Coventry Health Care of Kansas, Inc. (Kansas City area)

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--62

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

2
Coventry Health Care of Kansas, Inc. (Kansas City area)
http:// www. chckansas. com
2003

Serving: Kansas City Metropolitan Area Kansas and Missouri
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
HA1 Self Only HA2 Self and Family

RI 73-128

Attach Your
Logo

For changes in benefits
see page 7.

A Health Maintenance Organization 1.
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2.
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Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

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

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

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
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2003 Coventry Health Care of Kansas, Inc. 2 Table of Contents
Table of Contents
Introduction......................................................................................... 4
Plain Language....................................................................................................................................................................................... 4
Stop Health Care Fraud! ........................................................................................................................................................................ 5
Section 1. Facts about this HMO plan................................................................................................................................................... 6
How we pay providers.......................................................................................................................................................... 6
Your Rights .......................................................................................................................................................................... 6
Service Area ......................................................................................................................................................................... 6
Section 2. How we change for 2003 .................................................................................................................................................... 7
Program-wide changes ......................................................................................................................................................... 7
Changes to this Plan ............................................................................................................................................................. 7
Clarification.......................................................................................................................................................................... 7
Section 3. How you get care ................................................................................................................................................................. 8
Identification cards ............................................................................................................................................................... 8
Where you get covered care ................................................................................................................................................. 8
Plan providers ................................................................................................................................................................ 8
Plan facilities.................................................................................................................................................................. 8
What you must do to get covered care ................................................................................................................................. 8
Primary care ................................................................................................................................................................... 8
Specialty care ................................................................................................................................................................. 8
Hospital care .................................................................................................................................................................. 9
Circumstances beyond our control ....................................................................................................................................... 9
Services requiring our prior approval ................................................................................................................................. 10
Section 4. Your costs for covered services.......................................................................................................................................... 11
Copayments.................................................................................................................................................................. 11
Deductible .................................................................................................................................................................... 11
Coinsurance.................................................................................................................................................................. 11
Your catastrophic protection out-of-pocket maximum....................................................................................................... 11
Section 5. Benefits............................................................................................................................................................................... 12
Overview............................................................................................................................................................................ 12
(a) Medical services and supplies provided by physicians and other health care professionals.................................... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................ 24
(c) Services provided by a hospital or other facility, and ambulance services .............................................................. 28
(d) Emergency services/ accidents ................................................................................................................................. 32
(e) Mental health and substance abuse benefits ............................................................................................................ 34
(f) Prescription drug benefits ........................................................................................................................................ 36 5.
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2003 Coventry Health Care of Kansas, Inc. 3 Table of Contents
(g) Special features ....................................................................................................................................................... 39
24 Hour Nurse Line
Services for the deaf and hearing impaired
Transplant Network for transplants/ heart surgery/ etc.
Flexible benefits option
(h) Dental benefits ......................................................................................................................................................... 40
Section 6. General exclusions --things we don't cover ....................................................................................................................... 42
Section 7. Filing a claim for covered services..................................................................................................................................... 43
Section 8. The disputed claims process ............................................................................................................................................... 44
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 46
When you have other health coverage................................................................................................................................ 46
What is Medicare ........................................................................................................................................................ 46
Medicare managed care plan....................................................................................................................................... 49
TRICARE and CHAMPVA........................................................................................................................................ 49
Workers' Compensation .............................................................................................................................................. 49
Medicaid ..................................................................................................................................................................... 50
Other Government agencies ........................................................................................................................................ 50
When others are responsible for injuries ..................................................................................................................... 50
Section 10. Definitions of terms we use in this brochure ..................................................................................................................... 51
Section 11. FEHB facts ....................................................................................................................................................................... 53
Coverage information....................................................................................................................................................... 53
No pre-existing condition limitation......................................................................................................................... 53
Where you get information about enrolling in the FEHB Program.......................................................................... 53
Types of coverage available for you and your family .............................................................................................. 53
Children's Equity Act............................................................................................................................................... 53
When benefits and premiums start ........................................................................................................................... 54
When you retire ....................................................................................................................................................... 54
When you lose benefits..................................................................................................................................................... 54
When FEHB coverage ends...................................................................................................................................... 54
Spouse equity coverage ........................................................................................................................................... 54
Temporary Continuation of Coverage (TCC).......................................................................................................... 54
Converting to individual coverage........................................................................................................................... 55
Getting a Certificate of Group Health Plan Coverage ............................................................................................. 55
Long term care insurance is still available ........................................................................................................................................... 56
Index......................................................................................................................................................................................... 57

Summary of benefits ............................................................................................................................................................................ 58
Rates....................................................................................................................................................................................... Back cover 6.
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2003 Coventry Health Care of Kansas, Inc. 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Coventry Health Care of Kansas, Inc., under our contract (CS 1948) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for the administrative
offices is:
Coventry Health Care of Kansas, Inc. 1001 E. 101 st Terrace, Suite 300
Kansas City, Missouri 64131-3368
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

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

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means Coventry Health Care of Kansas, Inc.

