Pages 1--60

For changes in benefits
see page 8.

Serving: The Greater Des Moines, Central Iowa, Waterloo, Sioux City, and Cedar Rapids area.

Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
SV1 Self Only SV2 Self and Family

RI 73-186 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

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

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), .
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected, . To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and

. Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
. To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our
assistance regarding a benefit or customer service issue. . To review, make a decision, or litigate your disputed claim.

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

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.
By law, you have the right to:
. See and get a copy of your personal medical information held by OPM. .
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical

information. . Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover
your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O.
Box instead of your home address). 3.
3 Page 4 5

. 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.
4 Page 5 6
Table of Contents
Introduction. ........................................................................................ 5
Plain Language ....................................................................................................................................................................................... 5
Stop Health Care Fraud! ......................................................................................................................................................................... 5
Section 1. Facts about this HMO plan ................................................................................................................................................... 7
How we pay providers .......................................................................................................................................................... 7
Your Rights........................................................................................................................................................................... 7
Service Area.......................................................................................................................................................................... 7
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
. Physician care................................................................................................................................................................. 9
. Specialty care.................................................................................................................................................................. 9
. Hospital care ................................................................................................................................................................. 10
Circumstances beyond our control ...................................................................................................................................... 10
Services requiring our prior approval.................................................................................................................................. 10
Section 4. Your costs for covered services .......................................................................................................................................... 11
. Copayments .................................................................................................................................................................. 11
. Deductible..................................................................................................................................................................... 11
. Coinsurance .................................................................................................................................................................. 11
Your out-of-pocket maximum for coinsurance ................................................................................................................... 11
Your catastrophic protection out-of-pocket maximum....................................................................................................... 11
Section 5. Benefits ............................................................................................................................................................................... 12
Overview............................................................................................................................................................................. 12
(a) Medical services and supplies provided by physicians and other health care professionals .................................... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................. 21
(c) Services provided by a hospital or other facility, and ambulance services .............................................................. 26
(d) Emergency services/ accidents.................................................................................................................................. 29
(e) Mental health and substance abuse benefits ............................................................................................................. 31
(f) Prescription drug benefits......................................................................................................................................... 33

2003 Coventry Health Care of Iowa, Inc. 2 Table of Contents 5.
5 Page 6 7
(g) Special features ....................................................................................................................................................... 35
. Services for deaf and hearing impaired
. High risk pregnancies
. Centers of Excellence
. Travel benefits/ services overseas
(h) Dental benefits.......................................................................................................................................................... 36
(i) Non-FEHB benefits available to Plan members....................................................................................................... 37
Section 6. General exclusions --things we don't cover........................................................................................................................ 38
Section 7. Filing a claim for covered services ..................................................................................................................................... 39
Section 8. The disputed claims process................................................................................................................................................ 41
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 43
When you have other health coverage ................................................................................................................................ 43
What is Medicare ................................................................................................................................................................ 43
. The original Medicare Plan (Part A or Part B)............................................................................................................. 43
. Medicare managed care plan ....................................................................................................................................... 46
. If you do not enroll in Medicare Part A or Part B........................................................................................................ 46
TRICARE and CHAMPVA................................................................................................................................................ 46
Workers' Compensation ...................................................................................................................................................... 46
Medicaid ............................................................................................................................................................................ 47
Other Government agencies................................................................................................................................................ 47
When others are responsible for injuries............................................................................................................................. 47
Section 10. Definitions of terms we use in this brochure...................................................................................................................... 48
Section 11. FEHB facts ........................................................................................................................................................................ 49

. No pre-existing condition limitation .......................................................................................................................... 49
. Where you get information about enrolling in the FEHB Program............................................................................ 49
. Types of coverage available for you and your family................................................................................................ 49
. Children's Equity Act ............................................................................................................................................... 49
. When benefits and premiums start ............................................................................................................................. 50
. When you retire.......................................................................................................................................................... 50
When you lose benefits ..................................................................................................................................................... 50
. When FEHB coverage ends ....................................................................................................................................... 50
. Spouse equity coverage.............................................................................................................................................. 50
. Temporary Continuation of Coverage (TCC) ............................................................................................................ 50
. Converting to individual coverage ............................................................................................................................. 51
. Getting a Certificate of Group Health Plan Coverage................................................................................................ 51

2003 Coventry Health Care of Iowa, Inc. 3 Table of Contents 6.
6 Page 7 8
Long term care insurance is still available............................................................................................................................................ 52
Index ......................................................................................................................................................................................... 53
Summary of benefits ............................................................................................................................................................................. 54
Rates ....................................................................................................................................................................................... Back cover

2003 Coventry Health Care of Iowa, Inc. 4 Table of Contents 7.
7 Page 8 9

Introduction
This brochure describes the benefits of Coventry Health Care of Iowa, Inc. under our contract (CS 1983) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.

