCP office visit, caused by accidental ocular injury or intraocular surgery $ 20 per specialist visit
( such as for cataracts)

You may receive one annual eye refraction in a twelve month period. $ 10 per PCP office visit, $ 20 per specialist visit
Note: See preventive care children for eye exams for children

Not covered: All charges.
Eyeglasses or contact lenses except as shown on page 19. Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

Hearing services ( testing, treatment, and supplies)

2003 PacifiCare Health Plans Section 5 ( a) 19

Physical and Occupational Therapies
Speech Therapy
Vision services ( testing, treatment, and supplies)

You Pay 24.
24 Page 25 26
2003 PacifiCare Health Plans Section 5 ( a) 20
Routine foot care when you are under active treatment for a metabolic or $ 10 per PCP office visit,
peripheral vascular disease, such as diabetes. $ 20 per specialist visit

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

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

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

Artificial limbs and eyes; stump hose. Nothing Foot Orthotics when medical criteria is met.
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy.
Note: See 5( b) for coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint ( TMJ) pain dysfunction syndrome.

Prosthetic Replacements when the device is beyond repair or the patient requires a new device because of a physical change.

Not covered: All charges.
orthopedic and corrective shoes arch supports

heel pads and heel cups lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices
Prosthetic replacements provided less than three years after the last one we covered

Foot care
Orthopedic and prosthetic devices
You Pay 25.
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2003 PacifiCare Health Plans Section 5 ( a) 21
Rental or purchase, at our option, including repair and adjustment of Nothing
durable medical equipment, such as oxygen and dialysis equipment.
Under this benefit, we also cover durable medical equipment
prescribed by your Plan physician such as:

orthopedic brace; hospital beds;

wheelchairs; crutches;
walkers; insulin pumps.
Note: Call us at 1( 800) 531-3341 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.

Not covered: All charges.
Specialized wheelchairs for comfort and convenience.

Home health care ordered by a Plan physician and provided by a Nothing registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide for members who are
homebound or confined to an institution that is not a hospital. Homebound
members are those who have a physical condition such that there is a normal
inability to leave the home.

Services include oxygen therapy, intravenous therapy and medications such as injectables.

Injectable medications for home use and self-administration by patient when approved by the Plan or your Medical Group.

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

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, theraputic or rehabilitative.

Chiropractic services You may self refer to a participating chiropractor for $ 10 per office visit
up to 30 visits each calendar year

Manipulation of the spine and extremities Adjunctive procedures such as ultrasound, electrical muscle

stimulation, vibratory therapy, and cold pack application

Durable medical equipment ( DME)
Home health services
Chiropractic Care

You Pay 26.
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2003 PacifiCare Health Plans Section 5 ( a) 22
Note: See page 36 for the PacifiCare Perks SM program for discounts on
these services.

Not covered: All charges.
acupuncture naturopathic services

hypnotherapy biofeedback

Coverage is limited to:
Smoking cessation including all related expenses such as Nicotine ( ( Note: There is a $ 20 Drug copayment Replacement* for smoking cessation products)

Taking Charge of Your Heart Health Diabetes self-management ( Taking Charge of Diabetes ) For Health Improvement programs offered
Pregnancy to Pre-School in your area and for costs associated with Managing Depression those programs, call 1-800-531-3341

Alternative treatments
Educational classes and programs
You Pay 27.
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2003 PacifiCare Health Plans Section 5 ( b) 23
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care. We have no calendar year deductible
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in section 5( c) for charges associated with the

facility ( i. e. hospital, surgical center, etc. )
YOUR PHYSICIAN MUST GET PRECERTIFICATION 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.

A comprehensive range of services, such as: $ 10 per PCP office visit
Operative procedures $ 20 per specialist office; Treatment of fractures, including casting nothing for hospital visits

Normal pre-and post-operative care by the surgeon or outpatient surgical centers Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Circumcision 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. You must meet the National Institute of Health guidelines

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

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

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Section 5 ( b) . Surgical and anesthesia services provided by
physicians and other health care professionals

Benefit Description You Pay
Surgical procedures

Surgical procedures continued on next page. 28.
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2003 PacifiCare Health Plans Section 5 ( b) 24
Not covered: All charges.
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.

Surgery to correct a functional defect Nothing 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.

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

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

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

appearance through change in bodily form, except repair of
accidental injury

Surgeries related to sex transformation

Oral surgical procedures, limited to: Nothing
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.
TMJ surgery and related non-dental treatment.