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 us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 7.
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2003 Coventry Health Care of Kansas, Inc. 5 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get
it paid.

Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 969-3343 and explain the situation.
If we do not resolve the issue:

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

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 8.
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2003 Coventry Health Care of Kansas, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers are paid in a number of ways, including salary, capitation, per diem rates, case rates, and fee for service. You will also be responsible
for unauthorized care or services not covered under this plan.
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.
Coventry Health Care of Kansas, Inc., is a for profit domiciled Kansas health maintenance organization (HMO) with certificates of authority to operate in both Kansas and Missouri. Coventry Health Care of Kansas, Inc., has been in existence since 1961, and has

two unique service areas: Kansas City and Wichita for a combined total membership of over 170,000. We are dedicated to providing quality health care at an affordable price. We offer prepaid health care benefit plans to employers for employees and their dependents.
We provide our members the security of knowing they are being offered a health care delivery system supported by a long tradition of quality and service.

If you want more information about us, call 816/ 941-3030, or write to Coventry Health Care of Kansas, Inc., 1001 E. 101 st Terrace, Suite 300, Kansas City, MO 64131-3368. You may also contact us by fax at 816/ 941-8516 or visit our website at www. chckansas
city. com.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
Kansas Anderson, Atchison, Douglas, Franklin, Jackson, Jefferson, Johnson, Leavenworth, Linn, Miami, Shawnee, and Wyandotte Counties

Missouri Andrew, Benton, Buchanan, Caldwell, Carroll, Cass, Clay, Clinton, Daviess, DeKalb, Gentry, Grundy, Henry, Jackson, Johnson, Lafayette, Livingston, Pettis, Platte, and Ray Counties
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 outside 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 employer or retirement office. 9.
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2003 Coventry Health Care of Kansas, Inc. 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

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

Changes to this Plan
Your share of the non-postal premium will increase by 30.2% for Self Only or 30.2% for Self and Family.

The primary care physicians and specialists' office visit copayments are now $15 instead of $10 per visit.
The inpatient hospital admission copayment is $100 per day up to $300 maximum. Previously, you paid nothing .
Outpatient X-rays, laboratory and other diagnostic tests NOT received during a doctor's office visit are subject to $15 per visit. Previously, members paid no copayment for test not received during a doctor's office visit. You will continue
to pay no copayment for these test when received as part of the doctor's visit.
The outpatient hospital or ambulatory surgery copayment is now $50 per surgery. Previously, you paid nothing.
Under Rehabilitative therapies, we cover Physical, Speech, Occupational and Chiropractic care for subluxation and manipulation up to 60 days per condition. You pay a $15 copayment per visit. Previously, we covered physical, speech
and occupational therapies up to 32 visits per condition subject to a $10 copayment per visit; and Chiropractic care up to 20 visits subject to a $15 copayment per visit.

The hospital emergency room visit copayment is now $75 instead of $50.
The land ambulance coinsurance is now 30% of covered charges up to a maximum Plan benefit of $400 per trip. Previously, you paid $50 per trip.

The air ambulance coinsurance is now 30% of covered charge. Previously, you paid $50 per trip.
Under prescription drugs, you now pay $10 for generic drugs, $20 for formulary brand name drugs and $50 for non-formulary drugs. Previously, you paid $5 for generic drugs, $15 for formulary brand name drugs and $45 for non-formulary
drugs.
Under mail order prescription drugs, you now pay $20 for generic drugs and $40 for formulary brand name drugs. Previously, you paid $10 for generic drugs and $30 for formulary drugs.

The out-of-pocket maximum is now $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment. Previously, the out-of-pocket maximum was $1,000 for Self Only enrollment and $3,000 for Self and Family enrollment.
We now cover a more comprehensive list of dental benefits. See Section 5( h) Dental benefits for details.
We have expanded our Missouri service area to include the following counties: Andrew, Carroll, Gentry, Grundy, Livingston, and Pettis.

Clarification
We show coverage for surgical treatment of morbid obesity. See section 5( b). 10.
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2003 Coventry Health Care of Kansas, Inc. 8 Section3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-969-3343 or write to us at
Coventry Health Care of Kansas, Inc., 1001 E. 101 st Terrace, Suite 300, Kansas City, MO, 64131. You may also request replacement cards through our website at
www. chckansas. com.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website www. chckansas. 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.
It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care.
Primary care Your primary care physician can be a family practitioner, internist, or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see
a specialist. You may choose a primary care physician for the entire family or a different primary care physician may be selected for individual family members.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us at 800/ 969-3343 or visit our website at www. chckansas. com to change
your PCP. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for a consultation. If after the consultation, the specialist requires additional visits, then the specialist must obtain pre-certification
of services that require authorization. Some lab, radiology, and therapy services may require authorization by our utilization management department. Your
participating specialist must obtain this authorization. However, you may see an OB/ Gyn or a mental health provider without a referral.

