Dean Health Plan, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--56

Page 1 2
Dean Health Plan, Inc. http:// www. deancare. com
2003

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

(HMO)
Enrollment codes for this Plan:
WD1 Self Only WD2 Self and Family

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

RI 73-189

For changes in benefits
see page 7 .

A Health Maintenance Organization 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).

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice. 3.
3 Page 4 5
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
2003 Dean Health Plan, Inc. 2
Table of Contents
Introduction. .................................................................................... 4
Plain Language............................................................................................................................................................................... 4
Stop Health Care Fraud!.................................................................................................................................................................. 4
Section 1. Facts about this HMO plan............................................................................................................................................. 6
How we pay providers ................................................................................................................................................... 6
Your Rights................................................................................................................................................................... 6
Service Area .................................................................................................................................................................. 6
Section 2. How we change for 2003 ............................................................................................................................................... 7
Program-wide changes................................................................................................................................................... 7
Changes to this Plan....................................................................................................................................................... 7
Section 3. How you get care .......................................................................................................................................................... 8
Identification cards ........................................................................................................................................................ 8
Where you get covered care........................................................................................................................................... 8

Plan providers.......................................................................................................................................................... 8
Plan facilities........................................................................................................................................................... 8
What you must do to get covered care............................................................................................................................ 8

Primary care............................................................................................................................................................ 8
Specialty care .......................................................................................................................................................... 8
Hospital care ........................................................................................................................................................... 9
Circumstances beyond our control.................................................................................................................................. 9
Services requiring our prior approval ........................................................................................................................... 10
Section 4. Your costs for covered services .................................................................................................................................... 11

Copayments........................................................................................................................................................... 11
Coinsurance........................................................................................................................................................... 11
Section 5. Benefits ....................................................................................................................................................................... 12
Overview..................................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals................................... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................... 22
(c) Services provided by a hospital or other facility, and ambulance services............................................................ 26
(d) Emergency services/ accidents............................................................................................................................ 28
(e) Mental health and substance abuse benefits ........................................................................................................ 30
(f) Prescription drug benefits .................................................................................................................................. 32
(g) Special features ................................................................................................................................................ 33
(h) Dental benefit ................................................................................................................................................... 35
Section 6. General exclusions --things we don't cover .................................................................................................................. 36
Section 7. Filing a claim for covered services ............................................................................................................................... 37 5.
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2003 Dean Health Plan, Inc. 3
Section 8. The disputed claims process......................................................................................................................................... 38
Section 9. Coordinating benefits with other coverage ................................................................................................................... 40
When you have other health coverage .......................................................................................................................... 40

What is Medicare.................................................................................................................................................. 40
Medicare managed care plan ................................................................................................................................ 42
TRICARE and CHAMPVA .................................................................................................................................. 42
Workers' Compensation ........................................................................................................................................ 43
Medicaid .............................................................................................................................................................. 43
Other Government agencies .................................................................................................................................. 43
When others are responsible for injuries ................................................................................................................ 43
Section 10. Definitions of terms we use in this brochure................................................................................................................ 44
Section 11. FEHB facts ................................................................................................................................................................ 45
Coverage information................................................................................................................................................. 45

No pre-existing condition limitation .................................................................................................................... 45
Where you get information about enrolling in the FEHB Program........................................................................ 45
Types of coverage available for you and your family ........................................................................................... 45
Children's Equity Act. 45
When benefits and premiums start ....................................................................................................................... 46
Your medical and claims records are confidential ................................................................................................ 46
When you retire .................................................................................................................................................. 46
When you lose benefits .............................................................................................................................................. 46

When FEHB coverage ends................................................................................................................................. 46
Spouse equity coverage ....................................................................................................................................... 46
Temporary Continuation of Coverage (TCC) ....................................................................................................... 46
Converting to individual coverage ....................................................................................................................... 47
Getting a Certificate of Group Health Plan Coverage ........................................................................................... 47 Long term care insurance is still available ..................................................................................................................................... 48

Index ................................................................................................................................................................................ 49
Summary of benefits..................................................................................................................................................................... 50
Rates .............................................................................................................................................................................. Back cover 6.
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2003 Dean Health Plan, Inc. 4 Section 2
Introduction
This brochure describes the benefits of Dean Health Plan under our contract (CS 1996) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Dean Health Plan administrative offices is:
Dean Health Plan 1277 Deming Way
Madison WI 53717
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 pages 7. Rates are shown at the end of this brochure.

