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Cimarron Health Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO Plan
How we pay providers
Your Rights
Service Area
Section 2. How we change for 2003
Program-wide changes
Changes to this Plan
Section 3. How you get care
Identification cards
Where you get covered care
Plan providers
Plan facilities
What you must do to get
Primary care
Specialty care
Hospital care
Circumstances beyond our
Services requiring our prior
Section 4. Your costs for covered services
Copayment
Deductible
Coinsurance
Your catastrophic protection
Section 5. Benefits
OVERVIEW
(a) Medical services and supplies provided by physicians and other health care professionals
(b) Surgical and anesthesia services provided by physicians and other health care professionals
(c) Services provided by a hospital or other facility, and ambulance services
(d) Emergency services/accidents
(e) Mental health and substance abuse benefits
(f) Prescription drug benefits
(g) Special features
Prenatal care and infant safety classes
Child safety program
24-hour Nurse line
(h) Dental benefits
(i) Non-FEHB benefits available to Plan members
Section 6. General exclusions: things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
When you have other health
What is Medicare?
Medicare managed care plan
TRICARE and CHAMPVA
Workers Compensation
Medicaid
When others are responsible
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
No pre-existing condition
Where you can get
Types of coverage
Childrens Equity Act
When you lose benefits
When FEHB coverage ends
Spouse equity coverage
Temporary continuation of
Converting to individual
Getting a Certificate of
Long Term Care Insurance Is Still Available!
Index
Summary of benefits
Rates

Pages 1--56

Page 1


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

Cimarron Health Plan http:// www. cimarronhealthplan. com
2003 A Health Maintenance Organization

Serving: All counties in the State of New Mexico
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:
PX1 Self Only PX2 Self and Family

RI73-251

For changes in benefits
see page 7.

This plan has 3 year accreditation from NCQA with a score of Commendable. See the 2003
Guide for more information on accreditation. 1.
1 Page 2 3

2.
2 Page 3 4
Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice
to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,

To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.

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

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

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

medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that

you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to
a P. O. Box instead of your home address). 3.
3 Page 4 5

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to
agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 Cimarron Health Plan 2 Table of Contents
Introduction ............... ............................................... ............................... ............................... ............... ............... ............. 4
Plain language ............... ............................................... ............................... ............................... ............... ............... ............. 4
Stop Health Care Fraud! . ............................................... ............................... ............................... ............... ............... ............. 5
Section 1. Facts about this HMO plan..................... ............................... ............................... ............... ............... ............. 6
How we pay providers.............. .............. ............................. .............................. ............... ............... ............. 6
Your Rights ............. ............................... ............................... ............................... ............... ............... ............. 6
Service Area .............................................. ............................... ............................... ............... ............... ............. 6
Section 2. How we change for 2003........................ ............................... ............................... ............... ............... ............. 7
Program-wide changes............................ ............................... ............................... ............... ............... ............. 7
Changes to this Plan................................. ............................... ............................... ............... ............... ............. 7
Section 3. How you get care...................................... ............................... ............................... ............... ............... ............. 8
Identification cards .................................. ............................... ............................... ............... ............... ............. 8
Where you get covered care ................... ............................... ............................... ............... ............... ............. 8
Plan providers .................................. ............................... ............................... ............... ............... ............. 8
Plan facilities.................................... ............................... ............................... ............... ............... ............. 8
What you must do to get covered care ... ............................... ............................... ............... ............... ............. 8
Primary care ..................................... ............................... ............................... ............... ............... ............. 8
Specialty care ................................... ............................... ............................... ............... ............... ............. 8
Hospital care..................................... ............................... ............................... ............... ............... ............. 9
Circumstances beyond our control........ ............................... ............................... ............... ............... ........... 10
Services requiring our prior approval... ............................... ............................... ............... ............... ........... 10
Section 4. Your costs for covered services............. ............................... ............................... ............... ............... ........... 11
Copayments...................................... ............................... ............................... ............... ............... ........... 11
Deductible......................................... ............................... ............................... ............... ............... ......... 11
Coinsurance...................................... ............................... ............................... ............... ............... ........... 11
Your catastrophic protection out-of-pocket maximum...... ............................... ............... ............... ........... 11
Section 5. Benefits ...... ............................................... ............................... ............................... ............... ............... ........... 12
Overview.... ............................................... ............................... ............................... ............... ............... ........... 12
(a) Medical services and supplies provided by physicians and other health care
professionals ................................ ............................... ............................... ............... ............... ........... 13
(b) Surgical and anesthesia services and supplies provided by physicians
and other health care professionals ......................... ............................... ............... ............... ........... 21
(c) Services provided by a hospital or other facility, and ambulance services ...... ............... ........... 24
(d) Emergency services/ accidents . ............................... ............................... ............... ............... ........... 27
(e) Mental health and substance abuse benefits .......... ............................... ............... ............... ........... 29
(f) Prescription drug benefits ........ ............................... ............................... ............... ............... ........... 31

