Pages 1--60

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

Serving: Central, East Central, North Central, Southern and Western Illinois, Western
For changes in benefits

see page 8.

Indiana and Central and Eastern Iowa

Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 6 for requirements.

This Plan has Excellent accreditation from NCQA. See the 2003 Guide for more
information on accreditation.

Enrollment codes for this Plan:
FX1 Self Only FX2 Self and Family

RI 73-168 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 who received your personal medical information from OPM in the past six years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you 3.
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authorized OPM to release, or information that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call (202) 606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
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Table of Contents
Introduction. ........................................................................................ 4
Plain Language....................................................................................................................................................................................... 4
Stop Health Care Fraud!......................................................................................................................................................................... 4
Section 1. Facts about this HMO plan................................................................................................................................................... 6
How we pay providers.......................................................................................................................................................... 6
Your rights............................................................................................................................................................................ 6
Service area .......................................................................................................................................................................... 6
Section 2. How we change for 2003...................................................................................................................................................... 8
Program-wide changes ......................................................................................................................................................... 8
Changes to this Plan ............................................................................................................................................................. 8
Section 3. How you get care ................................................................................................................................................................. 9
Identification cards ............................................................................................................................................................... 9
Where you get covered care ................................................................................................................................................. 9
Plan providers ................................................................................................................................................................ 9
Plan facilities.................................................................................................................................................................. 9
What you must do to get covered care.................................................................................................................................. 9
Primary care ................................................................................................................................................................... 9
Specialty care ................................................................................................................................................................. 9
Hospital care ................................................................................................................................................................ 10
Circumstances beyond our control ..................................................................................................................................... 11
Services requiring our prior approval................................................................................................................................. 11
Section 4. Your costs for covered services.......................................................................................................................................... 12
Copayments.................................................................................................................................................................. 12
Deductible .................................................................................................................................................................... 12
Coinsurance.................................................................................................................................................................. 12
Your catastrophic protection out-of-pocket maximum....................................................................................................... 12
Section 5. Benefits............................................................................................................................................................................... 13
Overview ............................................................................................................................................................................ 13
(a) Medical services and supplies provided by physicians and other health care professionals.................................... 14
(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 ................................................................................................................................. 30
(e) Mental health and substance abuse benefits ............................................................................................................ 32
(f) Prescription drug benefits ........................................................................................................................................ 34

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(g) Special features ....................................................................................................................................................... 37
Flexible benefits option
Services for the deaf and hearing impaired
Reciprocity benefit
(h) Dental benefits ........................................................................................................................................................ 38
(i) Non-FEHB benefits available to Plan members ...................................................................................................... 39
Section 6. General exclusions --things we don't cover ...................................................................................................................... 40
Section 7. Filing a claim for covered services..................................................................................................................................... 41
Section 8. The disputed claims process............................................................................................................................................... 42
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 44
When you have other health coverage................................................................................................................................ 44
What is Medicare..................................................................................................................................................... 44
Medicare managed care plan .................................................................................................................................. 47
TRICARE and CHAMPVA..................................................................................................................................... 47
Workers' Compensation .......................................................................................................................................... 48
Medicaid ................................................................................................................................................................. 48
Other government agencies ..................................................................................................................................... 48
When others are responsible for injuries ................................................................................................................. 48
Section 10. Definitions of terms we use in this brochure ..................................................................................................................... 49
Section 11. FEHB facts ....................................................................................................................................................................... 51
Coverage information ....................................................................................................................................................... 51
No pre-existing condition limitation......................................................................................................................... 51
Where you get information about enrolling in the FEHB Program.......................................................................... 51
Types of coverage available for you and your family .............................................................................................. 51
Children's Equity Act............................................................................................................................................... 51
When benefits and premiums start ........................................................................................................................... 52
When you retire ........................................................................................................................................................ 52
When you lose benefits..................................................................................................................................................... 52
When FEHB coverage ends...................................................................................................................................... 52
Spouse equity coverage ............................................................................................................................................ 52
Temporary Continuation of Coverage (TCC)........................................................................................................... 52
Converting to individual coverage ........................................................................................................................... 53
Getting a Certificate of Group Health Plan Coverage .............................................................................................. 53
Long term care insurance is still available ........................................................................................................................................... 54
Index..................................................................................................................................................................................................... 55
Summary of benefits ............................................................................................................................................................................ 56