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

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 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 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. 7.
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2003 Dean Health Plan, Inc. 5 Section 2
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800-279-1301 and explain the situation.
If we do not resolve the issue:

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

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 8.
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2003 Dean Health Plan, Inc. 6 Section 2
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.
Dean Health Plan Inc. is for-profit HMO, and has been is business since 1983. If you want more information about us, call 800-2719-1301, or write to Dean Health Plan, Attention Customer Service, 1277 Deming Way Madison WI 53717.

You may also contact us by fax at 608-827-4152 or visit our website at www. deancare. 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: Columbia, Crawford, Dane, Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Lafayette, Marquette, Racine,
Richland, Rock, Sauk, Vernon, Waukesha, and Walworth counties in Wisconsin.
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. 9.
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2003 Dean Health Plan, Inc. 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes

We changed the address for sending disputed claims to OPM. (Section 8)
A Notice of the Office of Personnel Management's Privacy Practices is included. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

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

Changes to this Plan
Your share of the non-Postal premium will increase by 7.4% for Self Only or -2.5% for Self and Family.
Hospital Emergency Room visit is now covered with a $75 copay (not waived if admitted).

Durable Medical Equipment is covered with a 25% coinsurance per purchase or rental.
CAT scans have a $50 member copay.
MRI have a $150 member copay when performed outpatient.
You pay $10 generic, 30% brand copay under the prescription drug benefit 30% brand copay up to $1,500 brand drug out of pocket maximum per member per contract year; $10 copay applies thereafter.

Physical, Speech & Occupational Therapy are covered up to 50 visits per member per year. A 20% coinsurance on each visit.
A new service area expansion Green, Vernon and Juneau counties. 10.
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2003 Dean Health Plan, Inc. 8 Section 3
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 800-279-1301 or write to us at
1277 Deming Way Madison WI 53717. You may also request r replacement cards through our website www. deancare. 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 NCQA and Dean Health Plan standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website. Provider updates are also included in the quarterly mailing to all
members in the Notables newsletter

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.
It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. When you enroll, you (and your family members) must chose a primary care physician. Each member of your family may select
a different primary care physician. Your primary care physician must be a doctor who practices a general scope of medicine. A physician who specializes in only one area of
medicine would not be able to treat all of your basic health care needs.

Primary care The following types of physician can be a primary care physician for you: Family Practice doctors treat people of all ages. They focus on family health problems. General
Practice doctors treat people of all ages. Pediatric doctors treat children and adolescents, and generally manage their health. Internal Medicine doctors treat adult men and women.
Obstetrics and Gynecology doctors manage a woman's care during pregnancy and childbirth. They also treat conditions unique to females. Your primary care physician will
provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will arrange your referral to a specialist for needed care. You may also seek services from other Plan providers, including specialists, located at
the same clinic as your primary care physician, without a referral. Written referrals are not required for the following types of services when provide by a Dean Health Plan
Provider: MRI (Magnetic Resonance Imaging), Diagnostic tests & respiratory therapy, Home Health, Oral Surgery for covered procedures, Routine vision care, and Chiropractic
care.
Here are other things you should know about specialty care:

What you must do to get covered care 11.
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2003 Dean Health Plan, Inc. 9 Section 3
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your
treatment plan (the physician may have to get an authorization or approval beforehand).

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-279-1301. If you are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care. 12.
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2003 Dean Health Plan, Inc. 10 Section 3
Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain prior authorization before sending you to a hospital, referring you to a non-plan provider
or facility, or recommending follow up care.
We will provide benefits for covered services only when the services are medically necessary to prevent, diagnose, or treat your illness or condition.

Services requiring our prior approval 13.
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2003 Dean Health Plan, Inc. 11 Section 5
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing per admission.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of actual charges for diagnosis and treatment of infertility services, and 25% of charges for orthopedic services, prosthetic devices, lenses
following cataract removal, and durable medical equipment. 14.
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2003 Dean Health Plan, Inc. 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 50 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 800-279-1301website at www. deancare. com

a) Medical services and supplies provided by physicians and other health care professionals .................................................... 13-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children Maternity care

Family planning Infertility services
Allergy care Treatment therapies
Physical and occupational therapies

Speech therapy Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices

Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs
b) Surgical and anesthesia services provided by physicians and other health care professionals............................................... 22-25