(g) Special features ........................... ............................... ............................... ............... ............... ........... 34
Prenatal Program ................. ... ............................... ............... ............... ............... ............... ........... 34

Table of Contents Page 5.
5 Page 6 7

2003 Cimarron Health Plan 3 Table of Contents
Child Safety Program ......... ... ............................... ............... ............... ............... ............... ........... 34
24-hour nurse line ............... ... ............................... ............... ............... ............... ............... ........... 34
(h) Dental benefits ........................ ... ............................... ............... ............... ............... ............... ........... 35
(i) Non-FEHB benefits available to Plan members.... ............... ............... ............... ............... ........... 36
Section 6. General exclusions things we don't cover............................ ............... ............... ............... ............... ........... 37
Section 7. Filing a claim for covered services ....... ... ............................... ............... ............... ............... ............... ........... 38
Section 8. The disputed claims process....................... ............................... ............................... ............... ............... ........... 39
Section 9. Coordinating benefits with other coverage.............................. ............................... ............... ............... ........... 41
When you have other health coverage.... ............................... ............................... ............... ............... ........... 41
What is Medicare............................ ............................... ............................... ............... ............... ........... 41
Medicare managed care plan ........ ............................... ............................... ............... ............... ........... 44
TRICARE and CHAMPVA .......... ............................... ............................... ............... ............... ........... 44
Workers' Compensation ............... ............................... ............................... ............... ............... ........... 45
Medicaid........................................... ............................... ............................... ............... ............... ........... 45
Other Government agencies ......... ............................... ............................... ............... ............... ........... 45
When others are responsible for injuries .................... ............................... ............... ............... ........... 45
Section 10. Definitions of terms we use in this brochure....................... ............................... ............... ............... ........... 46
Section 11. FEHB facts ............................................... ............................... ............................... ............... ............... ........... 47
Coverage information.............................. ............................... ............................... ............... ............... ........... 47
No pre-existing condition limitation............................ ............................... ............... ............... ........... 47
Where you get information about enrolling in the FEHB Program........ ............... ............... ........... 47
Types of coverage available for you and your family............................... ............... ............... ........... 47
Children's Equity Act..................... ............................... ............................... ............... ............... ........... 47
When benefits and premiums start ............................... ............................... ............... ............... ........... 48
When you retire ............................... ............................... ............................... ............... ............... ........... 48
When you lose benefits........................... ............................... ............................... ............... ............... ........... 48
When FEHB coverage ends.......... ............................... ............................... ............... ............... ........... 48
Spouse equity coverage ................. ............................... ............................... ............... ............... ........... 49
Temporary Continuation of Coverage (TCC)............. ............................... ............... ............... ........... 49
Converting to individual coverage............................... ............................... ............... ............... ........... 49
Getting a Certificate of Group Health Plan Coverage .............................. ............... ............... ........... 49
Long term care insurance is still available ..................... ............................... ............................... ............... ............... ........... 50
Index...... ............................... ............................................... ............................... ............................... ............... ............... ........... 51
Summary of benefits .. ....... ............................................... ............................... ............................... ............... ............... ........... 52

Rates .................. .. ....... ....................... ................ .............. ............... ............... ............................... ............... ...................... Back cover

Table of Contents continued Page 6.
6 Page 7 8

2003 Cimarron Health Plan 4 Introduction Plain Language Advisory
Introduction
This brochure describes the benefits of Cimarron Health Plan under our contract (CS 2062) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Cimarron Health Plan
administrative offices is:
Cimarron Health Plan
P. O. Box 3887 Albuquerque, NM 87190

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2003 unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003 and changes are summarized on page 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means Cimarron 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. 7.
7 Page 8 9
2003 Cimarron Health Plan 5 Stop Health Care Fraud
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to
your doctor, other provider or authorized plan or OPM representative. Let only the appropriate medical professionals review your medical record or recommend services.

Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us
to get it paid. Carefully review explanations of benefits (EOB's) that you receive from us.

Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or
service. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service,

or misrepresented any information, do the following:
-Call the provider and ask for an explanation. There may be an error.
-If the provider does not resolve the matter, call us at 800-473-0391, or (505) 342-4680, 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 Cimarron Health Plan 6 Section 1
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for
the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

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

Your Rights
OPM requires all FEHB Plans to 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.
Find out about care management, which includes medical practice guidelines, disease management programs and how we
determine if procedures are experimental or investigational.
Our number of years in existence Our profit status

If you want more information about us, call 800/ 473-0391, or write to Cimarron Health Plan, P. O. Box 3887, Albuquerque, NM 87190. You may also contact us by fax at 505/ 798-4558 or visit our website at www. cimarronhealthplan. 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 the entire State of New Mexico

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 also reimburse routine care received at Student Health Care Centers at the out-of-area colleges or universities that your covered dependent children attend, less the office visit copayment. We will not pay

for any other health care services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Section 1. Facts about this HMO Plan 9.
9 Page 10 11
2003 Cimarron Health Plan 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that
does not change benefits.
Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

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

Changes to this Plan
Your share of the non-Postal premium will increase by 15.1% for Self Only or 25.4% for Self and Family.
The chiropractic office visit copayment is now $10 per visit. You now have direct access to chiropractors without a referral from your primary care doctor. Previously, you paid 50% of covered charges with a referral from your primary

care doctor.
Prescription drug benefit copayments are now $5 for generic drugs, $10 for brand name drugs for which no approved generic exists, and $25 for non-formulary drugs and drugs for which approved generics exists. Previously, prescription

drug benefit copayments were $5 for generic drugs and $8 for brand name drugs.
Mail Order prescription drug benefit copayments are now $10 for generic drugs, $20 for brand name drugs for which no approved generic exists, and $50 for non-formulary drugs and drugs for which approved generics exists. Previously, mail

order prescription drug benefit copayments were $10 for generic drugs and $16 for brand name drugs.
Clarification
The brochure has been clarified to show additional Educational classes and programs covered by us.
The brochure now shows that you may choose a nurse practitioner or a physician's assistant as a primary care provider if
they are listed in the Primary Care section of your provider directory. 10.
10 Page 11 12
2003 Cimarron Health Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from
a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health

benefits enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at (800) 473-0391 or (505) 342-4680. You may also write to us at Cimarron Health Plan, P. O. Box 3887,

Albuquerque, NM 87190

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential
Plan providers according to national standards.

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

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider
directory, which we update periodically. The list is also on our website, which is
updated every two weeks.

What you must do to get covered care 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. Call Customer Service
at (800) 473-0391 or (505) 342-4680 to choose or change your primary care physician. Physician changes are effective on the first day of the following month.

Primary care Your primary care physician can be a family practitioner, internist, or pediatrician. Primary care providers may also be physicians' assistants or nurse practitioners if
they are listed in the Primary Care section of the provider directory. Your primary
care physician or primary care provider will provide most of your health care, or will 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 primary care physician gives you a referral. However, all
members can directly access chiropractic care without a referral and women may see their OB-Gyn physicians for female-related conditions without a referral. Services of

providers who are not Plan contracted providers are covered only when approved in
advance by the Plan.

How you get care continued on next page. 11.
11 Page 12 13
2003 Cimarron Health Plan 9 Section 3
Section 3. How you get care continued
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with the Plan to develop

a treatment plan that allows you to see your specialist for a certain number of visits
without additional referrals. Your primary care physician will use our criteria
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 specialis t and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may
receive services from your current specialist until we can make arrangements for
you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist
until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing
or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at (800) 473-0391 or (505) 342-4680. 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
How you get care continued on next page 12.
12 Page 13 14
2003 Cimarron Health Plan 10 Section 3
Section 3. How you get care continued
Circumstances beyond our control
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
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.