2003 Health Alliance HMO 3 Table of Contents
Rates....................................................................................................................................................................................... Back cover 6.
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Introduction
This brochure describes the benefits of Health Alliance Medical Plans, Inc., on behalf of itself and Health Alliance Midwest, Inc., its wholly owned subsidiary, under our contract (CS 1980) with the Office of Personnel Management (OPM), as authorized
by the Federal Employees Health Benefits law. The address for Health Alliance Medical Plans, Inc. is:
Health Alliance HMO 102 East Main Street
Urbana, IL 61801
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 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means Health Alliance HMO.

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

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

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

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.
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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 1-800-851-3379 and explain the situation. If we do not resolve the issue:

CALL --THE HEALTH CARE FRAUD HOTLINE (202) 418-3300

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

Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud, and your agency may take action against you, if you falsify a claim to obtain 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.

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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 us for a copy of our most recent provider directory. You can also view our provider directory at our website www. healthalliance. org.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have
to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us and you will only be responsible for your copayments or coinsurance.

Your rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is stated below.
Health Alliance is a unique managed care organization because physicians own it. Health Alliance Medical Plans, Inc., is the corporate successor to CarleCare, Inc., a not-for-profit health maintenance organization founded by one of the largest multi-specialty

group practices in the nation Carle Clinic Association, P. C., in Urbana, Illinois. CarleCare HMO enrolled its first member in March 1980 and five years later became a federally qualified HMO. In 1989, CarleCare was reorganized as a for-profit domestic insurance
company owned by Carle Clinic and renamed Health Alliance Medical Plans. As such, Health Alliance can underwrite and administer a full range of managed care products.

Today, Health Alliance is the largest managed care organization based in downstate Illinois, covering most of central and east central Illinois, as well as numerous counties in southern Illinois and central Iowa. The corporate office is located in Urbana, Illinois.
Health Alliance provides convenient access to health care with a large network of quality providers. Physicians and specialists as well as clinics, hospitals, pharmacies and other providers were selected to be part of the Health Alliance provider network because of their
reputation for excellence.
If you want more information about us, call 1-800-851-3379, or write to Health Alliance Medical Plans, 102 East Main Street, Urbana, IL, 61801. You may also contact us by fax at (217) 255-4699 or visit our website at http:// www. healthalliance. org.

Service area
To enroll in this Plan, you must live in or work in one of our service areas. This is where our providers practice. A service area is a geographic region consisting of one or more counties. The county in which you live or work determines your service area and
subsequently your provider network. When you enroll in the Plan, you will be required to select a Primary Care Physician in your service area. This physician will coordinate all of your medical care.

Should you require specialty or ancillary care, your Primary Care Physician will refer you to a provider in your service area. It is your responsibility to make sure your primary care physician refers you to Plan doctors. Please refer to your provider directory or you can
2003 Health Alliance HMO 6 Section 1 9.
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view our provider directory at our website http:// www. healthalliance. org. If you require care that is not available within your service area, your physician will request an out-of-network referral from a Plan medical director. The Plan will notify the referring physician
and you in writing of the decision. To assure coverage, please be sure the out-of-network service has been approved prior to seeking services. Our service areas are listed below.

Our Illinois service areas are:
DeKalb Service Area: DeKalb county
East Central Illinois Service Area: Illinois: Champaign, Clark, Coles, Cumberland, DeWitt, Douglas, Edgar, Effingham, Fayette, Ford, Grundy, Iroquois, Jasper, Kendall, LaSalle, Livingston, McLean, Moultrie, Piatt, Shelby, Tazewell, Vermilion
and Woodford counties Indiana: Fountain, Vermillion and Warren counties

Macomb Service Area: Henderson, McDonough and Warren counties
Quad Cities Service Area: Illinois: Henry, Mercer and Rock Island counties Iowa: Scott county

Quincy Service Area: Adams, Brown, Hancock, Pike and Schyuler counties
Southern Illinois Service Area: Franklin, Gallatin, Hardin, Jackson, Johnson, Perry, Randolph, Saline, Union, Washington and Williamson counties