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 xx. Rates are shown at the end of this brochure.

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

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

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

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

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

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your
doctor, other provider, or authorized plan or OPM representative. . Let only the appropriate medical professionals review your medical record or recommend services.

. 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:

2003 Coventry Health Care of Iowa, Inc. 5 Introduction/ Plain Language/ Advisory 8.
8 Page 9 10
. Call the provider and ask for an explanation. There may be an error. .
If the provider does not resolve the matter, call us at 800-257-4692 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.

2003 Coventry Health Care of Iowa, Inc. 6 Introduction/ Plain Language/ Advisory 9.
9 Page 10 11

Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

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

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.
. Coventry Health Care of Iowa, Inc. came together officially on January 1, 2000. Formerly it was known as Principal Health Care
of Iowa, Inc.

If you want more information about us, call 800/ 257-4692 or write to 4600 Westown Parkway, Suite 200, West Des Moines, Iowa 50266-1099. You may also contact us by fax at 302/ 283-6786 or visit our website at www. chciowa. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: Benton, Black Hawk, Boone, Bremer, Clark, Dallas, Guthrie, Jasper, Linn, Lucas, Madison, Marion, Polk, Story, Woodbury, and Warren
counties. You may also enroll with us if you live in the following places: Hamilton, Mahaska, Marshall, and Poweshiek 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 move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

2003 Coventry Health Care of Iowa, Inc. 7 Section 1 10.
10 Page 11 12
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
. A Notice of the Office of Personnel Management's Privacy Practices is included. .
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage. . Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB

Program enrollment. . Program information on Medicare is revised.
. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
. We have changed to an Open Access Plan that does not require the selection of a Primary Care Physician (PCP). However,
members are still required to utilize our network and provider facilities.

. $10 Copay when going to any Network Provider for an office visit (Specialist, etc.).
. Chiropractic visits have been limited to 20 visits per calendar year.
. Copays will no longer apply to the Out-of-Pocket Maximum.
. Language regarding services requiring Prior Approval changed to: "Your Physician must obtain Prior Approval for the
following, but not limited to these services."

. Language regarding not covered services Hearing Services changed to: "Hearing aids and associated Audiometric services,
and bionics."

. Language regarding Home Health Services changed to: "Home Health care ordered by a Plan Physician and provided by a
participating registered nurse, licensed practical nurse, licensed vocational nurse, or home health aide.

. Language regarding Orthopedic and Prosthetic devices changed to: "Foot Orthotics when prescribed by a Physician at a
participating provider. Not Covered: Shoes and Over-the-Counter Orthotics."

. Language regarding Organ/ Tissue Transplants changed to: "Note: If the recipient resides more than 150 Miles from the
transplant facility: Reimbursement for travel may be authorized. Lodging for one family member or responsible adult may be authorized. Lifetime limitation for travel and lodging as determined by Coventry Health Care and reviewed annually."

. Language regarding Ambulance changed to: "Local professional ambulance transport service to or from the nearest hospital
equipped to adequately treat your condition when medically appropriate."

. Language regarding Ambulance adding: "Not Covered: Services for non-emergency medical conditions."

2003 Coventry Health Care of Iowa, Inc. 8 Section 2 11.
11 Page 12 13
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 800-257-4692 or write to us at
4600 Westown Parkway, Suite 200, West Des Moines, Iowa 50266-1099. You may also request replacement cards through our website at www. chciowa. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file claims.
. Plan providers Plan providers are physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.
. 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.

. Physician care You and each family member do not need to choose a Primary Care Physician to arrange
your health care services. However, you must always seek care through Our Participating Network Physicians, unless you have prior plan approval.