Surgical procedures ( Continued)
Reconstructive surgery

Oral and maxillofacial surgery

You Pay

Oral and maxillofacial surgery continued on next page. 29.
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2003 PacifiCare Health Plans Section 5 ( b) 25
Not covered: All charges.
Oral implants and transplants Procedures associated with oral and dental implants, such as skin or

bone grafting.
Procedures that involve the teeth or their supporting structures ( such as the periodontal membrane, gingiva, and alveolar bone)

Limited to: Nothing
Cornea Heart

Heart/ lung Kidney
Kidney/ Pancreas Liver
Lung: Single Double Pancreas
Allogeneic ( donor) bone marrow transplant 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 liver, stomach

and pancreas
National Transplant Program ( NTP) Limited Benefits Treatment for breast cancer, multiple myeloma,

and epithelial ovarian cancer may be provided in an NCI-or
NIH-approved clinical trial at a Plan-designated center of excellence
and if approved by the Plan s medical director in accordance
with the Plan s protocols.

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

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

Implants of artificial organs Transplants not listed as covered

Oral and maxillofacial surgery ( Continued)
Organ/ tissue transplants
You Pay 30.
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2003 PacifiCare Health Plans Section 5 ( b) 26
Professional services provided in Nothing
Hospital ( inpatient)

Professional services provided in Nothing
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office

Anesthesia You Pay 31.
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2003 PacifiCare Health Plans Section 5 ( c) 27
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility ( i. e. , hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the

professional charge ( i. e. , physicians, etc. ) are covered in Section 5( a) or ( b) .

pay
Room and board, such as Nothing

ward, semiprivate, or intensive care accommodations; general nursing care; and

meals and special diets. NOTE: If you want a private room when it is not medically
necessary, you pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms Diagnostic laboratory tests and X-rays

Administration of blood and blood products Blood or blood plasma
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Not covered: All charges.
Custodial care Non-covered facilities, such as nursing homes and schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

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Section 5 ( c) . Services provided by a hospital or
other facility, and ambulance services

Benefit Description You Pay
Inpatient hospital 32.
32 Page 33 34
2003 PacifiCare Health Plans Section 5 ( c) 28
Operating, recovery, and other treatment rooms Nothing 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.

Extended care benefit: We provide a wide range of benefits for full-time Nothing
nursing care and confinement in a skilled nursing facility when your
doctor determines it to be medically necessary. The Plan must also
approve this service.

All necessary services are covered up to 100 days per calendar year, including:
Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged

by the skilled nursing facility when prescribed by a Plan doctor.

Not covered: All charges.
Custodial care Homemaker Services

Supportive and palliative care for a terminally ill member is covered in Nothing
the home or hospice facility when approved by our Medical Director.
Services include:

Inpatient and outpatient care 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 twelve months or less.

Not covered: Independent nursing, homemaker services All charges.

Local professional ambulance service when medically appropriate Nothing

Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Hospice care
Ambulance

You Pay 33.
33 Page 34 35
2003 PacifiCare Health Plans Section 5 ( d) 29
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We have no deductible Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

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

What to do in case of emergency:
Emergencies within our service area:
If you have an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your
doctor, contact the local emergency system ( e. g. , the 911 telephone system) or go to the nearest hospital emergency room. Be sure to
tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify
the Plan within 48 hours ( unless it is not reasonably possible to do so) . It is your responsibility to notify us in a timely manner.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission,
unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance
charges covered in full. Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition. To be covered by us you must get all follow-
up care from our providers or follow up care must be approved by us.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately
required because of injury or unforeseen illness. If you need to be hospitalized, the Plan must be notified within 48 hours or on the
first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor
believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges
covered in full. To be covered by this Plan, you must get all follow up care from plan providers or your follow up care must be
approved by the Plan. Benefit Description You pay

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Section 5 ( d) . Emergency services/ accidents 34.
34 Page 35 36
2003 PacifiCare Health Plans Section 5 ( d) 30
Emergency care at a doctor s office $ 10 per PCP office visit, $ 20 per specialist visit
After hours care in your doctors office $ 10 per PCP office visit, $ 20 per specialist visit
Emergency care at an urgent care center $ 10 per visit
Emergency care at a hospital, including doctors services $ 75 per Emergency room visit Note: Your $ 75 copay is not waived if
you are admitted to the hospital.

