Capital Health Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--64

Page 1 2
Capital Health Plan http:// www. capitalhealth. com
A Health Maintenance Organization

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

Enrollment codes for this Plan:
EA1 Self Only
EA2 Self and Family

2003
For changes
in benefits
see page 8.

RI 73-197
August 14, 2001 -June 26, 2003
This Plan has "Excellent" accreditation
from NCQA. See the 2003 Guide for
more information on NCQA. 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. 3.
3 Page 4 5
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
Capital Health Plan 2 Table of Contents
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
Who provides my health care? ................................................................................................................................................... 6
Your Rights ................................................................................................................................................................................... 6
Service Area.................................................................................................................................................................................. 6
Section 2. How we change for 2003.............................................................................................................................................................. 8
Program-wide changes.................................................................................................................................................................. 8
Changes to this Plan...................................................................................................................................................................... 8
Section 3. How you get care ......................................................................................................................................................................... 9
Identification cards ....................................................................................................................................................................... 9
Where you get covered care ......................................................................................................................................................... 9

Plan providers......................................................................................................................................................................... 9
Plan facilities .......................................................................................................................................................................... 9
What you must do to get covered care ......................................................................................................................................... 9

Primary care............................................................................................................................................................................ 9
Specialty care.......................................................................................................................................................................... 9
Hospital care......................................................................................................................................................................... 11
Circumstances beyond our control............................................................................................................................................. 11
Services requiring our prior approval ........................................................................................................................................ 11
If you are referred to a specialist ................................................................................................................................................ 10
Section 4. Your costs for covered services.................................................................................................................................................. 12
Copayments .......................................................................................................................................................................... 12
Deductible............................................................................................................................................................................. 12
Coinsurance .......................................................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum ............................................................................................................. 12
Section 5. Benefits........................................................................................................................................................................................ 13
Overview ..................................................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ........................................ 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................... 26
(c) Services provided by a hospital or other facility, and ambulance services ................................................................... 31
(d) Emergency services/ accidents......................................................................................................................................... 34
(e) Mental health and substance abuse benefits ................................................................................................................... 36 5.
5 Page 6 7
Capital Health Plan 3 Table of Contents
(f) Prescription drug benefits................................................................................................................................................ 38
(g) Special features ............................................................................................................................................................... 41
(h) Dental benefits ................................................................................................................................................................. 42
Section 6. General exclusions --things we don't cover .............................................................................................................................. 43
Section 7. Filing a claim for covered services ............................................................................................................................................ 44
Section 8. The disputed claims process....................................................................................................................................................... 45
Section 9. Coordinating benefits with other coverage ............................................................................................................................... 47
When you have other health coverage ....................................................................................................................................... 47
What is Medicare................................................................................................................................................................. 47
Medicare managed care plan ............................................................................................................................................. 50
TRICARE and CHAMPVA................................................................................................................................................ 50
Workers' Compensation ...................................................................................................................................................... 50
Medicaid ............................................................................................................................................................................. 51
Other Government agencies................................................................................................................................................ 51
When others are responsible for injuries ............................................................................................................................ 51
Section 10. Definitions of terms we use in this brochure ............................................................................................................................ 52
Section 11. FEHB facts ................................................................................................................................................................................ 53
Coverage information ............................................................................................................................................................... 53
No pre-existing condition limitation................................................................................................................................... 53
Where you get information about enrolling in the FEHB Program .................................................................................. 53
Types of coverage available for you and your family ....................................................................................................... 53
Children's Equity Act.......................................................................................................................................................... 54
When benefits and premiums start...................................................................................................................................... 54
When you retire ................................................................................................................................................................... 55
When you lose benefits............................................................................................................................................................. 55
When FEHB coverage ends .............................................................................................................................................. 55
Spouse equity coverage..................................................................................................................................................... 55
Temporary Continuation of Coverage (TCC) .................................................................................................................. 55
Converting to individual coverage.................................................................................................................................... 55
Getting a Certificate of Group Health Plan Coverage ..................................................................................................... 55