What you must do to get covered care

. Specialty care Here are things you should know about specialty care:
. 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, 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 Physician 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 Physician 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.
2003 Coventry Health Care of Iowa, Inc. 9 Section 3 12.
12 Page 13 14
If you are in the second or third trimester of pregnancy and you lose access to your Physician based on the above circumstances, you can continue to see your Physician until
the end of your postpartum care, even if it is beyond the 90 days.
. Hospital care Your Plan Physician or Specialist will make necessary hospital arrangements and
supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-257-4692. If you are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
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. Your physician must obtain prior approval for the following services, but not limited to these services: Hospital Inpatient Admissions,
Outpatient Surgeries, Home Health Care, Home Infusion Services, Durable Medical Equipment, Outpatient Therapy (Physical, Occupational, Speech, and Manipulative
Services), Growth Hormone Therapy, and any Out of Network Services.

Services requiring our prior approval

2003 Coventry Health Care of Iowa, Inc. 10 Section 3 13.
13 Page 14 15
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 a Network Provider you pay a copayment of $10 per office visit.

. 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 50% of our allowance for infertility services and 20% of our allowance for durable medical equipment.

After your coinsurance total $750 per person or $1, 500 per family enrollment in any calendar year, you do not have to pay any more for covered services. However,
copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments for these services:
Your out-of-pocket maximum for coinsurance

. Pharmacy Benefits .
Office Visits

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

Your catastrophic protection out-of-pocket maximum We do not have a catastrophic protection out-of-pocket maximum.

2003 Coventry Health Care of Iowa, Inc. 11 Section 4 14.
14 Page 15 16
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 54 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 800-257-4692 or at our website at www. chciowa. com.

(a) Medical services and supplies provided by physicians and other health care professionals........................................................ 13-20
. 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 ................................................ 21-25
. Surgical procedures .
Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue transplants . Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services.............................................................................. 26-28
. Inpatient hospital
. Outpatient hospital or ambulatory surgical center
. Extended care benefits/ skilled nursing care facility benefits
. Hospice care .
Ambulance

(d) Emergency services/ accidents ................................................................................................................................................. 29-30 . Medical emergency . Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................ 31-32
(f) Prescription drug benefits ........................................................................................................................................................ 33-34
(g) Special features ............................................................................................................................................................................. 35

. Services for deaf and hearing impaired
. High risk pregnancies
. Centers of Excellence
. Travel benefit/ services overseas
(h) Dental benefits .............................................................................................................................................................................. 36
(i) Non-FEHB benefits available to Plan members ............................................................................................................................ 37
Summary of benefits ............................................................................................................................................................................. 54

2003 Coventry Health Care of Iowa, Inc. 12 Section 5 (Overview) 15.
15 Page 16 17
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office $10 per office visit

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

Nothing
Nothing
Nothing
$10 per office visit

Nothing

At home $10 per House Call by a Physician
Lab, X-ray and other diagnostic tests
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. Cat Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

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

2003 Coventry Health Care of Iowa, Inc. 13 Section 5 (a) 16.
16 Page 17 18
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol once every three years
. Colorectal Cancer Screening, including

Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

$10 per office visit

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$10 per office visit

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

$10 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, 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 and over

$10 per office visit

Preventive care, children
. Childhood immunizations recommended by the American Academy
of Pediatrics

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

. Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

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

$10 per office visit

.
.

.
.
.

2003 Coventry Health Care of Iowa, Inc. 14 Section 5 (a) 17.
17 Page 18 19
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).

$50 at the time of delivery. One copay per pregnancy.

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.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges.

2003 Coventry Health Care of Iowa, Inc. 15 Section 5 (a) 18.
18 Page 19 20
Infertility services You pay
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
. Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

50% of the allowable charges

Not covered:
. Infertility services after voluntary sterilization
. Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
. Services and supplies related to excluded ART procedures

. Cost of donor sperm
. Cost of donor egg

All charges.

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

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

. .
.

. .
.

2003 Coventry Health Care of Iowa, Inc. 16 Section 5 (a) 19.
19 Page 20 21
Treatment therapies You pay
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 24.
. Respiratory and inhalation therapy
. Dialysis hemodialysis and peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy Home IV and antibiotic
therapy

. Growth hormone therapy (GHT)
Note: We will only cover GHT for medically necessary conditions when we have preauthorized treatment. Such authorization must be

obtained through Health Services at 800-470-6352. See Services requiring our prior approval in Section 3.