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

What you must do to get covered care 11.
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2003 Coventry Health Care of Kansas, Inc. 9 Section3
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 60 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 60 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. Be sure to tell the hospital you are a Coventry Health Care HMO member and remember to present your identification card when you are admitted. This will ensure we
are notified.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-969-3343. If you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care. 12.
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2003 Coventry Health Care of Kansas, Inc. 10 Section3
Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process prior authorization of services. Your physician must obtain authorization for the following services: hospitalization, referral to a
specialist outside of the network, or recommendations for follow-up-care.
You are responsible for ensuring that your physician has obtained authorization for a planned hospital admission or surgery.

In addition, we may retract or refuse to pay an authorization, referral, or claim if:
You make a material misrepresentation or omission about your health condition or the cause for your health condition.

You permit someone else to use your health plan identification card, you use another person's card or you deface the card in order to obtain services at a higher level of
benefits. Except when the member is unaware another person is using their Identification card (i. e. lost or stolen card)

Your group terminates its contract before your health care services are provided; or
Your coverage under the group agreement terminates before the health care services are provided.

Services requiring our prior approval 13.
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2003 Coventry Health Care of Kansas, Inc. 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $15 per office visit.
Deductible We have no deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services and allergy testing.

After your copayments and coinsurance total $2,000 per person or $4,000 per family enrollment in any calendar year, you do not have to pay any more for covered services.
However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay
copayments or coinsurance for these services:
Extended care services Durable medical equipment
External prostheses and braces Chiropractic services
Dental care services Prescription drugs

Be sure to keep accurate records of your copayments or coinsurance since you are responsible for informing us when you reach the maximum.

Your catastrophic protection out-of-pocket maximum for
copayments and coinsurance 14.
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2003 Coventry Health Care of Kansas, Inc. 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 58 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 1-800-969-3343 or at our website at www. chckansascity. com.

(a) Medical services and supplies provided by physicians and other health care professionals ....................................................... 13-23
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................................. 24-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 28-31
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents.................................................................................................................................................. 32-33 Medical emergency Ambulance

(e) Mental health and substance abuse benefits............................................................................................................................. 34-35
(f) Prescription drug benefits......................................................................................................................................................... 36-38
(g) Special features ............................................................................................................................................................................. 39 24 Hour Nurse Line

Services for the deaf and hearing impaired
Transplant Network for transplants/ heart surgery/ etc.
Flexible Benefits Option
(h) Dental benefits ........................................................................................................................................................................ 40-41
Summary of benefits ............................................................................................................................................................................ 58 15.
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2003 Coventry Health Care of Kansas, Inc. 13 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
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A N
T

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

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

I M
P O
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T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office

$15 per office visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

$15 per office visit

At home Nothing
Diagnostic and treatment services --continued on next page 16.
16 Page 17 18
2003 Coventry Health Care of Kansas, Inc. 14 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

$15 when the test is not performed during your office visit. You only pay the office
visit copayment when the test is performed during your office visit.

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

$15 per office visit

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $15 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$15 per office visit

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Note: In addition to routine screening, we cover mammograms when medically necessary to diagnose or treat your illness.

$15 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Preventive care adult--continued on next page 17.
17 Page 18 19
2003 Coventry Health Care of Kansas, Inc. 15 Section 5( a)
Preventive care, adult (continued) You pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

$15 per office visit

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care charges for routine examinations, immunizations and care (through age 22)
Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

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

$15 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel All charges. 18.
18 Page 19 20
2003 Coventry Health Care of Kansas, Inc. 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Physician ordered sonograms
Note: Here are some things to keep in mind:
You need to precertify your normal delivery; see page 30 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. (Surgical
benefits, not maternity benefits, apply towards circumcision of the newborn; see page 24)

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

$15 for initial office visit to confirm pregnancy. All other copayments for
prenatal visits during the course of pregnancy are waived.

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

$15 per office visit

Voluntary Sterilization (See surgical procedures Section 5( b)) $100 per procedure
Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges. 19.
19 Page 20 21
2003 Coventry Health Care of Kansas, Inc. 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI) intracervical insemination (ICI)

intrauterine insemination (IUI)

50% of our allowance per procedure

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

Zygote transfer Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg
Drugs and supplies for the treatment of infertility

All charges.

Allergy care
Testing and treatment

Allergy injection
50% of our allowance per visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 20.
20 Page 21 22
2003 Coventry Health Care of Kansas, Inc. 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under

Organ/ Tissue Transplants on page 26.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we pre-authorize the treatment. Call 1-800-969-3343 for preauthorization. We will ask you to submit

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

$15 per office visit

Physical and occupational therapies and chiropractic
$15 for each outpatient session; Nothing per visit during covered inpatient

admission
60 days per condition for the services of each of the following:
qualified physical therapists occupational therapists

chiropractor (coverage limited to subluxation and manipulation) Cardiac rehabilitation following a heart transplant, bypass surgery
or myocardial infarction
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Not covered:
exercise programs

Non-neuroskelatal disorders
Vocational rehabilitation services
Thermography
Long-term rehabilitative therapy