Services requiring our prior approval Your primary care physician has authority to refer you for some services. For certain services, however, your physician must obtain approval from us. Before giving
approval, we consider if the service is covered, medically necessary, and follows
generally accepted medical practice.

We call this review and approval process "prior authorization". Your physician must obtain a prior authorization for services such as hospitalization and outpatient surgery
and procedures, testing such as CT Scans and MRI's, and nuclear medicine for them to be covered by the Plan. Your physician will request these services directly from
the Plan. If care must be extended, your physician will request additional visits or
procedures from the Plan. 13.
13 Page 14 15
2003 Cimarron Health Plan 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayment 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 visit an emergency room, you pay a $50 copayment.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for those services. We do not have
deductibles.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services and 20%
for durable medical equipment.

Your catastrophic protection out-of-pocket maximum for
coinsurance and copayments
After your out-of-pocket expenses total $ 6,881 per member in any calendar year,
you do not have to pay any more for covered services. However, copayments for the
following services do not count toward your catastrophic protection out-of-pocket
maximum, and you must continue to pay copayments for these services:

Dental Services Prescription Drugs

Substance Abuse Rehabilitation Vision Benefits

Be sure to keep accurate records of your out-of-pocket expenses, since you are
responsible for informing us when you reach the maximum. 14.
14 Page 15 16

2003 Cimarron Health Plan 12 Section 5
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 X; they apply to the benefits in the following subsections. To obtain claims filing advice, or more information about our benefits, contact us at (800) 473-0391 or (505)

342-4680, or at our website at www. cimarronhealthplan. com.
(a) Medical services and supplies provided by physicians and other health care professionals . ............... ............... ............ 13-20
Diagnostic and treatment services Speech Therapy Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)

Preventive care, adult Vision services (testing, treatment, and supplies) Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices Family planning Durable medical equipment (DME)
Infertility services Home health services Allergy care Chiropractic
Treatment therapies Alternative treatments Physical and occupational therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............. ............... ............ 21-23
Surgical procedures Oral and maxillofacial surgery Reconstructive surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .............. ............... ............... ............... ............ 24-26
Inpatient hospital Extended care benefits/ skilled nursing care Outpatient hospital or ambulatory facility benefits

surgical center Hospice care
Ambulance (d) Emergency services/ accidents .......... ............... ................ .............. ............... ............... ............... ............... ............... ............ 27-28

Medical emergency Ambulance
(e) Mental health and substance abuse benefits .. ................ .............. ............... ............... ............... ............... ............... ............ 29-30
(f) Prescription drug benefits ................. ............... ................ .............. ............... ............... ............... ............... ............... ............ 31-33

(g) Special features ................................... ............... ................ .............. ............... ............... ............... ............... ............... ............ 34
Prenatal care and infant safety classes Child safety program

24-hour Nurse line
(h) Dental benefits ................................... ............... ................ .............. ............... ............... ............... ............... ............... ............ 35
(i) Non-FEHB benefits available to Plan members ............. .............. ............... ............... ............... ............... ............... ............ 36
Summary of benefits .................................. ............... ................ .............. ............... ............... ............... ............... ............... ............ 52

Section 5. Benefits ... OVERVIEW (See page x for how our benefits changed this year and page 55 for a benefits summary.) 15.
15 Page 16 17
2003 Cimarron Health Plan 13 Section 5( a)
Medical services and supplies continued on next page.

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
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 please read Section 9 about coordinating benefits with other coverage,
including with Medicare.

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

Professional services of physicians
In an urgent care center $25 per office visit

During a hospital stay Nothing
In a skilled nursing facility Nothing
Office medical consultations $10 per office visit
Second surgical opinion $10 per office visit

At home $20 per visit
Lab, X-ray and other diagnostic tests

Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

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

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2003 Cimarron Health Plan 14 Section 5( a)
Maternity care continued on next page.

Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy screening

Prostate Specific Antigen (PSA test) Routine pap test

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

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

-At age 65 and older, one every two consecutive calendar years

$10 per office visit

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

All charges

Routine immunizations, such as:
Tetanus-diphtheria (Td) booster
Influenza vaccines
Pneumococcal vaccine

$10 per office visit

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

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

$10 per office visit

Maternity care
Complete maternity (obstetrical) care, such as:

Prenatal care
Delivery
Postnatal care

$10 per office visit 17.
17 Page 18 19
2003 Cimarron Health Plan 15 Section 5( a)
Infertility services continued on next page.

Maternity care continued You pay
Note: Here are some things to keep in mind:
You need to precertify your normal delivery; see page 10 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).

Not covered:
Routine sonograms to determine fetal age, size or sex. All charges

Family planning
A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5 (b)) $10 per office visit; nothing per hospital procedure
Surgically implanted contraceptives (such as Norplant) 50% of charges
Injectable contraceptive drugs (such as Depo Provera) $10 per office visit

Intrauterine devices (IUDs) 50% of charges
Diaphragms 50% of charges

Note: We cover oral contraceptives under the prescription drug benefit.

Not covered:
Reversal of voluntary sterilization
All charges

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)

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

50% of charges 18.
18 Page 19 20
2003 Cimarron Health Plan 16 Section 5( a)
Medical services and supplies continued on next page.

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

Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment $10 per office visit
Allergy injection $3 per visit and $10 office visit copay, if applicable

Allergy serum Nothing
Treatment therapies

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 23.

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 medical benefits.
Note: We will only cover GHT when we preauthorize treatment. Your
attending physician must call the Plan for preauthorization. We will ask your physician to submit information that establishes that the GHT is

medically necessary. We must authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date the treatment is authorized. If your physician does not ask or if we determine GHT is not

medically necessary, we will not cover the GHT or related services and
supplies.

$10 per office visit

Not covered:
All treatment therapies not shown as covered by the Plan All charges 19.
19 Page 20 21
2003 Cimarron Health Plan 17 Section 5( a)
Medical services and supplies continued on next page.

Physical and occupational therapies You pay
60 consecutive days per condition for the services of each of the following:
-qualified physical therapists; and $10 per office visit
-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 outpatient visit

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 36 sessions per cardiac event. Nothing per visit during inpatient admission
Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges

Speech therapy
Up to 60 consecutive days per condition. Services may be extended if significant improvement is noted. $10 per visit

Not covered:
All services beyond 60 days if significant improvement ceases
All charges

Hearing services (testing, treatment, and supplies)
Initial hearing evaluation
Hearing screening 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)
One pair of eyeglasses or contact lenses to correct an impairment directly
caused by intraocular surgery (such as for cataracts). We limit coverage to
$300 per surgery for eyeglasses or contact lenses.

Eye exam to determine the need for vision correction for children through
age 17. Note: See preventive care, children for eye exams for children.

$10 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges 20.
20 Page 21 22
2003 Cimarron Health Plan 18 Section 5( a)
Medical services and supplies continued on next page.

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; and of any instability, imbalance
or subluxation of the foot (unless the treatment is by open cutting surgery).

All charges

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

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants and surgically implanted breast implant following mastectomy.

Note: We pay internal prosthetic devices as hospital benefits; see Section 5
(c) for payment information. See 5 (b) for coverage of the surgery to insert
the device.

Corrective orthopedic appliances for treatment of temporo-mandibular joint (TMJ) pain caused by dysfunction syndrome, if trauma related.

Medically necessary podiatric appliances for prevention of feet complications associated with diabetes, including therapeutic molded or
depth-inlay shoes, functional orthotics, custom molded inserts,
replacement inserts, preventive devices and shoe modification for prevention and treatment.

20% of charges when you obtain prior authorization from the Plan

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive
devices.

All charges 21.
21 Page 22 23
2003 Cimarron Health Plan 19 Section 5( a)
Medical services and supplies continued on next page.