$10 per office visit

Physical and occupational therapies
Covered from the original onset of the condition up to 60 days per condition for the services of each of the following:

. . qualified physical therapists and occupational therapists.

Note: These services are covered when determined by the plan to be medically necessary.
. Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to two months.

$10 per outpatient visit
Nothing per visit during covered inpatient admission

Not covered:
. Services after 60 days per condition
. Long-term rehabilitation therapy
. Exercise programs

All charges.

Speech therapy
Covered from the original onset of the condition up to 60 days per condition. $10 per Outpatient session; nothing per Inpatient visit

Not covered:
. Services after 60 days per condition
All charges.

2003 Coventry Health Care of Iowa, Inc. 17 Section 5 (a) 20.
20 Page 21 22
Hearing services (testing, treatment, and supplies) You pay
. First hearing aid and testing only when necessitated by accidental
injury

. Hearing testing for children through age 17 (see Preventive care,
children)

$10 per office visit

Not covered: . all other hearing testing
. hearing aids and associated Audiometric services and bionics,
testing and examinations for them

All charges.

Vision services (testing, treatment, and supplies)
. One Annual Eye Refraction (which includes the written lens
prescription) may be obtained from Plan Providers. Nothing to an Optometrist; $10 per office visit to an Ophthalmologist

. One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery (such as for cataracts) 20% of Allowable Charges

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

. Annual eye refractions Nothing to an Optometrist; $10 per office visit to an Ophthalmologist

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

. Eye exercises and orthoptics
. Radial keratotomy and other refractive surgery

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

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

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

All charges.

2003 Coventry Health Care of Iowa, Inc. 18 Section 5 (a) 21.
21 Page 22 23
Orthopedic and prosthetic devices You pay
. Artificial limbs and eyes; stump hose
. Foot Orthotics
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5( b) for coverage of the surgery

to insert the device.

20% of Allowable Charges

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 3 years after the last one
we covered

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:
. manual wheelchairs;
. manual hospital beds;
. crutches;
. walkers;
. blood glucose monitors; and
. insulin pumps.

20% of Allowable Charges

Not covered: . Motorized wheel chairs
. Convenience items or exercise equipment
All charges.

2003 Coventry Health Care of Iowa, Inc. 19 Section 5 (a) 22.
22 Page 23 24
Home health services You pay
. Home health care ordered by a Plan physician and provided by a
participating 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.

$10 per office visit; nothing by nurse or home health aide

Not covered: . Nursing care requested by, or for the convenience of, the patient or
the patient's family;
. Services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship, or giving oral medication.

All charges.

Chiropractic
Covered under alternative treatment.

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

. Note: Limited to 20 Visits Per Year

Not covered:
. services after 20 visits per year .
naturopathic services . hypnotherapy

. biofeedback .
acupuncture services

$10 per office visit
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 drugs.

. Diabetes self-management

Call us at 800-257-4692 for benefit restrictions and guidelines.

2003 Coventry Health Care of Iowa, Inc. 20 Section 5 (a) 23.
23 Page 24 25
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.
. We have no calendar year deductible..
. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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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 --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible members must be age 18 or over

. Insertion of internal prosthetic devices, such as pacemakers and
artificial joints. See 5( a) Orthopedic and prosthetic devices for device coverage information.

. Voluntary sterilization (e. g., Tubal ligation, Vasectomy) .
Treatment of burns

$10 per office visit
Nothing as an Inpatient

40% of allowable charges
$10 per office visit
Nothing as an Inpatient
Surgical procedures continued on next page.

2003 Coventry Health Care of Iowa, Inc. 21 Section 5 (b) 24.
24 Page 25 26
Surgical procedures (continued) You pay
Not covered: . Reversal of voluntary sterilization

. Routine treatment of conditions of the foot; see Foot care.
All charges.

Reconstructive surgery . Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

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

palate; birth marks; webbed fingers; and webbed toes.

$10 per office visit
Nothing as an Inpatient

. 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.

See above. $10 per office visit
Nothing as an Inpatient

.
.