Not covered: Elective care or non-emergency care All charges.

Emergency care at a doctor s office $ 10 per PCP office visit, $ 20 per specialist visit
Emergency care at an urgent care center $ 10 per PCP office visit, $ 20 per specialist visit
Emergency care at a hospital, including doctors services $ 75 copay per Emergency Room visit Note: Your $ 75 copay is not waived if you
are admitted to the hospital.

Not covered: All charges.
Elective care or non-emergency care Emergency care provided outside the service area if the need for care

could have been foreseen before leaving the service area.
Medical and hospital costs resulting from a full-term delivery of a baby outside the service area.

Professional ambulance service, including air ambulance services when Nothing
medically appropriate.

See 5( c) for non-emergency service.

Benefit Description
Emergency within our service area

Emergency outside our service area

Ambulance

You Pay 35.
35 Page 36 37
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 to keep in mind about these benefits:
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.

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

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

Professional services, including individual or group therapy $ 20 per visit by Behavioral Health providers such as psychiatrists,
Psychologists, or clinical social workers
Medication management

Diagnostic tests such as routine lab work and x-rays $ 10 per visit or test
Complex radiology $ 20 copay per diagnostic test
CT Scans Ultrasound

PET Scans MRI s
SPECT Scans
Services provided by a hospital or other facility Nothing Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

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

2003 PacifiCare Health Plans Section 5 ( e) 31

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Section 5 ( e) . Mental health and substance abuse benefits

Benefit Description You Pay
Mental health and substance abuse benefits 36.
36 Page 37 38
2003 PacifiCare Health Plans Section 5 ( e) 32
Preauthorization To receive these benefits you must obtain a treatment plan and follow the authorization processes. Please call the following customer service department
in your area to access benefits or to obtain a list of providers:

PacifiCare Behavioral Health at 1( 800) 999-9585
( website -www. pbhi. com)
California ( CY)
Oklahoma ( 2N)
Oregon ( 7Z)
Texas ( GF)
Washington ( WB)

C ontact Behavioral Health at 1( 800) 888-1477
( website -www. contact. com)
Arizona ( A3)

Harmony Behavioral Health at 1( 800) 363-4874
( website -www. harmony. com)
Nevada ( K9)

Mental health and substance abuse benefits ( Continued) 37.
37 Page 38 39
2003 PacifiCare Health Plans Section 5 ( f) 33
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician must write the prescription including medically necessary prescriptions authorized for dental treatment.
Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication. We use a formulary. The PacifiCare Formulary is a list of prescription drugs that Physicians use as a guide when prescribing
medications for patients. The Formulary helps us provide safe, effective and affordable prescription drugs to PacifiCare
members. We work with physicians and pharmacists to make sure you are getting the drug therapy you need.
A Pharmacy and Therapeutics Committee evaluates prescription drugs for safety, effectiveness, quality treatment and overall
value. The committee considers the safety and effectiveness of a medication before they review the cost. Our physicians may get
pre-authorization for non-formulary drugs. Your doctor may start the pre-authorization request by phoning or faxing it. Requests
are usually processed within ten minutes although some may take up to two ( 2) working days if we need more information from
your doctor. We cover non-Formulary drugs prescribed by a Plan doctor.
We have a closed formulary. If your physician believes a name brand product is necessary and there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs

that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1( 800) 824-0428.
Non-Formulary drugs will be covered if:
No Formulary alternative is appropriate You have tried the Formulary drugs and they have not worked or you have had side effects or interactions with other drugs. The

physicians are asked to provide a copy of the medical chart notes stating treatment failure with the Formulary alternatives.
You have been under treatment and remain stable on a non-Formulary prescription drug and changing to a Formulary drug would not be medically suitable.

Your physician provides us with documents, records, or clinical trials which shows that use of the requested non-Formulary drug instead of the Formulary drug is medically necessary, as determined by PacifiCare.