Long-term care insurance is still available ................................................................................................................................................... 56
Index .................................................................................................................................................................................................. 57
Summary of benefits...................................................................................................................................................................................... 59

Rates................................................................................................................................................................................................. Back cover 6.
6 Page 7 8
2003 Capital Health Plan 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Capital Group Health Services of Florida, Inc. d. b. a. Capital Health Plan under our
contract (CS 2034) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for Capital Health Plan administrative offices is:

Capital Health Plan
2140 Centerville Place
Tallahassee, FL. 32308

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 8. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means Capital 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 (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of
the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative. 7.
7 Page 8 9
2003 Capital Health Plan 5 Introduction/ Plain Language/ Advisory
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 850/ 383-3311 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.
8 Page 9 10
2003 Capital Health Plan 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments
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 employ physicians and 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 when you follow
Plan procedures for accessing care.

Who provides my health care?
Capital Health Plan, as a mixed model prepaid direct service health plan, offers members a choice of primary care physicians at many
different locations in the greater Tallahassee area. Members choose a primary care physician and receive their basic care (prevention
and treatment) from this doctor. The Plan offers internal medicine doctors, family practice doctors and pediatricians as primary care
physicians. Laboratory tests and X-rays, as well as referrals to specialists and for hospital services, are authorized and coordinated by
your primary care physician.

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.

We operate under a State of Florida Certificate of Authority and are federally qualified under Title XIII, PHSA.
20 years in existence
Not-for-Profit Corporation
If you want more information about us, call 850/ 383-3311, or write to Capital Health Plan, 2140 Centerville Place, Tallahassee, FL
32308. You may also contact us by fax at 850/ 383-3590 or visit our website at www. capitalhealth. 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:
Gadsden, Jefferson, Leon and Wakulla counties.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only
for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO 9.
9 Page 10 11
2003 Capital Health Plan 7 Section 1
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.

. 10.
10 Page 11 12
2003 Capital Health Plan 8 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.
A 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 24.7% for Self Only or 58.8% for Self and Family. 11.
11 Page 12 13
2003 Capital Health Plan 9 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 850/ 383-3311 or write to us at
Capital Health Plan, 2140 Centerville Place, Tallahassee, Fl. 32308. You may also
request replacement cards through our website at www. capitalhealth. com.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards. You must select a primary care physician to
direct all of your medical care. Capital Health Plan offers you a choice of primary care
physicians at many different locations in the greater Tallahassee area.

We list Plan providers in the provider directory, which we update frequently. The list is
also on our website, www. capitalhealth. com.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update frequently. The list is also on our website, www. capitalhealth. com. Primary
care physician offices in our two health centers at Centerville Road and Governors
Square Boulevard also offer the convenience of lab, x-ray, vision care and/ or pharmacy
services.

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. Capital Health Plan's Directory of
Physicians and Service Providers lists the primary care physicians and their office
locations. You can make your selections from this list. This directory is provided to all
new members at the time of enrollment and upon request by calling CHP's Member
Services Department at 850/ 383-3311 or on our website at www. capitalhealth. com. This
directory is subject to change and is updated on a regular basis. On occasion, some
physicians may not accept new patients. CHP's Member Services staff will gladly assist
you with your selection of a primary care physician.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see
a specialist.
If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your

What you must do
to get covered care 12.
12 Page 13 14
2003 Capital Health Plan 10 Section 3
primary care physician gives you a referral. However, you may see a Plan optometrist,
chiropractor, or podiatrist for covered services without a referral. Female members may
also see a Plan gynecologist for an annual routine exam only without a referral. You may
see a Plan dermatologist for up to five visits per year without a referral.

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

If you are referred to a specialist 1) We process routine visits to specialists through an automated system. You can
confirm your referral and obtain your referral number within 3 to 5 working days by
dialing 850/ 383-3530 and following the instructions given.