.
.
.

2003 Coventry Health Care of Iowa, Inc. 22 Section 5 (b) 25.
25 Page 26 27
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: . Reduction of fractures of the jaws or facial bones;

. Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; . Removal of stones from salivary ducts;

. Excision of leukoplakia or malignancies; .
Excision of cysts and incision of abscesses when done as independent procedures; and

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

$10 per office visit
Nothing as an Inpatient

Not covered: . Oral implants and transplants
. Conservative or surgical treatment of Temporomandibular Joint
(TMJ) Syndrome . Procedures that involve the teeth or their supporting structures (such as

the periodontal membrane, gingiva, and alveolar bone)

All charges.

2003 Coventry Health Care of Iowa, Inc. 23 Section 5 (b) 26.
26 Page 27 28
Organ/ tissue transplants You pay
Limited to: A facility within the transplant network determined by
Coventry Health Care of Iowa, Inc.
. 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.

. National Transplant Program (NTP) -Limited Benefits -Treatment
for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical trial at a

Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

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

Note: If the recipient resides more than 150 miles from the transplant facility:
. Reimbursement for travel may be authorized. .
Lodging for one family member or responsible adult may be authorized.

. Lifetime limitation for travel and lodging as determined by
Coventry Health Care of Iowa, Inc. and reviewed annually.

Nothing as an Inpatient

Not covered: . Donor screening tests and donor search expenses, except those
performed for the actual donor . Implants of artificial organs

. Transplants not listed as covered

All charges.

2003 Coventry Health Care of Iowa, Inc. 24 Section 5 (b) 27.
27 Page 28 29
Anesthesia You pay
Professional services provided in
. Hospital (inpatient)
Nothing

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

. Office

Nothing

2003 Coventry Health Care of Iowa, Inc. 25 Section 5 (b) 28.
28 Page 29 30
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 with Medicare.

. The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center)
or ambulance service for your surgery or care. Any costs associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

. YOU 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; and .
meals and special diets.

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

Nothing

inpatient hospital continued on next page.

2003 Coventry Health Care of Iowa, Inc. 26 Section 5 (c) 29.
29 Page 30 31
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as: . Operating, recovery, maternity, and other treatment rooms

. Prescribed drugs and medicines .
Diagnostic laboratory tests and X-rays . Administration of blood and blood products

. Blood or blood plasma, if not donated or replaced .
Dressings, splints, casts, and sterile tray services . Medical supplies and equipment, including oxygen

. Anesthetics, including nurse anesthetist services .
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, convalescent
facilities, and schools . Personal comfort items, such as telephone, television, barber

services, guest meals and beds . Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
. Operating, recovery, and other treatment rooms .
Prescribed drugs and medicines . Diagnostic laboratory tests, X-rays, and pathology services

. Administration of blood, blood plasma, and other biologicals .
Blood and blood plasma, if not donated or replaced . Pre-surgical testing

. Dressings, casts, and sterile tray services .
Medical supplies, including oxygen . Anesthetics and anesthesia service

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

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges.
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit:
We cover a comprehensive range of benefits up to 62 days per calendar year when full-time skilled nursing is necessary and confinement in

a skilled nursing facility is medically appropriate as determined by a plan doctor and approved by the plan.

Nothing

Not covered: custodial care All charges.
2003 Coventry Health Care of Iowa, Inc. 27 Section 5 (c) 30.
30 Page 31 32
Hospice care You pay Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient care and family counseling; these services are provided under the
direction of the plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six
months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
. Local professional ambulance transport service to or from the
nearest hospital equipped to adequately treat your condition when medically appropriate Nothing

Not covered: Services for non-emergency medical conditions

2003 Coventry Health Care of Iowa, Inc. 28 Section 5 (c) 31.
31 Page 32 33
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.

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

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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 contact your doctor. In extreme emergencies, if you are unable to contact your
doctor, contact the local emergency room 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 must notify your doctor as soon as possible and/ or contact the Plan within 48 hours of the emergency room visit. It is your responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the plan must be notified within 48 hours or on the first working day following your admission, unless it is not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible and any ambulance charges are covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability, or significant jeopardy to your condition.
To be covered by this Plan, a follow-up care recommended by non-Plan providers must be approved by the Plan.
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers. You pay $50 copayment or 50% of the covered charges, whichever is less, per hospital emergency
room visit or $30 copayment per urgent care center visit for emergency services which are covered benefits of this Plan. The copayment or coinsurance will be waived if you are admitted as a result of your condition.