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants Anesthesia

c) Services provided by a hospital or other facility, and ambulance services ........................................................................... 26-27
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
d) Emergency services/ accidents........................................................................................................................................ 28-29
Medical emergency Ambulance

e) Mental health and substance abuse benefits ....................................................................................................................... 30-31
f) Prescription drug benefits................................................... ....... 32-34
g) Special features ..................................................................................................................................................................... 35
Dean On Call

h) Dental benefits....................................................................................................................................................................... 35
Summary of benefits..................................................................................................................................................................... 50 15.
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2003 Dean Health Plan, Inc. 13 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
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 You Pay
Professional services of physicians
In physician's office

$10 per office visit

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

$10 per office visit

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Ultrasound
Electrocardiogram and EEG

Nothing

CAT Scan $50 copay
MRI $150 copay 16.
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2003 Dean Health Plan, Inc. 14 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as annual physical:
Total Blood Cholesterol
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

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

$10 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit 17.
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2003 Dean Health Plan, Inc. 15 Section 5( a)
Well-child care charges for routine examinations, immunizations and care (through age 17)
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 17)

$10 per office visit

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 xx for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical
benefits, not maternity benefits apply to circumcision.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

$10 per office visit

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 18.
18 Page 19 20
2003 Dean Health Plan, Inc. 16 Section 5( a)
Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI) -intracervical insemination (ICI)

-intrauterine insemination (IUI) Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. Coverage for
infertility services is limited to one diagnostic treatment per member per lifetime.

$10 per office visit

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

-Zygote transfer Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 19.
19 Page 20 21
2003 Dean Health Plan, Inc. 17 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

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

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when your primary care provider prior authorizes the treatment.

$10 per office visit

Physical and occupational therapies
Inpatient or outpatient basis for a combined 50 visits per condition if significant improvement can be expected with in two months for the
services of each of the following:
-qualified physical therapists and -occupational therapists.

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.
Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other
activities of daily living.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction. Phase II treatment must begin within 90

days of surgery.

20% coinsurance

Not covered:
long-term rehabilitative therapy
exercise programs

All charges

Speech therapy
Inpatient or outpatient basis for a combined 50 visits per condition when medically necessary. 20% coinsurance 20.
20 Page 21 22
2003 Dean Health Plan, Inc. 18 Section 5( a)
Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

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

$10 per office visit

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

Vision services (testing, treatment, and supplies) You pay
In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye, annual eye refractions

(which include the written lens prescription for eyeglasses)
$10 per office visit

Eye exam to determine the need for vision correction $10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$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. 21.
21 Page 22 23
2003 Dean Health Plan, Inc. 19 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

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

NOTE: Purchases exceeding $200 per month must be authorized by the plan's Medical Director. Your plan doctor will obtain the prior
authorization.

25% of the charges per purchase or rental

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

prosthetic replacements provided less than 3 years after the last one we covered

All charges. 22.
22 Page 23 24
2003 Dean Health Plan, Inc. 20 Section 5( a)
Durable medical equipment (DME)
NOTE: Medical supplies and equipment are covered when prescribed by your plan physician for treatment of a diagnosed illness or injury. The

supplies or equipment must be purchased from a plan durable medical equipment provider.

NOTE: Purchases exceeding $200 per month or rentals exceeding $200 per month must be authorized by the plan's Medical Director. Your plan
doctor will obtain the prior authorization.
hospital beds;
wheelchairs; (requires prior authorization by our health services department)

crutches, splints, trusses, orthopedic braces, and appliances
walkers;
blood glucose monitors; and
insulin pumps.
TENS unit;
Oxygen therapy and other inhalation therapy and related items for home use must be prior authorized by the Health Services Department

Rental of a ventilator or other mechanical equipment or purchase of such equipment at the option of Dean Health Plan
Note: Call us at 800-279-1301 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell
you durable medical equipment at discounted rates and will tell you more about this service when you call.

25% pf the charges per purchases or rental

Not covered:
Repairs and replacement of durable medical equipment/ supplies unless they are prior authorized by the Health Services Department

Elastic support stockings (e. g., TEDS, JOBST, etc.) Shoes or orthotics that are not custom made and can be purchased
over the counter.
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or

rehabilitative.
Medical supplies and durable medical equipment for comfort, personal hygiene, and convenience such as, but not limited to: air

conditioners, air cleaners, humidifiers, physical fitness equipment, physician's equipment, disposable supplies, alternative
communication devices, and self-help devices not medical in nature.
Home testing and monitoring supplies and related equipment except those used in connection with the treatment of diabetes,

Equipment, models or devices that have features over the above that which is medically necessary. Coverage will be limited to the
standard model as determined by Dean Health Plan.
Any durable medical equipment or supplies used for work, athletic or job enhancement.