Durable medical equipment (DME) You pay
Rental or purchase, at our option (rental price not to exceed purchase price), including repair and adjustment, of durable medical equipment prescribed by
your Plan physician, such as oxygen and dialysis equipment. Under this
benefit, we also cover:

walkers
hospital beds
standard wheelchairs
crutches
blood glucose monitors
insulin pumps
oxygen

Note: Durable medical equipment must be prior authorized by the Plan

20% of allowable charges

Not covered:
Motorized wheel chairs.

All charges

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home health aide
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
Nursing care requested by, or for the convenience of, the patient or the
patient's family;
Homecare primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges

Chiropractic
Medically necessary and appropriate services directly related to the relief of neuromusculoskeletal pain, limited to 20 visits per calendar year.

Note: You do not need a referral from your primary care doctor to access these services.

$10 per office visit

Not covered:
All other chiropractic care
All charges 22.
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2003 Cimarron Health Plan 20 Section 5( a)
Coverage is limited to:
Smoking cessation -Classes $10 per session of 6 classes

-Prescription drugs limited to $500 per member per lifetime (See
Prescription drug benefits, Section 5 (f). $10 per prescription for a standard course of treatment (generally 12 weeks), limited to once
per year
Prenatal education class and child safety class with free infant car seat is available to all member mothers who deliver children while enrolled in

the Plan.
$10

Bike safety class available to all member children ages 4-18, includes free bike helmet.. $10
A variety of other health education programs including topics such as: -Alternative medicine
-Asthma
-Children's health
-Diabetes
-Ergonomics
-Health and well-being
-Nutrition and weight control
-Safety and first aid
-Stress
-Women's health

$10 per office visit

Alternative treatments You pay
Acupuncture by a contracted Plan provider for: treatment of piercing
specific peripheral nerves with needles to relieve the discomfort of painful disorders or for therapeutic purposes; limited to 20 visits per calendar year.
50% of charges

Not covered:
Naturopathic services
Hypnotherapy
Biofeedback.

All charges

Educational classes and programs 23.
23 Page 24 25
2003 Cimarron Health Plan 21 Section 5( b)
Surgical and anesthesia services continued on next page.

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

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

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility
charge (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 or call us
at (800) 473-0391 to identify which surgeries require precertification.

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 18 or over.

Insertion of internal prosthetic devices. See 5( a) -Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns.

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker
.

$10 per office visit; nothing per inpatient or outpatient
hospital admission

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

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2003 Cimarron Health Plan 22 Section 5( b)
Surgical and anesthesia services continued on next page.

Reconstructive surgery
Surgery to correct a functional defect.
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate;
birth marks; webbed fingers; and webbed toes.
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.

$10 per office visit; nothing per hospital admission

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

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

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

$10 per office visit; nothing for inpatient services

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

Dental work related to the treatment of TMJ

All charges 25.
25 Page 26 27
2003 Cimarron Health Plan 23 Section 5( b)
.

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; aplastic anemia; Wiskott-Aldrich Syndrome; 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.

All transplants must be prior approved by us.

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

$10 per visit; nothing for inpatient services

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

All charges

Anesthesia You pay
Professional services provided in:
Hospital (inpatient) Nothing

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

Nothing
Nothing Nothing

Office $10 per office visit 26.
26 Page 27 28
2003 Cimarron Health Plan 24 Section 5( c)
Inpatient hospital continued on next page.

Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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 and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating the 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 Section 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

Benefit Description You pay
Inpatient hospital
Room and board, such as:

ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

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

Nothing

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

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2003 Cimarron Health Plan 25 Section 5( c)
Services provided by a hospital or other facility continued on next page. .

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

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood or blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, splints, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics, including nurse anesthetist service
Take home items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home.

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

Nothing

Not covered:
Blood and blood derivatives not replaced by the member
All charges

Extended care benefits/ skilled nursing care facility benefits
We cover up to 30 days per calendar year 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 28.
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2003 Cimarron Health Plan 26 Section 5( c)
Hospice care You pay
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. Maximum benefit is 210

days per member per lifetime (includes 7 days of respite care).

Nothing

Not covered:
Independent nursing, homemaker services
All charges

Ambulance
Local professional ambulance service when medically appropriate $50 ground ambulance per trip $100 air ambulance per trip 29.
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2003 Cimarron Health Plan 27 Section 5( d)
Emergency care at a doctor's office or "same day care" office $10 per office visit
Emergency care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services.