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. If you need to be hospitalized, you or a family member must notify the Plan within 48 hours or on

the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes that care can be better provided in a Plan hospital, you will be transferred when medically
feasible with any ambulance charges covered in full.

2003 Coventry Health Care of Iowa, Inc. 29 Section 5 (d) 32.
32 Page 33 34
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers. You pay a $50 copayment or 50% of covered charges, whichever is less, per hospital emergency room
visit for emergency services received at a non-Plan facility or doctor's office or urgent care center. The copayment or coinsurance will be waived if you are admitted to the hospital as a result of your condition.

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 at a hospital

$10 per office visit
$30 per visit
$50 per visit or 50% of allowable charges, whichever is less

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

$50 per visit or 50% of allowable charges, whichever is less

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
Local professional ambulance transport service to or from the nearest hospital equipped to adequately treat your condition when medically

appropriate.
Note: Air ambulance covered only when medically necessary
See 5( c) for non-emergency service.

Nothing

Not Covered: Services for non-emergency medical conditions All charges.
2003 Coventry Health Care of Iowa, Inc. 30 Section 5 (d) 33.
33 Page 34 35
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.

. We have no calendar year deductible.

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

. 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

$10 per office visit

Mental health and substance abuse benefits -continued on next page

2003 Coventry Health Care of Iowa, Inc. 31 Section 5 (e) 34.
34 Page 35 36
Mental health and substance abuse benefits (continued) You pay
. Diagnostic tests $10 per office visit of test

. Services provided by a hospital or other facility Nothing
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
All mental conditions/ substance abuse services are coordinated by American Psych Systems (APS). To access your mental conditions/ substance abuse benefits, call APS
directly at 1-800-752-7242.

2003 Coventry Health Care of Iowa, Inc. 32 Section 5 (e) 35.
35 Page 36 37
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.

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

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There are important features you should be aware of. These include:
. Who can write your prescription. A licensed physician must write the prescription
. Where you can obtain them. You may fill the prescription at a Plan pharmacy or by mail for a maintenance
prescription.

. We use a formulary. We have an open formulary. If your physician believes a name brand product is
necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower

cost. To order a prescription drug brochure, call 800-257-4692.
. These are the dispensing limitations. One Copayment is due each time a prescription is filled or refilled up
to a thirty-one (31) day supply. Maintenance drugs obtained through a mail order pharmacy designated by the Plan, may be dispensed with two (2) Copayments for up to a ninety-three (93) day supply. Drugs that are

not listed on the maintenance listing are not eligible for the mail order program.
If a brand name prescription drug is dispensed, and an equivalent generic prescription drug is available, you will pay an ancillary charge in addition to the formulary brand name copayment. The ancillary charge will

be due regardless of whether or not your physician indicates that the pharmacy is to "Dispense as written". The ancillary charge is the difference between the average wholesale price (AWP) of the brand name
prescription and the MAC price of the generic prescription. Call 800-257-4692 for additional questions.
. Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs.
The generic name of a drug is its chemical name, the name brand is the name under which the manufacturer advertises and sells a drug. Under Federal Law, generic and name brand drugs must meet the same standards

for safety, purity, strength, and effectiveness. A generic prescription costs you and us less than a name brand prescription

. When you have to file a claim. Participating pharmacies will file a claim for you.

2003 Coventry Health Care of Iowa, Inc. 33 Section 5 (f) 36.
36 Page 37 38
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:

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

. Insulin One Copayment per vial .
Disposable needles and syringes for the administration of covered medications

. Maintenance drugs .
Smoking cessation drugs, limited to ProStep, Habitrol, and Nicoderm patches. Call us for benefit restrictions and guidelines.

. Diabetic supplies, including insulin syringes, needles, glucose test
tablets and test tapes, Benedict's solution or equivalent, and acetone test tablets.