All charges. 23.
23 Page 24 25
2003 Dean Health Plan, Inc. 21 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

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

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

All charges.

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

$10 per office visit

Alternative treatments
No Benefits All charges.

Educational classes and programs
Coverage is limited to:

Smoking Cessation Limited coverage available in the following programs:

Group Counseling
Self-Direct Kit
Internet Program
Telephonic Program
NOTE: Please call us at 800-279-1301 for details on each of the above options

$100 per member per lifetime through program
Zyban is covered for a 2-month supply under this program, You pay a 30% brand
name coinsurance. See prescription drug benefits. 24.
24 Page 25 26
2003 Dean Health Plan, Inc. 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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.).

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

Nothing

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

$10 per office visit

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

All charges. 25.
25 Page 26 27
2003 Dean Health Plan, Inc. 23 Section 5( b)
Reconstructive surgery You Pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

-the condition produced a major effect on the member's appearance and

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

Nothing

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.

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

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

All charges. 26.
26 Page 27 28
2003 Dean Health Plan, Inc. 24 Section 5( b)
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.
Diagnostic procedures and medically necessary surgical or non-surgical treatment for the correction of temporomandibular disorders
(TMD) if all of the following apply:
The condition is caused by congenital, developmental or acquired deformity, disease or injury.

Under the accepted standards of the profession of the health care provider rendering the service, the procedure or device is
reasonable and appropriate for the diagnosis or treatment of this condition.

The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction. This includes coverage for
prescribed intra oral splint therapy devices. All services must be prior authorized by the Health Services Department, and provided
by a plan provider designated by us to treat TMD.

$10 per office visit

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

the periodontal membrane, gingiva, and alveolar bone)

All charges. 27.
27 Page 28 29
2003 Dean Health Plan, Inc. 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and

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

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

Nothing

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

Implants of artificial organs
Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in
Hospital (inpatient)
Nothing

Professional services provided in
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office

Nothing 28.
28 Page 29 30
2003 Dean Health Plan, Inc. -26 -
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).

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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.

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

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year deductible applies.)
NOTE: Inpatient dental procedures limited benefit. Hospitalization for certain procedures is covered when a Plan doctor determines there is
a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of
the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heat
disease; the need for anesthesia, by itself, is not a condition. The Plan will not cover the cost of the professional dental services.

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. 29.
29 Page 30 31
2003 Dean Health Plan, Inc. -27 -
Inpatient hospital (continued) You pay
Not covered:
Custodial care Non-covered facilities, such as nursing homes, schools

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

All charges.

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

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: The plan provides a comprehensive range of benefits for up to 120 days per benefit period when full-time skilled

nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and
approved by the Plan.
All necessary services are covered, including:

Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a Plan doctor.

Hospice Care

Nothing

Not covered: custodial care All charges.
Hospice care
See above-Extended Care Benefits Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate (ground or air) Nothing 30.
30 Page 31 32
2003 Dean Health Plan, Inc. -28 -
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.

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

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation please call your primary care doctor. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the plan. You
or a family member should be notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been notified.

If you need to be hospitalized in a non-Plan facility, the Plan should be notified within 48 hours following; your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilitie and Plan
doctors believe care is better provided in Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
Any follow up care recommended by non-Plan providers must be prior authorized by the Plan, or provided by Plan providers.
Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

You pay a $75 copayment per hospital emergency room visit.
Emergencies outside our service area:
Benefits are available for any medically necessary health services that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan should be notified within 48 hours following your admission, unless it was not reasonably possible to notify the Plan within that time. If a plan believes you can be better provided in a Plan hospital, you
will be transferred when medically feasible with any ambulance charges covered in full.

Any follow care recommended by non-Plan providers must be prior authorized by the plan, or provided by plan providers. 31.
31 Page 32 33
2003 Dean Health Plan, Inc. -29 -
Plan pay reasonable charges for emergency care services to the extent the services would have been covered in received from Plan providers.
You pay a $75 copayment per hospital emergency room visit.

Emergency within our service area
Emergency care at a doctor's office

Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$10 per office visit
$10 per office visit

$75 per hospital emergency room visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$10 per office visit
$10 per office visit
$75 per hospital emergency room visit

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

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

All charges.