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Section 5 ( f) . Prescription drug benefits 38.
38 Page 39 40
2003 PacifiCare Health Plans Section 5 ( f) 34
These are the dispensing limitations.
You can get your prescription drugs at a participating pharmacy as long as it is written by your primary care doctor or specialist.
You will get up to a 30 day supply, 2 vials of the same kind of insulin or one commercially prepared unit ( i. e. , one inhaler, one
vial of ophthalmic medication, topical ointment or cream) for a $ 10 copayment per prescription unit or refill for generic drugs or
a $ 20 copayment for name brand drugs when generic substitution is not available.
A generic equivalent will be dispensed if it is available unless your physician specifically requires a name brand. If you receive
a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as
Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic and the
copay per prescription unit or refill. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan s drug
formulary.
Prescription drugs can also be obtained through the mail order program for up to a 90 day supply of oral medication; 6 vials of
the same kind of insulin; or 3 commercially prepared units ( i. e. , inhaler, vials ophthalmic medication or topical ointments or
creams) . You pay a $ 20 copay per prescription unit or refill for generic drugs or a $ 40 copayment for name brand maintenance
medications. Call 1( 800) 531-3341 for mail order customer service.

When you have to file a claim. Please refer to Section 7 for information on how to file a pharmacy claim, or contact our Customer Service Department at 1( 800) 531-3341.
Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name drugs; therefore, you may reduce your out-of-pocket
costs by choosing to use a generic drug.

You pay

Prescription drug benefits ( Continued) 39.
39 Page 40 41
2003 PacifiCare Health Plans Section 5 ( f) 35
We cover the following medications and supplies prescribed by a Plan $ 10 per generic formulary
physician and obtained from a Plan pharmacy or through our mail prescription unit or refill.
order program: $ 20 per brand formulary prescription
Drugs and medicines that by Federal law of the United States require unit or refill. a physician s prescription for their purchase, except those listed as not

covered Note: If there is no generic equivalent
Insulin available, you will still have to pay Diabetic supplies such as lancets and blood glucose test strips the brand name copay

Disposable needles and syringes for the administration of covered medications
Contraceptive drugs and devices Intravenous fluids and medications for home use ( covered under
Section 5( a) Home Health Services -see page 21)
Prenatal vitamins Oral medications prescribed to treat infertility, or the underlying cause of

infertility including Clomiphene Citrate, Bromocriptine Mesylate and
Dexamethasone ( Note: Injectable infertility drugs are covered under Section
5( a) Infertility Services)

Limited benefits
Drugs to treat sexual dysfunction are covered when Plan s medical criteria is met. Contact the plan for dose limits; you pay a 50% copayment

up to the dosage limits and all charges above that.

Not covered: All Charges.
Non-prescription medicines Drugs obtained at a non-Plan pharmacy except for out of area emergencies.

Vitamins, nutrients and food supplements even if a physician prescribes or administers them( except prenatal Vitamins)
Medical supplies such as dressings and antiseptics Diet Pills
Drugs and/ or supplies for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medication, including nicotine patches unless you are enrolled in our Smoking Cessation program. ( See page 36)
Diabetic supplies, except those shown above Injectable medications prescribed for the treatment of infertility
Drugs prescribed by a dentist

Benefit Description You Pay
Covered medications and supplies 40.
40 Page 41 42
2003 PacifiCare Health Plans Section 5 ( g) 36
PacifiCare Perks SM Program A PacifiCare members only program which offers discounts for health clubs, alternative care, vitamins and much more! Call 1/ 800-531-3341 for more
information regarding PacifiCare Perks benefits.

Hearing Aids for Children The Oklahoma Plan ( 2N) covers hearing aids for children up to the age of 13 years old.

Immunizations The Oklahoma plan ( code 2N) covers immunizations 100% for children through age 18.
You won t have to pay a copay if you don t have other services when you get
your immunization.

The Texas Plan ( GF) covers immunizations at 100% for children 6 years of age or younger.

If you are enrolled in the California Plan ( CY) or the Washington Plan ( WB) you may receive the influenza or pneumococcal vaccine regardless of your
age.
In Arizona all members can have routine DPT, Tetanus Toxoid, Oral Polio, MMR, Smallpox and Hepatitis B immunizations/ Vaccines regardless of age.

Dental anesthesia and anesthesiologist costs The Oklahoma Plan ( code 2N) covers expenses associated with any medically
necessary anesthesiologist costs and dental procedures if; you are a child 8
years of age or under and have a medical or an emotional condition or if you
are severely disabled with a medical or emotional condition.

Vision Screening eyeglasses and contact lenses If you are enrolled in the Oklahoma Plan ( code 2N) or the and contact lenses
Texas Plan ( code GF) you will get a 20% discount on eyeglasses or contact
lenses.