2) Once you receive authorization, your primary care physician's staff will schedule your
appointment with the specialist. Many times, however, your physician will ask you to
schedule the appointment yourself. If you schedule your own appointment, please allow
five (5) working days for the necessary records to arrive at the specialist's office. If your
appointment is scheduled within five (5) working days from the date your primary care
physician refers you, you will want to make arrangements to hand-carry any required
records or x-rays.

3) Your referral to the specialist will be for a specific number of visits and is valid for
sixty (60) days. 13.
13 Page 14 15
2003 Capital Health Plan 11 Section 3
4) If the specialist recommends additional services, office visits, diagnostics tests,
surgery, hospitalization, or other specialty care, you MUST call your primary care
physician for authorization before such services are scheduled.

5) However, routine lab tests do not require authorization from your primary care
physician. The physician ordering the lab tests will give you appropriate lab orders and
directions.

6) X-rays may be done at Capital Health Plan's x-ray departments located at 2140
Centerville Place in Tallahassee or 1491 Governors Square Boulevard in Tallahassee,
unless other arrangements have been made by your primary care physician.

7) If you have any questions regarding the referral system, please call CHP's Member
Services Department at 850/ 383-3311.

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 850/ 383-3311. 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.
Your primary care physician has authority to refer you for most services. For certain
services (such as sending you to a hospital, referring you to a specialist, or recommending
follow-up care), 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 utilization management. Your physician must
obtain authorization for the following services:

Specialty care
Hospital care
Diagnostic services
All surgeries
Mental Health/ Substance Abuse care Growth Hormone Therapy

Services requiring our
prior approval 14.
14 Page 15 16
2003 Capital Health Plan 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per
office visit and when you go in the hospital, you pay $100 per admission.

Deductible We do not have a deductible
Coinsurance We do not have coinsurance.

Your catastrophic protection Your out-of pocket maximum for benefits under this Plan is limited to $1,500/ Self Only
out-of-pocket maximum or $3,000/ Self and Family per year. You must pay the copayment when you receive
for copayments services. You are responsible for keeping records and submitting to the Plan when you reach the maximums. 15.
15 Page 16 17
2003 Capital Health Plan 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 59 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 850/ 383-3311 or at our website at
www. capitalhealth. com.

(a) Medical services and supplies provided by physicians and other health care professionals ............................................................ 14-25
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...................................................... 26-30

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

(c) Services provided by a hospital or other facility, and ambulance services..................................................................................... 31-33

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

(d) Emergency services/ accidents .......................................................................................................................................................... 34-35

Medical emergency Ambulance

(e) Mental health and substance abuse benefits..................................................................................................................................... 36-37
(f) Prescription drug benefits ................................................................................................................................................................. 38-40
(g) Special features ...................................................................................................................................................................................... 41
TDD line: 850/ 383-3534

(h) Dental benefits........................................................................................................................................................................................ 42
Summary of benefits...................................................................................................................................................................................... 59 16.
16 Page 17 18
2003 Capital Health Plan 14 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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians

In physician's office
Office Medical consultations
Second surgical opinion

$10 per office visit

Professional services of physicians
In an urgent care center $15 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility
At home

Nothing 17.
17 Page 18 19
2003 Capital Health Plan 15 Section 5( a)
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

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

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

$10 per office visit

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

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

$10 per office visit

Preventive Care -Adult --continued on next page 18.
18 Page 19 20
2003 Capital Health Plan 16 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Nothing

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

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

Influenza vaccines, annually,
Pneumococcal vaccine, age 65 and over

$10 per office visit

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

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

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

$10 per office visit 19.
19 Page 20 21
2003 Capital Health Plan 17 Section 5( a)
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 9 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.

Copayments waived

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$100 per hospital admission

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5( b))

Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo-provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug
benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges. 20.
20 Page 21 22
2003 Capital Health Plan 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:

intravaginal insemination (IVI)

$10 per visit

Not covered:
Fertility drugs

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 You pay
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 21.
21 Page 22 23
2003 Capital Health Plan 19 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 29.