. Drugs to treat sexual dysfunction are limited to four tablets per
month. Prior approval is required by the Plan. (see Prior authorization below)

. FDA approved contraceptive drugs and devices

$5 per formulary generic drug and brand name insulin
$15 per formulary brand name drug
$30 per non-formulary drug

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

Fertility drugs Note: See Section 5 (b) for coverage of Norplant implementation and removal.
Note: Mail order drugs require two (2) copayments for up to a 93-day supply. 50% of the cost of the drug

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

All charges.

2003 Coventry Health Care of Iowa, Inc. 34 Section 5 (f) 37.
37 Page 38 39
Section 5 (g). Special features
Feature Description

Services for deaf and hearing impaired 1-877-843-1942, Extension 6979

High risk pregnancies Members identified as having high risk pregnancies will be assigned to a nurse within our organization who will work with them to monitor their care.
Centers of excellence Coventry Health Care of Iowa, Inc. utilizes a network of centers of excellence for transplant care.
Travel benefit/ services overseas Anytime you are outside of the service area, you and your covered dependents are always covered for true emergency situations.

2003 Coventry Health Care of Iowa, Inc. 35 Section 5 (g) 38.
38 Page 39 40
Section 5 (h). Dental benefits
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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 dentists must provide or arrange your care.
. We have no deductible.
. We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.

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

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. Prior authorization is required through your physician and the Plan.
20% of allowable charges

Dental benefits
We have no other dental benefits.

2003 Coventry Health Care of Iowa, Inc. 36 Section 5 (h) 39.
39 Page 40 41
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic
protection out-of-pocket maximums.

Discounts on eyeglasses and contacts: Coventry Health Care of Iowa, Inc. members receive a discount on their contact or eyeglasses at the following participating optometric locations: JC Penney Optical, Sears Optical,
Montgomery Ward Optical, Target, and Pearl Vision.
The Baby Beeper Program: During the last four weeks of pregnancy, Coventry Health Care of Iowa, Inc. members in the Des Moines area are provided a free baby beeper so that husbands or birthing coaches can be contacted
immediately when labor begins.
Health Club Discount Program: Fitness World West waived the enrollment fee and offers a reduced monthly rate to Coventry Health Care of Iowa, Inc. members.

2003 Coventry Health Care of Iowa, Inc. 37 Section 5 (i) 40.
40 Page 41 42
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
. Services, drugs, or supplies that are not medically necessary;
. Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric
practice;

. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the
fetus were carried to term or when the pregnancy is the result of an act of rape or incest

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

. Any over-the-counter items, medications or supplies.

2003 Coventry Health Care of Iowa, Inc. 38 Section 6 41.
41 Page 42 43
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 on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 800-257-4692.
When you must file a claim --such as for services you receive outside of the Plan's service area --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:
. Covered member's name and ID number;
. Name and address of the physician or facility that provided the service or supply;
. Dates you received the services or supplies;
. Diagnosis;
. Type of each service or supply;
. The charge for each service or supply;
. A copy of the explanation of benefits, payments, or denial from any primary payer --
such as the Medicare Summary Notice (MSN); and

. Receipts, if you paid for your services.

Submit your claims to: Coventry Health Care of Iowa, Inc.
P. O. Box 7709
London, KY 40742

Prescription drugs In most cases, participating pharmacies will file the claims for you. However, if you should need to file a claim for reimbursement (if you have to obtain a prescription out of
the area), receipts should be itemized and show:
. Covered member's name and ID Number;
. Name and Address of the dispensing pharmacy;
. Date the prescription was obtained; and
. Receipt reflecting that you paid for your prescription.

Submit your claims to: Caremark, Inc.
P. O. Box 686005
San Antonio, TX 78268-6005
2003 Coventry Health Care of Iowa, Inc. 39 Section 7 42.
42 Page 43 44
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 Coventry Health Care of Iowa, Inc. 40 Section 7 43.
43 Page 44 45
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: 4600 Westown Parkway, Suite 200, West Des Moines, IA 50266-1099; 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 Coventry Health Care of Iowa, Inc. 41 Section 8 44.
44 Page 45 46
The Disputed Claims process (Continued)
Send OPM the following information:
. A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
. Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and
explanation of benefits (EOB) forms;

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

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

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 800-257-4692 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 Coventry Health Care of Iowa, Inc. 42 Section 8 45.
45 Page 46 47
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
(Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,

or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

2003 Coventry Health Care of Iowa, Inc. 43 Section 9 46.
46 Page 47 48

Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
. When we are the primary payer, we process the claim first.
. When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do

anything. To find out if you need to do something to file your claim, call us at 800-257-4692 or visit our web-site at http:// www. chciowa. com.