Health Improvement Programs For Health Improvement programs offered in your area and costs associated
with these programs call 1/ 800-531-3341.
Managing your Heart Health, Managing Diabetes, * Smoking Cessation,
Pregnancy to
Pre-school and Managing Depression.
* There is a $ 20 Prescription Drug copayment for smoking cessation products.

Centers of excellence Services performed at Centers of Excellence are covered when medically necessary and preapproved. You pay $ 10 for outpatient PCP visits, $ 20 for
specialist visits and nothing for inpatient hospitalization.

Travel benefit/ services overseas Covered for emergencies only.

Section 5 ( g) . Special features
Feature Description 41.
41 Page 42 43
2003 PacifiCare Health Plans Section 5 ( h) 37
Here are some important things to keep in mind about these benefits:
For more information call PacifiCare Dental at 1( 800) 591-5915 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. For a full list of benefits, exclusions and limitations please refer to the
Plan information pamphlet for the 2003 PacifiCare Dental Indemnity Plan for Federal
Employees.
There is no waiting period for eligibility to access these dental benefits; however, there are waiting periods to obtain bridges and dentures.

There is a $ 1,000 calendar year maximum Your PacifiCare medical plan covers hospitalization for dental procedures only when a
non-dental physical impairment exists which makes hospitalization necessary to safeguard
the health of the patient; we do not cover the dental procedure unless it is described below.
For treatment or therapy of Temporal Mandibular Joint ( TMJ) disorders See section 5 ( a) Medical benefits

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.
For medically necessary prescriptions authorized for dental treatment see Section

We cover restorative services and supplies necessary to promptly repair You pay a $ 10 PCP office visit copayment
( but not replace) sound natural teeth, jawbone, or surrounding tissues within or a $ 20 specialist visit copayment. If you
48 hours of the injury or when medically stable. The need for these services receive services in an emergency room you
must result from an accidental injury. pay a $ 75 copayment. The Emergency room
copayment is not waived if you are
admitted to the hospital

This dental plan has no deductibles and no lifetime
maximums. You may see any provider you like.

Preventive and Diagnostic
ADA code
00150 Comprehensive Oral exam ( one every six months) 100% UCR All charges in excess of
the scheduled amounts
00210 Intraoral X-rays ( one bitewing series of four every For all preventive listed to the left
six months, one full mouth per five years) and diagnostic
services.
01110 Prophylaxis ( one every six months)

After the calendar year
deductible

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Section 5 ( h) . Dental benefits

Accidental injury benefit You pay
Service You Pay
Dental benefits
We Pay
( Scheduled Amount) 42.
42 Page 43 44
2003 PacifiCare Health Plans Section 5 ( h) 38
Basic and Major Services
01120 Amalgam fillings ( one tooth surface, permanent teeth) $ 18 All charges in excess of
02120 Amalgam fillings ( two tooth surfaces, permanent teeth) $ 23 the scheduled amount
02751 Porcelain with metal crown $ 200 listed to the left
02740 Porcelain Crown $ 125
03310 Single root canal $ 90
03320 Bi-root canal $ 115
04341 Periodontal root planing and scaling( per quadrant) $ 30
05110 Full mouth dentures( upper) $ 232.50
05120 Full mouth dentures( lower) $ 232.50
05213 Partial dentures $ 225
06250 Bridges: Tru-pontic type $ 82.50
07110 Extractions $ 15

Note: There is a waiting period for bridges and dentures. Initial dentures or bridges are covered after a 36-month deferment period.
If you were covered under another dental plan immediately before enrolling in this plan, that time will be applied to your deferment
period. Replacement dentures are covered only if we have written proof that your existing bridge or denture cannot be made fit for
use and it is at least 5 years old.

Service We Pay ( Scheduled Amount) You Pay
Dental benefits ( Continued) 43.
43 Page 44 45
Section 5 ( i) . Non-FEHB benefits available to Plan members
2003 PacifiCare Health Plans Section 5 ( i) 39
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.

In California, for a monthly premium, you can enroll in an HMO dental plan and/ or a PPO Vision
hardware plan through PacifiCare Dental and Vision as a supplement to your FEHB Plan. Call
1( 800) 228-3384 for more information. The Non-FEHB dental benefits will not be coordinated with the dental
benefits included with your medical plan.

In Arizona, for an annual premium, you can enroll in an HMO dental Plan as a supplement to your FEHB dental
plan. Call 1( 800) 531-3341 for more information. The Non-FEHB dental benefits will not be coordinated with
the dental benefits included with your medical plan.