Springfield Service Area: Cass, Christian, Greene, Jersey, Logan, Macon, Macoupin, Mason, Menard, Montgomery, Morgan, Sangamon and Scott counties
Our Iowa service area is:
Central Iowa Service Area: Boone, Calhoun, Carroll, Greene, Hamilton, Hardin, Marshall, Story, Tama, Webster and Wright 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 out of our service area unless the services have prior
Plan approval.
If you or a covered family member moves 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 moves, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

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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.
We changed the address for sending disputed claims to OPM. (Section 8)
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.
Changes to this Plan
Your share of the non-Postal premium will increase by 3.9% for Self Only or 4.2% for Self and Family.
We are now offering coverage for the following service areas: (Section 1) DeKalb Service Area DeKalb county

Quincy Service Area Adams, Brown, Hancock, Pike and Schuyler counties
The counties of Hancock and Schuyler are no longer part of the Macomb Service Area; they are now part of the Quincy Service Area. (Section 1)

The following counties have been added to the East Central Illinois Service Area: (Section 1) LaSalle, Grundy and Kendall Counties
The Decatur Service Area (Decatur St. Mary's Network) is now listed under the Springfield Service Area. (Section 1)
Your office visit copayments for services provided by your Primary Care Physician, specialist, nurse practitioner, nurse, or physician's assistant have increased to $15 per visit. (Section 5a)

Your copayments for prescription drugs have increased to $10 per generic, $20 per brand name on our formulary and $40 per brand name that is non-formulary. (Section 5f)

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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 1-800-851-3379 or write us at
Health Alliance, 102 East Main Street, Urbana, IL 61801. You may also request replacement cards through our website at www. healthalliance. org.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www. healthalliance. org.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our website at www. healthalliance. org.
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.
What you must do to get covered 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.
If you want to change Primary Care Physician or if your Primary Care Physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your Primary Care Physician will refer you to a specialist for needed care. When you receive a referral from your Primary Care Physician, you must return to the Primary Care
Physician after the consultation, unless your Primary Care Physician authorized a certain number of visits without additional referrals. The Primary Care Physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits unless your Primary Care Physician gives you a referral. However, you may receive optometric care
for routine eye exams and females may see a Woman's Principal Health Care Provider without a referral. You are responsible for making sure your Primary Care Physician
refers you to an in-network specialist. Please refer to your provider directory or you can view our provider directory on our website at http:// www. healthalliance. org.

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

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when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your Primary Care Physician. Your Primary Care Physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan Primary Care Physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or
other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 1-800-851-3379. 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.

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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.
Your Primary Care Physician has the 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 preauthorization. Your physician must obtain approval before sending you to a provider outside your service area or to a non-Plan
provider. Before giving approval, we consider if the service is medically necessary and if it follows generally accepted medical practice.

Services requiring our prior approval

Preauthorization is also required for services such as durable medical equipment, home care, home infusion services, hospice care, infertility services, organ transplants,
pharmaceutical recombinant biologicals, prosthetic devices, reconstructive surgery and spinal manipulations for assurance that the service, procedure or supply is medically
necessary and will be covered.
Medical necessity determination of covered health care services under this Plan is subject to the medical policies presently in effect and adopted or amended by Health Alliance
HMO. A copy of the medical policies and procedures relevant to a pending coverage decision will be made available to members upon written request.

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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, and when you go in the hospital, you pay $100 per admission.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 20 percent of our allowance for durable medical equipment.

After your copayments and/ or coinsurance total $1500 per person or $3000 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:

Your catastrophic protection out-of-pocket maximum for
coinsurance and copayments

Durable medical equipment
Prosthetic devices
Prescription drugs
Vision care

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

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Section 5. Benefits --Overview
(See page 8 for how our benefits changed this year and page 56 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 1-800-851-3379 or visit our website at www. healthalliance. org.

(a) Medical services and supplies provided by physicians and other health care professionals ....................................................... 14-23
Diagnostic and treatment services Lab, X-ray and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................................. 24-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility and ambulance services ............................................................................... 28-29
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents.................................................................................................................................................. 30-31 Medical emergency Ambulance

(e) Mental health and substance abuse benefits............................................................................................................................. 32-33
(f) Prescription drug benefits ........................................................................................................................................................ 34-36
(g) Special features ............................................................................................................................................................................. 37

Flexible benefits option
Services for the deaf and hearing impaired
Reciprocity benefit

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

2003 Health Alliance HMO 13 Section 5 16.
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Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including Medicare.