All charges. 21.
21 Page 22 23
2003 Coventry Health Care of Kansas, Inc. 19 Section 5( a)
Speech therapy You pay
60 days per condition $15 copay for each outpatient session; Nothing per visit during covered inpatient
admission

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit

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

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)

Annual eye refraction's (see Preventive care, children)

$15 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$15 per office visit

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

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

treatment is by open cutting surgery)

All charges. 22.
22 Page 23 24
2003 Coventry Health Care of Kansas, Inc. 20 Section 5( a)
Orthopedic and prosthetic devices You pay
Our maximum allowance is $1,000.
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. Note:
See 5( b) for coverage of the surgery to insert the device
Note: External devices are limited to one each per member per lifetime, except if a bilateral mastectomy is performed

20% of covered charges up to a maximum Plan allowance of $1,000.

Not covered:
orthopedic and corrective shoes
arch supports
orthotics (regular or custom, including but not limited to ankle foot orthotics or podiatric orthotics)

heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

dental braces, devices, and appliances
braces for aid in sports activities
internally implanted devices, equipment, and prosthetics related to treatment of sexual dysfunction

repair and replacement of orthopedic and prosthetic devices, unless necessitated by normal growth
doc bands (Dynamic Orthotic Cranial Bands)

All charges. 23.
23 Page 24 25
2003 Coventry Health Care of Kansas, Inc. 21 Section 5( a)
Durable medical equipment (DME) You pay
Our maximum allowance is $1,000.

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
ostomy and urological supplies;
prosthetic and orthotic supplies;
blood glucose monitors; and
insulin pumps, and syringes for insulin pumps
apnea monitor
cane;
orthopedic braces for scoliosis;
pads, wires, tubing, electrodes, and masks
equipment required as a part of acute primary care such as back braces, rib belts, slings, and hard cervical collars;

replacement due to anatomical growth;
repair and replacement of DME determined to be medically necessary.

Note: Call us at 1-800-969-3343 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell
you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of covered charges up to a maximum Plan allowance of $1,000.

Not covered: Motorized wheel chairs
Comfort, convenience, or luxury items or features
Electric monitors of bodily functions, except for apnea monitors
Devices to perform medical testing of bodily fluids, excretions, or substances

Disposable supplies
Replacement of lost equipment
Repair, adjustment, or replacement necessitated by wear, tear, or misuse

More than one piece of durable medical equipment serving essentially the same function, except for replacement due to
anatomical growth; spare equipment or alternate use equipment is not provided

All charges. 24.
24 Page 25 26
2003 Coventry Health Care of Kansas, Inc. 22 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and approved by the primary care physician provided by a registered nurse (R. N.), licensed

practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), physical therapist, speech therapist, occupational therapist.

The agency rendering services is Medicare certified and licensed by the state of location
Services are a substitute or alternative to hospitalization
Services include intravenous therapy and medications
Other services include:
Drugs, supplies, and supplements
Home IV and antibiotic therapy

Nothing

Not covered: 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

Nursing care that could appropriately be rendered in a Plan medical office, affiliated hospital, or skilled nursing facility
Nursing care that can be performed safely and effectively by people whom, in order to provide the care do not require medical licenses
or certificates, or the presence of a supervising licensed nurse
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative

All charges.

Alternative treatments
No benefits All charges. 25.
25 Page 26 27
2003 Coventry Health Care of Kansas, Inc. 23 Section 5( a)
Educational classes and programs You pay
When provided or referred by a primary physician or other participating provider. Coverage is available for Health education, services including

instructions on achieving and maintaining physical well being; learning how to control and identify warning signs of asthma or diabetes; and
how to use medication and treat symptoms. Please call Customer Service at 1-800-969-3343 for assistance.

Coverage is limited to:
Asthma education (Telephonic No charge)
Diabetes self-management

$15 per office visit 26.
26 Page 27 28
2003 Coventry Health Care of Kansas, Inc. 24 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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A N
T

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.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3.

I M
P O
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T

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

Treatment of fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Treatment of burns Circumcision of a newborn
Correction of congenital anomalies (see reconstructive surgery) Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible
members must be age 18 or over Insertion of internal prosthetic devices. See 5( a) Orthopedic
and prosthetic devices for device coverage information
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.

$15 per office visit; Nothing in a hospital.

Voluntary sterilization (e. g., Tubal ligation, Vasectomy) $100 per procedure
Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 27.
27 Page 28 29
2003 Coventry Health Care of Kansas, Inc. 25 Section 5( b)
Reconstructive surgery You pay Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

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

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

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

$15 per office visit

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

Surgeries related to sex transformation

All charges.

Oral and maxillofacial surgery
Oral surgical procedures, when medically necessary, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures
Other medically necessary surgical procedures that do not involve the teeth or their supporting structures

Treatment of (TMJ) Temporomandibular Joint Dysfunction, including surgical and non-surgical intervention, corrective
orthopedic appliances and physical therapy.