Note: Hospital emergency care copay waived if you are admitted to the
hospital.

$50 per visit

Not covered:
Elective are or non emergency care
All charges

Emergency services/ accidents continued on next page.

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

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

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

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

What to do in case of emergency:
Emergencies within our service area: For true life or limb threatening emergencies, call 911 and go to the nearest facility.
For other emergency situations go to a Plan contracted facility or call the Plan at (800) 473-0391.

For non life-threatening, acute situations requiring prompt attention, when your primary care physician is not available, you
may call any St. Joseph Healthcare physicians' facility in Albuquerque and request "same day care". Call Customer Service at (505) 342-4680 or (800) 473-0391 or refer to your provider directory for telephone numbers.

Emergencies outside our service area: Life or limb threatening emergencies or medically necessary urgent care: Go to an emergency facility or doctor's office or call the Plan at (800) 473-0391 for assistance. You or a family member must notify
the Plan at within 48 hours, unless it was not reasonably possible to do so.
You must return to your primary care physician for all follow-up care. Do not return to the Emergency Room.

Benefit Description You pay
Emergency within our service area

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2003 Cimarron Health Plan 28 Section 5( d)
Emergency outside our service area You pay
Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

Note: Hospital emergency care copay waived if you are admitted to the hospital.

$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
Professional ambulance service when medically appropriate. See 5( c) for non-emergency service. $50 per trip for ground ambulance, $100 per trip for air ambulance

Not covered:
Non-emergent ambulance transport unless prior authorized by Plan
All charges 31.
31 Page 32 33
2003 Cimarron Health Plan 29 Section 5( e)
Mental health and substance abuse services continued on next page

Section 5 (e). Mental health and substance abuse benefits
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 for services will be no greater than
for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically necessary.

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

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 illnesses or conditions.

Professional services, including therapy by providers such as psychiatrists, psychologists, or clinical social workers
Medication management

$10 per hospital visit or
Nothing if hospital confined
Diagnostic tests Nothing
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.

Nothing
Nothing

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

All charges

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2003 Cimarron Health Plan 30 Section 5( e)
Mental health and substance abuse benefits continued
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
Call Customer Service at (505) 342-4680 or (800) 473-0391.
You will be connected with a Behavioral Health Representative who will triage your
care to an appropriate provider.

Limitation We may limit your benefits if you do not obtain a treatment plan. 33.
33 Page 34 35

2003 Cimarron Health Plan 31 Section 5( f)
Prescription drug benefits continued on next page.

Section 5 (f). Prescription drug benefits
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.

There are important features you should be aware of. These include:
Who can write your prescription? A licensed Plan physician must write the prescription.
Where you can obtain them. You may fill the prescription at a participating pharmacy, by internet, or by mail.
We use a formulary. A formulary is a listing of drugs we customarily use. This does not mean a drug may not be listed to
treat your condition. It may simply reflect the choice of drug manufacturer among those that produce the same category of
drug. The drugs and medications have been approved in accordance with guidelines established by us along with
consulting physicians and pharmacists. The list is reviewed periodically and is amended as necessary. We cover non-formulary
drugs when prescribed by a Plan doctor. Unless your physician writes "no substitutions" or "dispense as written"
on the prescription, it will be filled with an available generic drug. Non-formulary drugs will be filled for the appropriate
non-formulary copayment. You should discuss these things with your physician when he/ she prescribes a drug to receive
the best benefit available for you.

These are the dispensing limitations. Retail prescriptions will be dispensed for the lesser of a 30-day supply or 100 unit
dose, or manufacturer's standard trade package, including inhalers. Maintenance drugs may be ordered by mail order.
You will receive a 90-day supply for two copayments. Be sure to have your doctor specify that the prescription is for a 90-
day supply. If you do not have a mail order envelope, contact Customer Service at (800) 473-0391 or (505) 342-4680. You
may also order mail order drugs on the internet at the Website: www. catalystrx. com/ cimarron. If there is no generic
equivalent of your drug, you will still be required to pay the name brand copayment. A generic equivalent will be
dispensed if it is available, unless your physician specifically requires a name-brand. If your physician does not require it,
but you request a name-brand drug, or if your physician requires a non-formulary drug, you will have to pay the non-formulary
copay.