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Benefit Description You pay
Diagnostic and treatment services

Professional services of physicians, nurse practitioner, nurse or physician's assistant

In physician's office
$15 per office visit.

Professional services of physicians
In an urgent care center
Office medical consultations
Second surgical opinion

$15 per office visit.

Professional services of physicians


During a hospital stay
In a skilled nursing facility

Nothing if you are inpatient in a hospital or skilled nursing facility. You pay only your
hospital admission copayment.

At home $20 per visit.

Diagnostic and treatment services --continued on next page

2003 Health Alliance HMO 14 Section 5( a) 17.
17 Page 18 19
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing. You pay only your $15 office visit copayment.

Preventive care, adult
Routine screenings, such as
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including

Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50
Colonoscopy
Double contrast barium enemas

Nothing. You pay only your $15 office visit copayment.

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older Nothing. You pay only your $15 office visit copayment.
Routine pap test Nothing. You pay only your $15 office visit copayment.
Preventive Care -Adult --continued on next page

2003 Health Alliance HMO 15 Section 5( a) 18.
18 Page 19 20
Preventive care, adult (continued) You pay
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

Nothing. You pay only your $15 office visit copayment.

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)
Influenza vaccine, annually
Pneumococcal vaccine age 65 or older. Those at high risk should receive a booster at six years after initial dose.

Nothing. You pay only your $15 office visit copayment.

Not covered: Physical exam required for obtaining or continuing employment or insurance, attending schools or camp, or travel All charges.
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing. You pay only your $15 office visit copayment.

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

$15 per office visit.

2003 Health Alliance HMO 16 Section 5( a) 19.
19 Page 20 21
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
NOTE: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 10 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.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
We cover circumcision for male infants under Surgical Benefits (Section 5b).

$50 copayment per pregnancy. Care provided by specialists during prenatal
period is subject to the $15 office visit copayment.

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo Provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

Nothing. You pay only your $15 office visit copayment.

Not covered: Genetic counseling or reversal of voluntary surgical sterilization All charges.

2003 Health Alliance HMO 17 Section 5( a) 20.
20 Page 21 22
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial Insemination:

intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

Assisted reproductive technology (ART) procedures, such as:
In vitro fertilization
Embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer

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

$15 per office visit.

Not covered:
Services and supplies related to excluded ART procedures
Non-medical cost of donor sperm
Non-medical cost of donor egg
Infertility service after voluntary sterilization

All charges.

Allergy care
Testing and treatment
Allergy injection
$15 per office visit.

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

2003 Health Alliance HMO 18 Section 5( a) 21.
21 Page 22 23
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: We will only cover GHT when we preauthorize the treatment. Call 1-800-851-3379 for preauthorization. We will ask you to submit
information that establishes 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.
Nothing per visit during covered inpatient admission.

2003 Health Alliance HMO 19 Section 5( a) 22.
22 Page 23 24
Physical and occupational therapies You Pay
A combined total of 60 visits per condition per year for the services of each of the following:

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

Cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, is provided for up to 24 sessions in 12 consecutive weeks or less for Phase II. Phase I rehab is provided in

the hospital after surgery.

$15 per office visit.
$15 per outpatient visit.
Nothing per visit during covered inpatient admission.

Not covered:
Long-term rehabilitative therapy
Exercise programs
Phase III cardiac rehabilitation

All charges.

Speech therapy
60 visits per condition per contract year $15 per office visit.
$15 per outpatient visit.
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 screenings and evaluations
$15 per office visit.

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

2003 Health Alliance HMO 20 Section 5( a) 23.
23 Page 24 25
Vision services (testing, treatment and supplies) You Pay
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
$15 per office visit.

Eye exam to determine the need for vision correction for children (see Preventive care, children)
Annual eye refractions
$15 per office visit.

Not covered:
Eyeglasses or contact lenses
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 and similar routine treatment of conditions of the foot,

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

treatment is by open cutting surgery)

All charges.