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.
We will only cover GHT when we preauthorize the treatment. Your
primary care physician will request preauthorization. Ask us to
authorize GHT before you begin treatment; otherwise, we will only
cover GHT services from the date you submit the information. If we
determine GHT is not medically necessary, we will not cover the
GHT or related services and supplies. See Services requiring our
prior approval in Section 3.

$10 per visit to a physician office
You pay Nothing for the radiation therapy.

Not covered: All charges. 22.
22 Page 23 24
2003 Capital Health Plan 20 Section 5( a)
Physical and occupational therapies You pay
Up to two consecutive months per condition 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.

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

Not covered:
long-term rehabilitative therapy

exercise programs
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction.

All charges.

Speech therapy You pay
Up to two consecutive months per condition for the services of speech therapists. $10 per office visit.
Nothing per visit during covered hospital
admission.

Not covered:
Speech therapy beyond two consecutive months per condition. All charges. 23.
23 Page 24 25
2003 Capital Health Plan 21 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
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
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts). The initial pair of eyeglasses is limited to the
cost of the lens and up to $25 for the frame and must be obtained only
at CHP's Eye Care Centers.

$10 per office visit

Eye exam to determine the need for vision correction for children through age 17 (See Preventive care, children)
Annual eye refractions Note: See Preventive care, children for eye exams for children

Not covered:
Eyeglasses, except initial pair following cataract surgery or an accidental injury which requires corrective lenses.

An examination and fitting for contact lenses. CHP Eye Care offers this service on a fee for service basis.
Contact lenses
Replacements for any lenses provided during the same calendar year

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges. 24.
24 Page 25 26
2003 Capital Health Plan 22 Section 5( a)
Foot care You pay
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.

Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; to replace natural limbs and eyes lost
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 implants
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See 5( b)
for coverage of the surgery to insert the device

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

Braces and covered prosthetic devices (except cardiac pacemaker) are limited to the first such item prescribed for each specific medical
condition
Oxygen for home use including equipment is covered
Cardiac pacemakers

Nothing

Orthopedic and prosthetic devices-Continued on next page 25.
25 Page 26 27
2003 Capital Health Plan 23 Section 5( a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
All other prosthetic devices, including braces used during athletic activities, are excluded.

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

All charges.

Durable medical equipment (DME) You pay
Durable Medical Equipment which has been prescribed by your plan
physician and which has been authorized by CHP as a Covered Service.
CHP reserves the right to rent or purchase the most cost-effective DME
which meets the Member's needs. Maximum payment by CHP for durable
medical equipment will be up to $2,500 annually for a covered person.

This benefit covers a wide variety of durable medical equipment and
continuing development of patient care equipment makes it impractical to
provide a complete listing of covered durable medical equipment such as:

Crutches

Canes
Manual wheelchairs
Basic hospital beds
Walkers

All charges over $2500 per person per contract
year.

Durable medical equipment (DME) Continued on next page 26.
26 Page 27 28
2003 Capital Health Plan 24 Section 5( a)
Durable medical equipment (DME) -(Continued) You pay
Not covered:
Cost to repair or replace DME except when authorized by CHP
DME which has not been authorized by CHP
Durable Medical Equipment which is for patient convenience and/ or comfort

Water therapy devices such as Jacuzzis, hot tubs, swimming pools or whirlpools
Exercise and massage equipment
Electric scooters and motorized wheelchairs
Hearing aids
Dental braces, air conditioners, humidifiers, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, emergency alert

equipment.
This exclusion includes but is not limited to:
Modifications to motor vehicles
Modifications to homes, such as wheelchair lifts or ramps Escalators or elevators, stair glides, handrails, heat appliances

and dehumidifiers

All charges.

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. The Plan physician
will periodically review the program for continuing appropriateness
and need.

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.

All charges. 27.
27 Page 28 29
2003 Capital Health Plan 25 Section 5( a)
Chiropractic You pay
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$10 per office visit

Not covered:
Services that maintain rather than improve a physical function,
Services that we determine will not result in significant improvement of the member's condition within a 62-day period.