$15 per office visit; Nothing in a hospital. 28.
28 Page 29 30
2003 Coventry Health Care of Kansas, Inc. 26 Section 5( b)
Oral and maxillofacial surgery (continued) You pay
Not covered: Oral implants and transplants

Procedures that involve the teeth or their supporting structure (such as the periodontal membrane, gingiva, and alveolar bone).
Other procedures that involve the teeth or intra-oral areas surrounding the teeth, including shortening of the mandible or
maxillae for cosmetic purposes

All charges.

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and

peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

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

Note: We cover related medical and hospital expenses of the donor when we cover the recipient provided the recipient is a plan member. After referral to

a transplant facility, the following will apply:
If our Medical Director or the referral facility decides you do not satisfy criteria for a transplant, we only pay for covered services you receive

before that decision is made
We, and the plan providers are not responsible for finding, furnishing, or ensuring the availability of a bone marrow or organ donor

We cover reasonable medical and hospital expenses as long as the expenses are directly related to a covered transplant of the donor or an
individual identified as a potential donor, even if a member
Unless otherwise authorized by our Medical Director, we provide transplants only at approved Transplant Network facilities

Nothing 29.
29 Page 30 31
2003 Coventry Health Care of Kansas, Inc. 27 Section 5( b)
Organ/ tissue transplants (continued) You pay
Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Any related conditions or complications for a member who is
donating an organ or tissue when the recipient is not a member Outpatient immunosuppressive agents
Any transplant procedure that is performed in a facility that has not been designated by the Medical Director as a approved transplant
facility Implants of non-human or artificial organs

Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in:
Hospital (inpatient)
Nothing

Professional services provided in
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office

$15 per office visit 30.
30 Page 31 32
2003 Coventry Health Care of Kansas, Inc. 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including

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

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

your primary physician will arrange admission to one of our participating hospitals. Either your primary care physician will admit you or you will be referred to a participating provider who will
manage your inpatient coordination with your primary care physician. Your admitting physician will give you instructions about which hospital to go to, including the date and time you should
arrive. Before the arrangements are made, please remind your primary care physician or participating physician that you need to go to a participating hospital.

I M
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T

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

general nursing care; and meals and special diets.
special duty nursing care when medically necessary

NOTE: When it is medically necessary, a plan physician may prescribe private accommodations. If you want a private room when it is not
medically necessary, you pay the additional charge above the semiprivate room rate.

$100 per day up to a maximum of $300 per admission

Inpatient hospital continued on next page. 31.
31 Page 32 33
2003 Coventry Health Care of Kansas, Inc. 29 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms

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

Nothing

Not covered: Custodial care
Non-covered facilities, such as nursing homes, schools Personal comfort items, such as telephone, television, barber
services, guest meals and beds Private nursing care not medically necessary

All charges.

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

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
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.

$50 per surgery

Not covered: blood and blood derivatives not replaced by the member All charges. 32.
32 Page 33 34
2003 Coventry Health Care of Kansas, Inc. 30 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Up to 60 days per member per calendar year when:
Full-time skilled nursing care is necessary
Confinement in a skilled nursing facility is medically necessary
Services include:
Bed, board, and general nursing
Prescribed drugs and their administration
Biologicals
Supplies
Durable medical equipment ordinarily furnished by the facility

Nothing

Not covered: custodial care or care in an intermediate care facility All charges.
Hospice care Hospice care is a program for caring for the terminally ill that
emphasizes supportive and palliative services, such as home care and pain control, rather than curative care of the terminal illness. A person
who is terminally ill may elect to receive hospice benefits.
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 six months or less.
You must reside in the service area Services will be provided in the home or

in a Plan approved hospice facility
Services include inpatient care, outpatient care, and family counseling (except financial, legal or spiritual counseling provided

by a volunteer).
These palliative and supportive services include nursing care, medical social services, physician services, and short-term inpatient

care for pain control and acute chronic symptom management. We also provide services for symptom control to enable the person to
continue life with as little disruption as possible.

Nothing

Not covered:
Services in the member's home outside of the service area
Any service for which the hospice does not customarily charge the member, or his or her family

Independent nursing, homemaker services

All charges. 33.
33 Page 34 35
2003 Coventry Health Care of Kansas, Inc. 31 Section 5( c)
Ambulance You pay
Local professional ambulance service to the nearest hospital equipped to handle your medical condition when medically

appropriate. We limit coverage to $400 per transport.
Air ambulance when medically appropriate.

30% coinsurance per transport up to our $400 coverage limit

30% of covered charges
Not covered: Non-emergent transport due to absence of other transportation, non-emergent transport regardless of who requested
the ambulance service
All charges 34.
34 Page 35 36
2003 Coventry Health Care of Kansas, Inc. 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

I M
P O
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A N
T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
In a life-threatening emergency, call the local emergency system (e. g., the local 911 telephone system), or go to the nearest emergency facility. If an ambulance comes, tell the paramedics that the person who needs help is a Coventry Health Care of
Kansas member.