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

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants and surgically implanted breast implant following
mastectomy. NOTE: We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment information. See 5( b) for
coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Foot orthotics

20% coinsurance.

Orthopedic and prosthetic devices-Continued on next page
2003 Health Alliance HMO 21 Section 5( a) 24.
24 Page 25 26
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
Orthopedic and corrective shoes
Arch supports
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose and other supportive devices

Prosthetic replacements provided less than five years after the last one we covered, unless is irreparable and member has properly
maintained it

All charges.

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

oxygen and dialysis equipment. Under this benefit, we also cover:
Hospital beds
Wheelchairs
Crutches
Walkers
Blood glucose monitors
Insulin pumps
Note: Call us at 800/ 851-3379 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% coinsurance.

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.) or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

$15 per visit.

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

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

All charges.

2003 Health Alliance HMO 22 Section 5( a) 25.
25 Page 26 27
Chiropractic You Pay
Manipulation of the spine and extremities is covered if referred by the Primary Care Physician and approved by a medical director.

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy and cold pack application are covered as rehabilitative
therapy services and are subject to a limit of 60 treatments per condition per calendar year. X-rays and other diagnostic testing are covered under
diagnostic and treatment services and must be provided by a participating provider.

NOTE: Spinal manipulations and mobilizations are covered when long-term significant improvement can be expected from such treatment.

$15 per office visit.

Alternative treatments
Biofeedback under certain circumstances $15 per office visit.

Not covered:
Naturopathic services
Hypnotherapy
Acupuncture

All charges.

Educational classes and programs
Coverage is limited to:

Smoking Cessation Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as
prescription drugs
Diabetes self-management

$15 per visit.

2003 Health Alliance HMO 23 Section 5( a) 26.
26 Page 27 28
Section 5( b). Surgical and anesthesia services provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to identify which services and surgeries require
precertification.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity if medical criteria set by Plan is met

Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization (e. g., tubal ligation, vasectomy)
Treatment of burns
NOTE: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for

a pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per office visit.
or
Nothing if you are an inpatient in a hospital. You pay only your hospital

admission copayment.

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

All charges.

2003 Health Alliance HMO 24 Section 5( b) 27.
27 Page 28 29
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 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.
or
Nothing if you are an inpatient in a hospital. You pay only your hospital

admission copayment.

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, 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 surgical procedures that do not involve the teeth or their supporting structures

$15 per office visit.
or
Nothing if you are an inpatient in a hospital. You pay only your hospital

admission copayment.

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)

All charges.

2003 Health Alliance HMO 25 Section 5( b) 28.
28 Page 29 30
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ pancreas
Liver
Lung: Single -Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia, advanced Hodgkin's lymphoma, advanced non-Hodgkin's lymphoma, advanced
neuroblastoma, breast cancer, multiple myeloma, epithelial ovarian cancer and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach

and pancreas

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

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

Transportation, lodging and meals for the transplant recipient and a companion for travel to and from a Plan designated center of excellence
is covered. If the patient is a minor, transportation and reasonable and necessary lodging and meal costs for two persons who travel with the
minor are included. Expenses for meals and lodging are reimbursed at the per diem rates established by the Internal Revenue Service.

Nothing if you are an inpatient in a hospital. You pay only your hospital
admission copayment.

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

Implants of artificial organs
Transplants not listed as covered
Experimental organ or tissue transplants

All charges.

2003 Health Alliance HMO 26 Section 5( b) 29.
29 Page 30 31
Anesthesia You pay
Professional services provided in
Hospital (inpatient)
Nothing. You pay only your hospital admission copayment.

Professional services provided in
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center

Nothing.

Professional services provided in
Office
Nothing. You pay only your office visit copayment.

2003 Health Alliance HMO 27 Section 5( b) 30.
30 Page 31 32
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including

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.

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

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

$100 per admission.

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

Nothing.

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

Private nursing care

All charges.

2003 Health Alliance HMO 28 Section 5( c) 31.
31 Page 32 33
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays and pathology services
Administration of blood, blood plasma and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing.

Not covered: blood and blood derivatives not replaced by the member All charges.
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): up to 120 days per contract year Nothing.

Not covered: Custodial care All charges.

Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient or outpatient

care and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or less.

Nothing.