All charges.

Alternative treatments You pay
No Benefit All Charges

Educational classes and programs You pay
Coverage is limited to:

Smoking Cessation
Diabetes self-management
Newborn care
Childhood Safety and CPR
CPR and Basic Life Support Training
Adult Asthma Management
Pediatric Asthma Management

Nothing 28.
28 Page 29 30
2003 Capital Health Plan 26 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

I M
P O
R T
A N
T

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

I M
P O
R T
A N
T

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

Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
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.

$10 per office visit
You pay nothing for physician services at a
hospital or outpatient surgery center.

Surgical procedures continued on next page. 29.
29 Page 30 31
2003 Capital Health Plan 27 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization
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.

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.

$10 per office visit

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.

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. 30.
30 Page 31 32
2003 Capital Health Plan 28 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.
Surgical treatment of TMJ (Related dental care for TMJ is excluded)

$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. 31.
31 Page 32 33
2003 Capital Health Plan 29 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

Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer must be 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:
Any service in connection with the implant of an artificial organ, including the implant of the artificial organ.

Transplants not listed as covered
Any organ which is sold rather than donated to the Member
The cost for services associated with the identification of a potential donor from a local, state or national listing

Services related to the acquisition of an organ or tissue for a recipient who is not a covered member of CHP

Any service related to the transplantation of any non-human organ or tissue

All charges. 32.
32 Page 33 34
2003 Capital Health Plan 30 Section 5( b)
Anesthesia You pay
Professional services provided in
Hospital (inpatient)
Nothing

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

Nothing

Professional services provided in
Office
$10 per visit 33.
33 Page 34 35
2003 Capital Health Plan 31 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

I M
P O
R T
A N
T

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

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

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

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

precertification.

I M
P O
R T
A N
T

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

general nursing care; and
meals and special diets.

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

$100 per admission

Inpatient hospital continued on next page. 34.
34 Page 35 36
2003 Capital Health Plan 32 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Not covered:
Custodial care
Non-covered facilities, such as nursing homes, 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 You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges. 35.
35 Page 36 37
2003 Capital Health Plan 33 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care/ Skilled nursing facility (SNF): The Plan provides a
comprehensive range of benefits for up to 60 days per admission with
subsequent admission available 180 days from discharge date of
previous admission 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.

Nothing

Not covered: custodial care All charges.
Hospice care You Pay
Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance You Pay
Local professional ambulance service when medically appropriate Nothing 36.
36 Page 37 38
2003 Capital Health Plan 34 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

I M
P O
R T
A N
T
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 (Both within and outside 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 notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your
responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be provided in a Plan hospital, you will be transferred when medically feasible
with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers. 37.
37 Page 38 39
2003 Capital Health Plan 35 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office

Emergency care at an urgent care center
$15 per visit

$15 per visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area You pay
Emergency care at a doctor's office

Emergency care at an urgent care center
$15 per visit
$15 per visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per 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 You pay
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance-unless medically necessary and approved
by the Plan's Medical Director.
All charges. 38.
38 Page 39 40
2003 Capital Health Plan 36 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.

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

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All Diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

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

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

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 on next page 39.
39 Page 40 41
2003 Capital Health Plan 37 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests $10 per (visit or test)

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

$100 per admission

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
If you are referred to a specialist 1) We process routine visits to specialists through an automated system. You can
confirm your referral and obtain your referral number within 3 to 5 working days by
dialing 850/ 383-3530 and following the instructions given.

2) Once you receive authorization, your primary care physician's staff will schedule
your appointment with the specialist. Many times, however, your physician will ask
you to schedule the appointment yourself. If you schedule your own appointment,
please allow five (5) working days for the necessary records to arrive at the specialist's
office. If your appointment is scheduled within five (5) working days from the date
your primary care physician refers you, you will want to make arrangements to hand-carry
any required records or x-rays.

3) Your referral to the specialist will be for a specific number of visits and is valid for
sixty (60) days.