Ambulance
Professional ambulance service when medically appropriate. (ground or air). See 5( c) for non-emergency service. Nothing 32.
32 Page 33 34
2003 Dean Heath Plan, Inc. 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

Mental health and substance abuse benefits (continued)
Diagnostic tests Nothing 33.
33 Page 34 35
2003 Dean Heath Plan, Inc. 31 Section 5( e)
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:
If you are seeking care from a mental health or substance abuse provider at the same clinic as your primary car provider, no referral is needed. Your provider will need to file a treatment plan with us for prior approval for ongoing treatment.
If you are seeking care outside your primary care provider or clinic, you must obtain a referral from your primary care provider before receiving services. On your behalf, your provider must submit referral request (and treatment plan if applicable) to us for
prior approval. WE will provide written confirmation to the provider if approval is given for the services. For information on available plan providers or status of a referral, please contact Customer Service at 800-279-1301.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2003 Dean Heath Plan, Inc. 32 Section 5( e)
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.

Certain prescription drugs included in our formulary require prior authorization. The drug prior authorization process can be initiated by your Plan physician or your plan pharmacy by filling out a Drug Prior Authorization
Request form. A copy of this request including the determination will then be mailed to you, your plan pharmacy, and plan physician. Updates to our drug formulary are provided in Notables, our quarterly news
magazine sent to the member's home. Members may also obtain a listing by calling our Customer Service Department at 800-279-1301.

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There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or referral doctor must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy or national plan pharmacy.

We use a formulary. Prescription drugs are included in our formulary by our plan Pharmacy and Therapeutics Committee to ensure that our members receive safe, effective treatment at a reasonable cost.
The committee is staffed by providers from may different specialties. Drugs recently approved by the Food and Drug Administration are not automatically included in the formulary but may be added after the
committee determines therapeutic advantages of the drug and its medically appropriate application. In addition, certain drug products are excluded when therapeutic alternatives are available. If your physician
prescribes a drug that is not on our formulary, the physician must obtain prior authorization from the plan in order for the prescription to be covered under plan benefits. In some cases, the physician will need to
prescribe an alternative formulary drug if an alternative is available that is equally effective for the patient form treatment of the specific condition. To order a listing of the drugs that require prior authorization or are
excluded, call our Customer Service Department at 800-279-1301.
These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply, whichever is

less; 240 milligrams of liquid (8oz); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i. e., one inhaler, one vial opthamolic medication or insulin). You pay $10 copay
per prescription unit or refill for generic drugs and 30% coinsurance for name brand drugs when generic substitution is not permissible. When generic substitution is available, a generic equivalent will be
dispensed, unless your physician specifically requires a name brand. If you received a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispensed as
Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a
name-brand drug.

When you have to file a claim. If you receive a prescription outside of the area or a situation arises where the pharmacy cannot process a prescription under the plan, you may submit an itemized receipt to us for
reimbursement for all covered prescription drugs. Send the receipt to: Dean Health Plan, 1277 Deming Way, Madison, WI 53717. 35.
35 Page 36 37
2003 Dean Heath Plan, Inc. 33 Section 5( e)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase.
Insulin, with a copay charge applied to each vial. Disposable needles and syringes for the administration of covered
medications
Drugs for sexual dysfunction (see Prior authorization below) Oral and injectable contraceptive drugs up tot a 30 day supply;

contraceptive diaphragms.
Diabetic supplies, including disposable needles and syringes needed for injecting the covered prescribed medication, glucose

test tablets and test tape, Benedict's solution or equivalent and acetone test tablets; a copay will apply for each item purchased.

$10 per generic prescription
30% per name brand prescription
30% brand copay up to $1,500 brand drug out of pocket maximum per member per

contract year: $10 copay applies thereafter.
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.

Infertility drugs and growth hormones: you pay 50% of the cost of the prescription unit or refill. 50% of the cost
Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
Zyban is covered for one 2-month supply under the brand name prescription drug benefit through the Smoking Cessation program. 30% coinsurance
NOTE: (Limited Benefits): Drugs to treat sexual dysfunction are limited. Contact the plan for does limits. You pay 50% copay up to the doses limit
and all changes above that.
Here are some things to keep in mind about out prescription drug program.

A generic equilivant will be dispensed if it is available, unless your physician specifically required a name brand. If you receive a
name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispensed a
Written for the brand drug, you have to pay the difference in cost between the name brand drug and the generic.

We administer a closed 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 drug that
we selected to meet patient needs at a lower cost. To order a listing of the drugs that require prior authorization or are excluded, call
our Customer Service Department at 800-279-1301.