Not covered: Independent nursing and homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate Nothing.

2003 Health Alliance HMO 29 Section 5( c) 32.
32 Page 33 34
Section 5( d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

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 Medicare.

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

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

What to do in case of emergency
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, consider the local emergency system (e. g., the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours after care begins unless
it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been notified in a timely manner.
If you need to be hospitalized, the Plan must be notified within 48 hours after care begins or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in

non-Plan facilities and the Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan doctors.

Emergencies outside our service area: Benefits are available for any medically necessary service that is immediately required due to illness or unforeseen injury.
If you need to be hospitalized, the Plan must be notified within 48 hours after care begins or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes
care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan doctors.

2003 Health Alliance HMO 30 Section 5( d) 33.
33 Page 34 35
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 doctors' services

NOTE: If admitted, the emergency room copayment is waived and you pay the $100 inpatient hospital admission copayment.

$15 per office visit.
$15 per office visit.
$100 per emergency room 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 doctors' services

Note: If admitted, the ER copayment is waived and you pay the $100 inpatient hospital admission copayment.

$15 per office visit.
$15 per office visit.
$100 per emergency room visit.

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

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

All charges.

Ambulance
Professional ambulance service when medically appropriate
See 5( c) for non-emergency service
Nothing.

2003 Health Alliance HMO 31 Section 5( d) 34.
34 Page 35 36
2003 Health Alliance HMO 32 Section 5( e)
Section 5( e). Mental health and substance abuse benefits
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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.

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 Medicare.

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

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

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

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

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

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

Medication management

$15 per visit.

Mental health and substance abuse benefits -continued on next page 35.
35 Page 36 37
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing.

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

$100 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 obtain a treatment plan and follow all of the following authorization processes:
Except in a medical emergency or when a Primary Care Physician has designated another doctor to see patients when he or she is unavailable, you must contact your
Primary Care Physician for a referral before seeing any other doctor or obtaining specialty services. Referral to a participating specialist in your service area is given at
the primary care doctor's discretion. If specialists or consultants are required beyond those participating in the Plan, a Plan medical director must make the approval.

A list of participating mental health/ substance abuse providers can be found in the Plan's provider directory for your service area or you may contact the Customer
Service Department at 1-800-851-3379 to see which mental health/ substance abuse providers participate with the plan in your service area.

Limitation We may limit your benefits if you do not obtain a treatment plan.

2003 Health Alliance HMO 33 Section 5( e) 36.
36 Page 37 38
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.

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 Medicare.

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There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician in your service area or a referral doctor must write the prescription.

Where you can obtain them. You may fill the prescription at a Plan pharmacy.
We use a formulary. The Plan has a tiered pharmacy copayment structure for each 30-day supply. To keep your costs as low as possible, we ask that you and your physician select appropriate medicines from the list.

We have an open formulary. However, the Plan recognizes the value of using FDA-approved generic drugs whenever medically appropriate. For this reason, you will always pay the lowest copayment for generic
drugs. If your physician believes a brand name product is necessary or there is no generic available, your physician may prescribe a brand name drug from a formulary list. This list of brand name drugs is a preferred
list of drugs that we selected to meet patient's needs at a lower cost. When a generic drug doesn't exist, brand name drugs that are not on our preferred list require the highest copayment level. To order a prescription drug
brochure, call 1-800-851-3379 or you can view our formulary on our website, www. healthalliance. org.
These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply or manufacturer's standard package.

Manufacturer's standard package includes, but is not limited to:
Topical cream, solution, gel, or ointment
Otic, ophthalmic or nasal preparation, nasal, or oral inhaler
Three (10ml) vials of insulin
Antibiotic suspensions
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name drug. If you receive a brand name drug when a Federally-approved generic drug is available and your

physician has not specified Dispense as Written for the brand name drug, you have to pay the difference in cost between the brand name drug and the generic.

Prescriptions cannot be refilled before 75% of the previously dispensed supply should have been consumed if taken as prescribed.
Why use generic drugs? Generic drugs are 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.
When you have to file a claim. If you have to pay out-of-pocket for a prescription because you do not have your ID, please contact our Customer Service Department at 1-800-851-3379 for a claim form.