Emergencies within our service area:
If you are admitted to a non-participating facility, call Customer Service at (800) 969-3343. You must notify us about your medical emergency within a reasonable time period as dictated by the circumstances. If you are hospitalized in a non-participating
hospital and plan physicians believe your care can be provided in one of our participating hospitals, we will transfer you when medically feasible. Follow-up services will normally be performed by your primary care physician.

Benefits are available for care from non-participating providers in a medical emergency only if delay in reaching a participating facility would result in death, disability, or significant jeopardy to your condition.
If your symptoms are not life-threatening, contact your primary care physician who is on call 24 hours a day, seven days a week. After hours or weekends, your physician may use an answering service. Your physician or a covering physician will
generally return your call within 30 minutes. We also provide FirstHelp, which is available to our members 24 hours a day, seven days a week by calling (800) 622-9528. With this service registered nurses are available to help direct you to the
appropriate level of care or provide medical advice.
We also provide several Urgent Care centers which are open on evenings, weekends, and holidays and are designed to give our members fast, effective quality care for non-emergent conditions such as: sprains, influenza, sore throats, ear infections,
minor lacerations, and upper respiratory infections.
Emergencies outside our service area:
If you are hospitalized, We must be notified about your medical emergency within a reasonable time period as dictated by the circumstances. If a participating physician believes your care can be provided in one of our participating hospitals, we

will transfer you when medically feasible. 35.
35 Page 36 37
2003 Coventry Health of Kansas, Inc. 33 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctor's services

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

$15 per visit
$25 per visit
$75 per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctor's services

Nothing

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

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

Ambulance (within or outside of service area)
Local professional ambulance service to the nearest hospital equipped to handle your medical condition when medically

appropriate. We limit coverage to $400 per transport.
Air ambulance when medically appropriate.

30% coinsurance per transport up to our $400 coverage limit

30% of covered charges
Not covered: Transports we determine are not medically necessary All charges. 36.
36 Page 37 38
2003 Coventry Health Care of Kansas, Inc. 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

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

Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
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A N
T

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

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

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

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

Diagnostic and treatment of psychiatric conditions, mental illness and mental disorders. Services include:
Diagnostic evaluation
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers

Crisis intervention and stabilization for acute episodes
Medication evaluation and management
Psychological testing necessary to determine the appropriate treatment

$15 per visit
$15 when the test is not performed during your office visit. You only pay the office visit
copayment when the test is performed during your office visit.

Mental health and substance abuse benefits -continued on next page 37.
37 Page 38 39
2003 Coventry Health Care of Kansas, Inc. 35 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnosis and treatment of alcoholism and drug abuse. Services include:
Detoxification (medical management of withdrawal from the substance)
Treatment and counseling (including individual and group therapy visits)
Rehabilitation
Note: Your mental health or substance abuse provider will develop a treatment plan to assist you in improving or maintaining your condition and

functional level, or to prevent relapse.
Note: You may see an outpatient mental health or substance abuse provider without referral from your primary care physician. However, before you see

a mental health provider you must obtain authorization for the visit from APS Healthcare, Inc., at 800-752-7242. They can be reached for routine referrals
between 8 a. m. and 6 p. m. CST Monday through Friday, or for emergency services 24 hours a day. Your mental health provider will obtain subsequent
authorizations for treatment.

$15 per visit

Inpatient psychiatric care
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Inpatient substance abuse care
Inpatient detoxification

$100 per day up to a maximum of $300 per admission

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

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
APS Healthcare, Inc., is contracted by Coventry Health Care of Kansas, Inc., to provide a network of providers who offer a variety of therapeutic services on an
inpatient and outpatient basis.
All inpatient and outpatient treatment must be authorized through APS Healthcare, Inc., at 800-752-7242.

Limitation We may limit your benefits if you do not follow your treatment plan. 38.
38 Page 39 40
2003 Coventry Health Care of Kansas, Inc. 36 Section 5( f)
Section 5 (f). Prescription drug benefits
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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.

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

Where you can obtain them. You must fill the prescription at a participating pharmacy. You may obtain maintenance medication through Caremark, our mail order prescription drug program. Caremark's
Customer Service number is (800) 378-7040.
We use a formulary. A formulary is a list of specific generic and brand name prescription drugs authorized by the Health Plan, and subject to periodic review and modification. Since there may be more than one brand

name of a prescription drug, not all brands of the same prescription drug (e. g., different manufacturers) may be included in the Formulary. If you would like information on whether a specific drug is included in our
drug formulary, please call Customer Service at (800) 969-3343.
If your plan physician specifically prescribes a non-formulary drug because it is medically necessary, you will receive the non-formulary drug at the Plan non-formulary copayment. If you request a non-formulary drug

when your physician has prescribed a substitution, we will not provide the non-formulary drug. However, you may purchase the non-formulary drug from a Plan pharmacy at our allowance.