In Nevada you can enjoy great savings on prescription eyewear that includes a wide selection of glasses
( or contacts) when you take advantage of PacifiCare Vision s Eyewear Only Plan 1( 800) 228-3384.

Healthy Renewal Pass Introducing PacifiCare s Healthy Renewal Pass
You can now enroll in the Healthy Renewal Pass as a supplement to your medical plan. Healthy Renewal Pass is
a unique, voluntary buy-up card that encourages members to take care of their mind, body and spirit. For a
single monthly premium, members can enjoy a portfolio of enriched benefits including a fitness club
membership, access to additional chiropractic benefits ( on top of your FEHB benefits) , acupuncture benefits, and
massage therapy benefits, as well as, discounts on prescriptions, over-the-counter medications and a number of
other health related products. For more information visit www. pacificare. com or call 1-800-230-3034.

Medicare managed care and Medicare Supplement plans
If you are Medicare eligible and are interested in enrolling in a Medicare HMO or a Medicare Supplement Plan
sponsored by this Plan without dropping your enrollment in this Plan s FEHB plan, call 1( 800) 637-9284 for
information.

Medicare + Choice HMO With nearly a million members, Secure Horizons is one of the largest Medicare + Choice contracting plans in the nation. As a member of Secure Horizons, you benefit from low or no
plan copayments, low or no deductibles, and virtually no paperwork. Secure Horizons offers peace of mind for
Medicare beneficiaries residing in parts of AZ, CA, CO, NV, OK, OR, TX, & WA by offering more services than
original Medicare for little additional cost. For more information, call toll free 1-800-637-9284
( TDHI 1-800-647-6038) or visit our web site www. securehorizons. com.

Medicare Supplement Secure Horizons Medicare Supplement Plans pick up where Medicare leaves off, so you don t have to worry about overwhelming medical bills. Better yet, as a Medicare beneficiary you can choose
the level of coverage you feel best suits your needs. Choices range from a plan that covers some basic
hospitalization and medical coinsurance expenses. . . to a plan with a richer benefit package that includes foreign
travel emergency and at-home recovery. For more information, call toll free 1-800-637-9284
( TDHI 1-800-647-6038) or visit our web site www. securehorizons. com. 44.
44 Page 45 46
2003 PacifiCare Health Plans Section 6 40
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your
illness disease, injury, or condition.

We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies ( see Emergency Benefits) ;
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were
carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service.

Section 6. General exclusions things we don t cover 45.
45 Page 46 47
Section 7. Filing a claim for covered services
2003 PacifiCare Health Plans Section 7 41
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment.

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, In most cases, providers and facilities file claims for you. Physicians prescription drugs, and Durable must file on the form HCFA-1500, Health Insurance Claim Form.
Medical Equipment ( DME) Facilities will file on the UB-92 form. For claims questions and Benefits assistance, call us at 1( 800) 531-3341.

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:
PacifiCare Health Plans
5995 Plaza Drive
MS CY20-303
Cypress, CA 90630

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. 46.
46 Page 47 48
2003 PacifiCare Health Plans Section 8 42
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: :

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: 5995 Plaza Drive MS. CY 20-303, Cypress, CA 90630; and
( c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions
in this brochure; and
( d) Include copies of documents that support your claim, such as physicians letters, operative reports, bills,
medical records, and explanation of benefits ( EOB) forms.

2 We have 30 days from the date we receive your request to:
( a) Pay the claim ( or, if applicable, arrange for the health care provider to give you the care) ; or
( b) Write to you and maintain our denial go to step 4; ; or
( c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of
our request go to step 3. .

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us if we did not answer that request in some way within 30 days; ; or

120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street NW, Washington, D. C. 20415-3630.

Section 8. The disputed claims process
Step Description 47.
47 Page 48 49
2003 PacifiCare Health Plans Section 8 43
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 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 1( 800) 531-3341
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) 606-0737 between 8 a. m. and 5 p. m. eastern time.

The disputed claims process ( Continued) 48.
48 Page 49 50
2003 PacifiCare Health Plans Section 9 44
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called double coverage.

When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according
to the National Association of Insurance Commissioners guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our regular
benefit. We will not pay more than our allowance.

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

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

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

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

The Original Medicare Plan The Original Medicare Plan is a Medicare plan that 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 A and 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 covere