2003 Health Alliance HMO 34 Section 5( f) 37.
37 Page 38 39
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:
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day
supply or manufacturer's standard package. You pay a $10 copayment per prescription unit or refill for generic drugs, a $20
copayment for brand name drugs on the Plan's formulary and a $40 copayment for brand name drugs that are not on the Plan's
formulary. If the physician allows substitution and the member prefers a brand name drug on the formulary instead of the generic
(if available), the member pays $10 plus the difference in cost between the generic and the brand name drug. If the physician does
not allow substitutions, the member will pay the $20 copayment. 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 Disposable needles and syringes for the administration of covered
medications Drugs for sexual dysfunction (when the following conditions are
met and preauthorized by the Plan) Must be medically necessary
Member must be 18 years or older Covered quantity limited to four tablets per 30-day period
Member cannot be on nitrates No coverage for women

Contraceptive drugs and devices
Certain prescription drugs are covered under the medical benefits of this Plan and are not paid for at the dispensing pharmacy. These

include, but are not limited to, immunization agents, antigens, allergy and biological sera, drugs or drug products derived from
blood or blood plasma, radiologicals and pharmaceutical recombinant biologicals (i. e., Interferon, Erythropoieten, Human
Growth Hormone, etc.) Some prescription drugs require preauthorization from a Plan
medical director and certain criteria to be met by the member. The member's physician must contact the Plan in order to obtain
preauthorization. To accord with changes in medical technology, the Plan maintains a list of pharmaceuticals that require
preauthorization. This list is available to the member upon request. Failure to obtain preauthorization may result in the dispensing
pharmacy requiring personal payment from the member.

$10 per generic.
$20 per brand name on formulary.
$40 per brand name non-formulary.
NOTE: If there is no generic equivalent available, you will still have to pay the

brand name copayment.

Covered medications and supplies --continued on next page
2003 Health Alliance HMO 35 Section 5( f) 38.
38 Page 39 40
2003 Health Alliance HMO 36 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Drugs for which there is a nonprescription equivalent available
Medical supplies such as dressings and antiseptics

All charges. 39.
39 Page 40 41
Section 5 (g). Special features
Feature Description

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

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

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

Services for deaf and hearing impaired TDD (217) 337-8137
Reciprocity benefit The Plan offers a reciprocity program for family members living temporarily away from home in an area serviced by the Plan. Under this program, family members living away can receive coverage for medically necessary routine care. For
additional information on this program, or to enroll a family member, call the Customer Service Department at 1-800-851-3379.

2003 Health Alliance HMO 37 Section 5( g) 40.
40 Page 41 42
Section 5 (h). Dental benefits
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.

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 Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must

result from an accidental injury.
Nothing.

Dental benefits
We have no other dental benefits.

2003 Health Alliance HMO 38 Section 5( j) 41.
41 Page 42 43
2003 Health Alliance HMO 39 Section 5( j)
Section 5 (j). Non-FEHB benefits available to Plan members
This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 47, annuitants and
former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid
plan when one is available in their area. They may then re-enroll in the FEHB Program. Most Federal annuitants have Medicare Part
Those without Medicare Part A may join this Medicare prepaid plan, but will probably have to pay for hospital coverage in addition
to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so, what you will have to p
Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.
Contact the Plan at 1-800-965-4022 for information on the Medicare prepaid plan and the cost o

A.
ay.
f that enrollment.
The benefits on this page are not part of the FEHB contract or premium and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic
protection out-of-pocket maximums.

Medicare prepaid plan enrollment 42.
42 Page 43 44
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 is in imminent danger
Services, drugs or supplies related to sex transformations
Services, drugs or supplies you receive from a provider or facility barred from the FEHB Program
Services, drugs or supplies you receive without charge while in active military service

2003 Health Alliance HMO 40 Section 6 43.
43 Page 44 45
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file a HCFA-1500, Health Insurance Claim Form. Facilities will file a UB-92 form. For claims
questions and assistance, call us at 1-800-851-3379.
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)

Receipts, if you paid for your services
Submit your claims to: Health Alliance Medical Plans 102 E Main Street
Urbana, IL 61801

Prescription drugs All Plan pharmacies will file your claim electronically with you only being responsible for your copayment. However, if for any reason you had to pay for your prescriptions out-of-pocket,
please call the Customer Service Department at 1-800-851-3379 for a claim form.