These are the dispensing limitations. Prescription Drugs will be dispensed in the quantity determined by the Prescribing Provider. The following also apply:
One (1) applicable copayment is due each time a prescription is filled or refilled at a retail pharmacy for up to a thirty-one (31) day supply.
Mail Order Drugs are obtained through Caremark, our mail order prescription drug program, and may be dispensed with two (2) applicable copayment( s), or $20 formulary generic and $40 brand name generic, for a
ninety-three (93) day supply. To order prescriptions or refills please contact Caremark's Customer Service at (800) 378-7040 or visit the website www. rxrequest. com. Available 24 hours a day 7 days a
week.
If a brand name Prescription Drug is dispensed, and an equivalent generic Prescription Drug is available, you pay an Ancillary Charge in addition to the formulary brand name copayment. The Ancillary Charge will be

due regardless of whether or not the Prescribing Provider indicates that the pharmacy is to "Dispense as Written." The Ancillary Charge is the difference between the average wholesale price of the brand name and
the maximum allowable cost price of the generic prescription. Copayments and Ancillary Charges do not apply to the Catastrophic Protection Out-of-Pocket Maximum. 39.
39 Page 40 41
2003 Coventry Health Care of Kansas, Inc. 37 Section 5( f)
Generic drugs are a lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the
original brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand-name drugs. Generic drugs are indicated on the formulary listing of prescription drugs.

When you have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to file a claim. For a covered out-of-area emergency, you will need to file a claim when you receive drugs from a no-Plan
pharmacy.

Benefit Description You pay

Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

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

Insulin (per vial) and lancets
Glucose test strips
Oral contraceptive drugs
Injectable contraceptive drugs (such as Depo Provera)
Growth hormone

Retail Pharmacy
$10 per generic formulary
$20 per brand name formulary
$50 per non formulary

Mail Order (93-day supply)
$20 per generic formulary
$40 per brand name formulary
Note: Our mail order benefit is limited to the two tiers listed above

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

Drugs to treat sexual dysfunction (Note: This drug has dispensing limitations. Contact the Plan for details) 50% of our allowance
Insulin Under retail pharmacy benefit, you can obtain up to a 3 month supply of insulin. $30 generic, $60 brand name formulary, $150 non formulary brand
Oral Contraceptive drugs Under retail pharmacy benefit, you can obtain up to a 3 month supply of oral contraceptives drugs $30 generic, $60 brand name formulary, $150 non formulary brand
Disposable needles and syringes for the administration of covered medications.
Immunosuppressant drugs required after a covered transplant.
Nothing 40.
40 Page 41 42
2003 Coventry Health Care of Kansas, Inc. 38 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Medical supplies such as dressings and antiseptics
Smoking cessation drugs, and devices including nicotine gum
Drugs to enhance athletic performance
Fertility drugs
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
Drugs available without a prescription or for which there is a non-prescription equivalent

Prescription drugs for a non-covered service
Drugs used for hair restoration
Dietary supplements, appetite suppressants, and other drugs used to treat obesity or assist in weight reduction

All charges. 41.
41 Page 42 43
2003 Coventry Health Care of Kansas, Inc. 39 Section 5( g)
Section 5 (g). Special features
Feature Description

24 hour nurse line Call FirstHelp anytime you or a family member experience health symptoms that need attention. Nurses are available to you and your family 24 a day, 7 days a week and are trained to handle your questions. Any member who visits an
emergency room or urgent care center as a result of advice from FirstHelp will automatically have associated claims approved. With FirstHelp authorization, you
will know in advance if medical services will be covered. You may call 1-800-622-9528 or for the hearing impaired call 1-800-735-2966.

Services for deaf and hearing impaired The Missouri TDD relay number is 1-800-735-2966. The Kansas TDD relay number is 1-800-766-3777.

Transplant Network In order to provide members requiring a transplant the opportunity for the best outcomes and experiences, We have contracted with United Resource Networks for access to a network of transplant programs with proven expertise. United
Resource Networks evaluates transplant programs throughout the United States, and has built a nationally-recognized network of programs called the United
Resource Networks Transplant Network.

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

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

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. 42.
42 Page 43 44
2003 Coventry Health Care of Kansas, Inc. 40 Section 5( h)
Section 5 (h). Dental benefits
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Here are some important thingsto keep in mind about these benefits:
Please remember that all benefits are subject to thedefinitions, limitations, and exclusions in this brochure and are payable onlywhen we determine theyare dentallynecessary.

We have no calendar year deductible. There are no out-of-network benefits.
You must paythe dentist the listed copayat the time of service. You are not limited to a specific number of visits per year. Youdo not have to be assigned to a certainprovideroffice. You mayvisit anydentist in the plan. Aplan

dentist must provide or arrange your care.
We cover hospitalization for dental procedures onlywhen a non-dental physical impairment exist which makes hospitalization necessaryto safeguard the healthof the patient. See section 5( c) for inpatient benefits.

Be sure to read Section4, Your costs for covered services, for valuable information about howcost sharing works. Also read Section9 about coordinating benefits with other coverage, including with Medicare.