4) If the specialist recommends additional services, office visits, diagnostics tests,
surgery, hospitalization, or other specialty care, you MUST call your primary care
physician for authorization before such services are scheduled.

5) However, routine lab tests do not require authorization from your primary care
physician. The physician ordering the lab tests will give you appropriate lab orders
and directions.

7) If you have any questions regarding the referral system, please call CHP's Member
Services Department at 850/ 383-3311.

Limitation We may limit your benefits if you do not obtain a treatment plan. 40.
40 Page 41 42
2003 Capital Health Plan 38 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T

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.

I
M
P
O
R
T
A
N
T

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy
We administer an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of

name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. Brand
name drugs not on the preferred list are dispensed at a higher copay. To order a prescription drug brochure,
call 850/ 383-3311 or go to www. capitalhealth. com.

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 one commercially prepared unit

(i. e. one inhaler, one vial ophthalmic medication or insulin). You pay a $20 copay per prescription unit or
refill for any brand drug which appears on the plan's Preferred Medication List when generic substitution is
not available and a $7 copay per prescription unit or refill for generic drugs. For brand drugs not on the
plan's Preferred Medication List you pay $35. If a generic drug is available and at the request of the
member or the prescribing physician a brand name prescription is dispensed, you pay the price difference
between the generic and name brand drug as well as the copay for the preferred or non-preferred brand
name drug per prescription unit or refill. Prescription refills will not be covered until at least 75 percent of
the previous prescription has been used by the member (based on the dosage schedule prescribed by the
physician).

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in

strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name
product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these
drugs meet the same standards of quality and strength as brand-name drugs.

When you have to file a claim. 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. See page 44. 41.
41 Page 42 43
2003 Capital Health Plan 39 Section 5( f)
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 prescription for their purchase

Oral and injectable contraceptive drugs
Insulin with a $7 copay charge applied to each vial
Disposable needles and syringes needed to inject covered prescribed medication

Diabetic supplies including test strips and glucometers at the CHP Pharmacy only
Drugs for sexual dysfunction
Prenatal Vitamins
Contraceptive devices

Note: We cover injectable contraceptive drugs under the Family
Planning Benefit.

$7 per prescription for generic drugs
$20 per prescription for preferred brand name
prescription drugs.

$35 per prescription for non-preferred brand
name prescription drugs.

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

Covered medications and supplies --continued on next page 42.
42 Page 43 44
2003 Capital Health Plan 40 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes including appetite suppresants

Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Medical supplies such as dressing and antiseptics
Nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Smoking cessation drugs and medications, including nicotine patches

Vitamins, except prenatal vitamins

All charges. 43.
43 Page 44 45
2003 Capital Health Plan 41 Section 5( g)
Section 5 (g). Special features
Feature Description

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

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

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

Services for deaf and
hearing impaired TDD Line: 850/ 383-3534 44.
44 Page 45 46
2003 Capital Health Plan 42 Section 5( j)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Plan providers 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 (c) for inpatient hospital benefits. We

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

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

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

Nothing

Dental benefits You pay
We have no other dental benefits. All charges 45.
45 Page 46 47
2003 Capital Health Plan 43 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.

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

Services, drugs, or supplies related to sex transformations; 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. 46.
46 Page 47 48
2003 Capital Health Plan 44 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.

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

Medical, hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the
and drug benefits form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call us at 850/ 383-3311.

When you must file a claim --such as for services you receive outside of the Plan's
service area --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Capital Health Plan
Post Office Box 15349
Tallahassee, FL. 32317-5349

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. 47.
47 Page 48 49
2003 Capital Health Plan 45 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: Capital Health Plan, ATTN: Grievance Coordinator, P. O. Box 15349, Tallahassee, FL
32317-5349; 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. 48.
48 Page 49 50
2003 Capital Health Plan 46 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

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

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

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

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

OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if
not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 850/ 383-3311 and
we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 49.
49 Page 50 51
2003 Capital Health Plan 47 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to fault.
This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

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

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

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

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

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

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

The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription
drugs.