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.

2003 Health Alliance HMO 41 Section 7 44.
44 Page 45 46
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs or supplies, including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Health Alliance Medical Plans, 102 E Main Street, Urbana, IL 61801; 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 2, 1900 E Street, NW, Washington, DC 20415-3620.

2003 Health Alliance HMO 42 Section 8 45.
45 Page 46 47
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 1-800-851-3379 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 2 at (202) 606-3818 between 8 a. m. and 5 p. m. eastern time.

2003 Health Alliance HMO 43 Section 8 46.
46 Page 47 48
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 in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care
plan you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist or hospital that accepts Medicare. The Original Medicare Plan pays its share and you
pay your share. Some things are not covered under Original Medicare, like prescription drugs.

The Original Medicare Plan (Part A or Part B)

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 our Plan Primary Care Physician and precertified as required. We will waive copayments and coinsurance on all services except prescription drugs if you use
the Plan providers and follow Plan rules.
2003 Health Alliance HMO 44 Section 9 47.
47 Page 48 49
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare
Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claim will be coordinated automatically, and we will then provide secondary benefits for covered charges. You will not need to do anything.

To find out if you need to do something to file your claim, call us at 1-800-851-3379.

We waive some costs if the Original Medicare Plan is your primary payer--We will waive some out-of-pocket costs, as follows:
Medical services and supplies provided by physicians and other health care
professionals. If you are enrolled in Medicare Part B, we will waive copayments and coinsurance.

(Primary payer chart begins on next page.)

2003 Health Alliance HMO 45 Section 9 48.
48 Page 49 50
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

OriginalMedicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability)

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

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

2003 Health Alliance HMO 46 Section 9 49.
49 Page 50 51

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

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

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

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

If you do not enroll in Medicare Part A or Part B

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

2003 Health Alliance HMO 47 Section 9 50.
50 Page 51 52
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines

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

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

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

your care
We do not cover services and supplies when a local, State or Federal Government Agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

2003 Health Alliance HMO 48 Section 9 51.
51 Page 52 53
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care means services designed to help beneficiaries meet the needs of daily living whether they are disabled or not. These services include help in: a) walking or
getting in and out of bed; b) personal care such as bathing, dressing, eating, preparing special diets; and/ or c) taking medication which the beneficiary would normally be able
to take without help. Custodial care that lasts 90 days or more is sometimes known as long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 12.
The Plan considers factors which it determines to be most relevant under the circumstances, such as published reports and articles in the authoritative medical,
scientific and peer review literature, or written protocols used by the treating facility or being used by another facility studying substantially the same drug, device or medical
treatment. This Plan also considers federal and other government agency approval as essential to the treatment of an injury or illness by but not limited to the following:
American Medical Association, U. S. Surgeon General, U. S. Department of Public Health, the Food and Drug Administration or the National Institutes of Health.

Experimental or investigational services

Group health coverage Any group arrangement that provides a member with hospital, medical, surgical or dental benefits and that consists of employer-sponsored group insurance, association sponsored
group prepayment coverage, coverage under labor-management trusteed plans, employer organization plans, or employee benefit organizations.

Medical necessity A service or supply which is required to identify or treat a member's condition and is:

appropriate and necessary for and consistent with, the symptom or diagnosis and treatment or distinct improvement of an illness or injury; and
adequate and essential for the evaluation or treatment of a disease, condition or illness; and
can reasonably be expected to improve the member's condition or level of functioning; and
conforms with standards of good medical practice, uniformly recognized and professionally endorsed by the general medical community at the time it is provided;
and not mainly for the convenience of the member, a physician or other provider; and

the most appropriate medical service, supply or level of care, which can safely be provided to the member as an outpatient.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our
2003 Health Alliance HMO 49 Section 10 52.
52 Page 53 54
allowance based on the reasonable and customary charge. Preferred providers accept the Plan allowance as payment in full.
Us/ We Us and we refer to Health Alliance Medical Plans.
You You refers to the enrollee and each covered family member.

2003 Health Alliance HMO 50 Section 10 53.
53 Page 54 55

Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you enrolled limitation in this Plan solely because you had the condition before you enrolled.

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

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

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

Types of coverage ava