This is not a complete list of our Dental benefits. For a complete list of our Dental benefits, contact National Dental Plans (NDP) a CompDent company toll free at (800)
456-5500 or visit NDP's website at www. compdent. com.
Important Note: Prior to treatment, always discuss all fees with the dentist. Some of our
benefits list the amount you pay for the service. For other covered benefits, you pay a percentage of the dentist's usual and customary fee. IT IS YOUR

RESPONSIBILITY TO BE INFORMED ABOUT YOUR DENTAL COVERAGE.

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

services must result from an accidental injury.
The remaining cost after a 20% reduction of participating specialist fees

Dental Benefits
Service You pay
General dentist (you pay restorative services)
Amalgam (fillings silver, plastic or composite)
Crowns (Stainless steel, cast or porcelain/ metal)
$33 55
$431 458
Periodontic services
Root planning (per quadrant) $44 114

Orthodontic services
Standard fully banded case (available to members age 19 and under)
The remaining cost after a 20% reduction of the participating specialist usual &

customary fees for services provided

Endodontic services
Root canals
The remaining cost after a 20% reduction of the participating specialist usual &

customary fees for services provided
Dental benefits continued on next page 43.
43 Page 44 45
2003 Coventry Health Care of Kansas, Inc. 41 Section 5( h)
Dental benefits (continued) You pay
Oral surgery
Simple extraction
Extractions (each additional tooth)
Surgical removal of erupted tooth

$45
$39
$85
Prosthetic services

Dentures (complete upper or lower)
Partial dentures
$540
$455

Any treatment provided by a participating specialist (advanced degree) will be charged at a 20% reduction of participating specialist
fees for that particular case. Note: Some specialists may require a consultation visit before treatment is initiated.
The remaining cost after a 20% reduction of the participating specialist usual &
customary fees for services provided

Not covered:
Services for injuries or conditions that are covered under Workman's Compensation or Employer Liability Laws.

Services which are provided without cost to the member by any municipality, county, or other political subdivision.
Cost of dental care that is covered under automobile medical, no fault, or similar type insurance.
General anesthesia, IV sedation, nitrous oxide, hospitalization or hospital medical charges of any kind.
Osseointegrated implants
Member's dental fees apply only when treatment is performed at a participating dental office. If the services of a non-participating
specialist or non-participating general dentist are required, these dental fees do not apply, and the patient will be responsible for the
non-participating dentist's usual, customary and reasonable fee.
Reduced fees will not be honored if the dental treatment is already in progress or if the patient's membership is no longer valid.

Any member accepted for orthodontics must remain a member of the dental plan for the full duration of their treatment or risk additional
charges from their participating Orthodontist.
A patient's existing dental or medical condition may necessitate extra precautionary procedures and require additional charges.

Please discuss all fees with the dentist prior to treatment.

All charges. 44.
44 Page 45 46
2003 Coventry Health Care of Kansas, Inc. 42 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs or supplies you receive without charge while in active military service. 45.
45 Page 46 47
2003 Coventry Health Care of Kansas, Inc. 43 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital, and drug In most cases, providers and facilities file claims for you. Physicians must file on the benefits form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 1-800-969-3343.

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:
Coventry Health Care of Kansas, Inc. P. O. Box 7109
London, KY 40742

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 Coventry Health Care of Kansas, Inc. 44 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 90 days from the date of our decision; and
(b) Send your request to us at: Coventry Health Care of Kansas, Inc., Attn: Member Appeals, 1001 East 101 st Terrace, Suite 300, Kansas City, MO 64131; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

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

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We
will base our decision on the information we already have.
We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 47.
47 Page 48 49
2003 Coventry Health Care of Kansas, Inc. 45 Section 8
The Disputed Claims process (continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

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

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

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800-969-3343 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 48.
48 Page 49 50
2003 Coventry Health Care of Kansas, Inc. 46 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
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 on the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or precertified as required. We will not waive any of our copayments, coinsurance.

The Original Medicare Plan (Part A or Part B) 49.
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2003 Coventry Health Care of Kansas, Inc. 47 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find

out if you need to do something to file your claims, call us at 1-800-969-3343 or visit our website at www. chckansas. com.

We do not waive any costs if the Original Medicare Plan is your primary payer. 50.
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2003 Coventry Health Care of Kansas, Inc. 48 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Areanactiveemployee withthe Federalgovernment(includingwhen youora familymemberare eligibleforMedicaresolely becauseofadisability), .

2) Are an annuitant, .
.
3) Are a reemployed annuitant with the Federal government when

a) The position is excluded from FEHB, or

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

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

covered spouse is this type of judge), .
5) Are enrolled in Part B only, regardless of your employment status, . (for Part B services) . (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

.
(except for claims related to Workers'

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

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

b) Are an active employee, or .
c) Are a former spouse of an annuitant, or .
d) Are a former spouse of an active employee . 51.
51 Page 52 53
2003 Coventry Health Care of Kansas, Inc. 49 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --a Medicare managed care plan.
These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

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

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under the Medicare Part A or Part B the FEHB Program. We will not require you to enroll in Medicare Part B and, if you
can't get premium-free Part A, we will not ask you to enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these program