Covered medications and supplies --continued on next page 36.
36 Page 37 38
2003 Dean Heath Plan, Inc. 34 Section 5( e)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines

All charges. 37.
37 Page 38 39
2003 Dean Health Plan, Inc. 35 Section 5( h)
Section 5 (g). Special features
Feature Description

24 hour nurse line Dean on Call. For any of your health concerns, 24 hours a day, 7 days a week, you may call 800-576-8773 and talk with a registered nurse who will discuss treatment options and answer your health questions.

Section 5 (h). Dental benefits
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Plan dentists must provide or arrange your care.
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 for impatient hospital benefits.

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

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

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

result from an accidental injury.
Nothing

Dental benefits
We have no other dental benefits. 38.
38 Page 39 40
2003 Dean Health Plan, 2003 36 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition and we agree, as discussed under What Services Require Our Prior Approval on page 9.
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 ;

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. 39.
39 Page 40 41
2003 Dean Health Plan, Inc. 37 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, 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 800-279-1301.
When you must file a claim --such as for services you received 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: 1277 Deming Way, Madison WI 53717

Prescription drugs Send your prescription drug receipts to the address noted above.
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 40.
40 Page 41 42
2003 Dean Health Plan, Inc. 38 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 1277 Deming Way, Madison WI 53171; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 41.
41 Page 42 43
2003 Dean Health Plan, Inc. 39 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year 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 800-279-1301 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 42.
42 Page 43 44
2003 Dean Health Plan, Inc. 40 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our reasonable charge. After the primary plan pays, we will pay either what is left of the reasonable charge or our regular
benefit, whichever is less. We will not pay more than our reasonable charge. If we are the secondary payer, we may be entitled to received payment from your primary plan.

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you

should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

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

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.

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. Tell us if you or a family member is
enrolled in Medicare Part A and B. Medicare will determine who is responsible for paying for medical services and we will coordinate the payments. On occasion you may
need to file a Medicare claim form.

The Original Medicare Plan (Part A or Part B) 43.
43 Page 44 45
2003 Dean Health Plan, Inc. 41 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora family member are eligible for Medicare solely because of a disability),

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 44.
44 Page 45 46
2003 Dean Health Plan, Inc. 42 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find

out if you need to do something to file your claim, call us at 800-279-1301.

We do not waive any costs when you have Medicare.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may not enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan.

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, but we will not waive any of our copayments, 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.

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,

If you do not enroll in Medicare Part A or Part B 45.
45 Page 46 47
2003 Dean Health Plan, Inc. 43 Section 9
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.

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 medical or hospital for injuries 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. 46.
46 Page 47 48
2003 Dean Health Plan, Inc. 44 Section 10
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 The type of care given when the basic goal is to help a person in the activities of daily life. This includes help in walking; getting in and out of bed, bathing, dressing, eating,
using the toilet, preparing special diets, taking medications properly and 24 hour supervision for potentially unsafe behavior. Such care is custodial when it does not
require continued attention by trained medical personnel. Such care is custodial even if provided by registered nurses, licensed practical nurses, or other trained medical
personnel. Custodial care that lasts 90 days or more is sometimes known as Long term care.

We regularly evaluate new medical devices, new techniques, and new uses for older existing procedures. This process is both proactive and reactive. Health care experts in
the Dean organization, including physician, and specialty providers, review and evaluate all pertinent information. If new technology is approved, procedures and policies are
revised or established to implement this decision.

Medical necessity The services or supplies provided by a hospital, or plan provider (or a non-plan provider if there is an authorized referral requested or in an emergency or urgent care situation) that
are required to identify or treat a member's illness or injury as which, as determined by the Health Services Department, are: (a) consistent with the illness or injury; (b) in accordance
with generally accepted standards of acceptable medical practice; (c) not solely for the convenience of a member, hospital, plan provider, or other provider; and (d) the most
appropriate supply or level of services that can be safely provided to the member.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.

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

Experimental or investigational services 47.
47 Page 48 49
2003 Dean Health Plan, Inc. 45 Section 11
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: 48.
48 Page 49 50
2003 Dean Health Plan, Inc. 46 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option,
if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment

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

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

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

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

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

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

when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or
Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage
choices. You can also download the guide from OPM's website, www. opm. gov/ insure.

Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment

after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc. 49.
49 Page 50 51
2003 Dean Health Plan, Inc. 47 Section 11
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
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. 50.
50 Page 51 52
2003 Dean Health Plan, Inc. 48 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe 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. 51.
51 Page 52 53
2003 Dean Health Plan, Inc. 49 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 35 Allergy tests 16