We do not waive any costs if the Original Medicare Plan is your primary payer.
[Primary payer chart begins on next page.]

2003 Coventry Health Care of Iowa, Inc. 44 Section 9 47.
47 Page 48 49
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, or

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

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

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

(except for claims related to Workers'

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

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

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

2003 Coventry Health Care of Iowa, Inc. 45 Section 9 48.
48 Page 49 50

. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments 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 a one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.

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

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

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

2003 Coventry Health Care of Iowa, Inc. 46 Section 9 49.
49 Page 50 51
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 We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for for injuries 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 Coventry Health Care of Iowa, Inc. 47 Section 9 50.
50 Page 51 52
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 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care such as help walking, getting in and out of bed, bathing, dressing, shopping, preparing meals, or performing general household services. 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. We do not have
a deductible.

Deductible Any treatment, procedure, facility, equipment, drug or drug usage, device or supply that
is not accepted as standard medical practice by the general medical community or us, or does not have Federal government agency, approval for its use of application.
Experimental or investigational services

The Plan's experimental/ investigational determination process is based on authoritative information obtained from medical literature, medical consensus bodies, health care
standards, database searches, evidence from national medical organizations, State and Federal government agencies and research organizations. The review and approval
process for medical policies and clinical practice guidelines includes clinical input from doctors with specialty expertise in the subject.

Medical necessity A service or supply for prevention, diagnosis, or treatment that as determined by us, is, consistent with the illness or injury and is consistent with the approved, and generally
accepted medical or surgical practice.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Providers that participate with us agree to accept our Plan allowance as
payment in full, minus any copayment or coinsurance

Us/ We Us and we refer to Coventry Health Care of Iowa, Inc.
You You refers to the enrollee and each covered family member.

2003 Coventry Health Care of Iowa, Inc. 48 Section 10 51.
51 Page 52 53
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when
you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

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

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).

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

2003 Coventry Health Care of Iowa, Inc. 49 Section 11 52.
52 Page 53 54

Annotations

. If you have no FEHB coverage, your employing office will enroll you for Self and
Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,

. if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or

. if you are enrolled in an HMO that does not serve the area where the children live,
your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.

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

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

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

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

. Spouse equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's enrollment. This is the case even when the court has ordered your former spouse to supply health coverage to you. But,

you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation
of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM's website, www. opm. gov/ insure.
. Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
2003 Coventry Health Care of Iowa, Inc. 50 Section 11 53.
53 Page 54 55

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

. Converting to You may convert to a non-FEHB individual policy if:
individual coverage . Your coverage under TCC or the spouse equity law ends (If you canceled your

coverage or did not pay your premium, you cannot convert);
. You decided not to receive coverage under TCC or the spouse equity law; or
. You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.
. Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal
Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will

give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans. For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. See also the FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as
the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have
information about Federal and State agencies you can contact for more information.

2003 Coventry Health Care of Iowa, Inc. 51 Section 11 54.
54 Page 55 56

Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
. You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care
Insurance Program. . Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.

. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season. .
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

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

You Can Also Apply Later, But
. Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season
ends, but they will have to answer more health-related questions. . For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during

and after the Open Season.
You Must Act to Receive an Application
. Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request
one through the toll-free number or website listed below. . Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees

and their spouses, and the July 1 "age freeze"!
Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application.

2003 Coventry Health Care of Iowa, Inc. 52 Section 11 55.
55 Page 56 57
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 36 Allergy tests 16
Alternative treatment 20 Allogenetic (donor) bone marrow transplant 24
Ambulance 28 Anesthesia 25
Autologous bone marrow transplant 24 Biopsies 21
Birthing centers 15 Blood and blood plasma 27
Breast cancer screening 14 Casts 27
Catastrophic protection out-of-pocket maximum 11
Changes for 2003 8 Chemotherapy 17
Childbirth 15 Chiropractic 20
Cholesterol tests 14 Circumcision 15
Claims 39 Coinsurance 11
Colorect