The Original Medicare Plan (Part A or Part B) 50.
50 Page 51 52
2003 Capital Health Plan 48 Section 9
When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan's primary care physician.

We will not waive any of our copayments.

Claims process when you have the Original Medicare Plan --You
probably will never have to file a claim form when you have both our Plan and the
Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will then provide
secondary benefits for covered charges. You will not need to do anything. To find
out if you need to do something to file your claims, call us at Member Services
850/ 383-3311; or contact us at www. capitalhealth. com.

The plan will not pay in a secondary position for visits beyond the benefit limits.
(Primary payer chart begins on next page.) 51.
51 Page 52 53
Primary Payer Chart
1) Are an active employee with the Federal government (including when you
or a 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 (except for claims
that you are unable to return to duty, 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
c) Are a former spouse of an annuitant, or

d) Are a former spouse of an active employee

Please note: If your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.

A. When either you or your covered spouse are age 65 or over
and ...

Then the primary payer is...
Original Medicare This Plan

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.

2003 Capital Health Plan 49 Section 9 52.
52 Page 53 54
2003 Capital Health Plan 50 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: you may enroll in our Medicare
managed care plan and also remain enrolled in our FEHB plan. In this case, we do not
waive cost-sharing for your FEHB coverage.

This Plan and another plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even
out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments. 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,
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 settlement or other similar proceeding

that is based on a claim you filed under OWCP or similar laws.

If you do not enroll in Medicare Part A or Part B 53.
53 Page 54 55
2003 Capital Health Plan 51 Section 9
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.
Once OWCP or a similar agency pays its maximum benefits for your treatment, we will
cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in 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, or Federal Government
are responsible for your care agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care for injuries
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. 54.
54 Page 55 56
2003 Capital Health Plan 52 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.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care means care that serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding,
and using the toilet, preparation of special diets, and supervision of medication that
usually can be self-administered. Custodial care essentially is personal care that does not
require the continuing attention of trained medical or paramedical personnel. In
determining whether a person is receiving custodial care, consideration is given to the
level of care and medical supervision required and furnished. A determination that care
received is custodial is not based on the patient's diagnosis, type of Condition, degree of
functional limitation, or rehabilitation potential. Custodial care that lasts 90 days or more
is sometimes known as Long term care.

When CHP determines that an evaluation, treatment, therapy or device is
experimental/ investigational, it will not be covered by the Plan. CHP makes such
determinations based in part on information obtained from the United States Food and
Drug Administration, The Florida Department of Health and most recently published
medical literature in the United States, Canada or Great Britain. A consensus of opinion
among experts is sought showing that the evaluation, treatment, therapy or device is
considered safe and effective as compared with the standard means for treatment or
diagnosis of the condition in question.

Medical necessity Medical necessity means, for coverage and payment purposes, that a medical service or supply is required for the identification, treatment, or management of a condition, and is,
in the opinion of CHP: 1) consistent with the symptom, diagnosis, and treatment of the
Members' condition; 2) widely accepted by the practitioners' peer group as efficacious
and reasonably safe based upon scientific evidence; 3) universally accepted in clinical use
such that omission of the service or supply in these circumstances raises questions
regarding the accuracy of diagnosis or the appropriateness of the treatment; 4) not
experimental or investigational; 5) not for cosmetic purposes; 6) not primarily for the
convenience of the Member, the Member's family, the physician or other provider; and
7) the most appropriate level of service, care or supply which can safely be provided to the
Member. When applied to inpatient care, medically necessary further means that the
services cannot be safely provided to the Member in an alternative setting.

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

Experimental or
Investigational services 55.
55 Page 56 57
2003 Capital Health Plan 53 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you enrolled
limitation in this Plan solely because you had the condition before you enrolled.

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

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

When your enrollment ends; 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 you, your
for you and your family 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. 56.
56 Page 57 58
2003 Capital Health Plan 54 Section 11
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:

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 your 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 coverage If you are divorced from a Federal employee or annuitant, you may not 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 off