Why use generic drugs? Generic drugs offer a safe and economical way to meet your prescription needs. The generic
name of a drug is its chemical name, the name brand is the name under which the manufacturer advertises and sells the
drug. Under Federal law, generic and name-brand drugs must meet the same standards for safety, purity, strength, and
effectiveness. A generic prescription costs you and us less than a brand-name prescription.

When you have to file a claim. Under normal circumstances, you should not have to file a claim. If this becomes
necessary, for example, if you must purchase a drug because you have not yet received your ID card, call Customer Service
at (800) 473-0391 or (505) 342-4680.

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2003 Cimarron Health Plan 32 Section 5( f)
Prescription drug benefits continued on next page.

Benefit Description You pay
Covered medications and supplies

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
Full range of FDA-approved drugs, prescriptions, and devices for birth control. Contraceptive drugs (Contraceptive devices, including implanted devices and
implantable drugs such as Norplant are covered under Medical and Surgical
Benefits as a Limited benefit.)

Compounded dermatological preparations
Nitroglycerin, Phenobarbital, or Thyroid U. S. P.
Insulin, with a copay charge applied to every two vials
Fertility drugs are covered under Infertility benefits (see page 15)
Intravenous fluids and medications for home use, implants, some injectible
drugs, and growth hormones are covered under Medical and Surgical Benefits.

Disposable needles and syringes needed to inject covered prescribed
medication.

Diabetic supplies, including insulin syringes, needles, glucose test tablets and
test tape, Benedict's solution or equivalent, and acetone test tablets. Glucose
monitors are covered under Durable Medical Equipment (see page 19).

Appetite suppressants when prescribed for morbid obesity

Retail Pharmacy $5 per generic drug
$10 per name brand drug when no
generic equivalent exists, $25 per non formulary drug or brand

name drug when an approved generic
exists

Mail Order (Maintenance
medications only) $10 per generic prescription

$20 per name brand prescription
$50 per non-formulary prescription or name brand prescription when

an approved generic exists

Prescription drugs to aid in smoking cessation, limited to one standard course of treatment once per year. Benefit is limited to $500 per member per lifetime. $10 per prescription
Drugs for sexual dysfunction, with prior authorization from the Plan. 50% of covered charges
Growth hormones 20% of charges
Here are some things to keep in mind about our prescription drug program:
Certain drugs require your physician to prior authorize them in order to verify
medical necessity. These include such drugs as:
-Drugs for sexual dysfunction
-Drugs used for dual purposes such as Wellbutrin
-Appetite suppressants
-Growth hormones 35.
35 Page 36 37
2003 Cimarron Health Plan 33 Section 5( f)
Covered medications and supplies continued You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription or over-the-counter medicines or products
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs to aid in dieting, unless for morbid obesity

All charges 36.
36 Page 37 38
2003 Cimarron Health Plan 34 Section 5( g)
Section 5 (g). Special features
Feature Description

Prenatal Program
Member mothers are encouraged to attend one prenatal class and one infant safety class, for a

$10 copay, after which they will receive a free
car seat to encourage infant safety.

Child Safety Program
Parents of children ages 4 through 18 are encouraged to bring them to a bicycle safety
class that teaches safe riding. The cost of the
class is $10. At the conclusion of the class, children can be properly fitted for and receive a

free bicycle helmet to encourage child safety.

24-hour nurse line
For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-564-8596
and talk with a registered nurse who will discuss
treatment options and answer your health questions. 37.
37 Page 38 39
2003 Cimarron Health Plan 35 Section 5( h)
Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We have no calendar year deductible.

We cover hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the patient. See
Section 5( c) for inpatient hospital beneftis. 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.

Accidental injury benefit You pay
We cover services and supplies necessary to promptly restore sound natural teeth. The need for these services must result from an accidental injury, but
is not limited to injuries that occurred during enrollment under this plan.
$10 per office visit

Preventive dental benefit
These preventive and diagnostic services are provided by participating Delta
Dental Advantage Plan dentists. This benefit is limited to two visits per
year.

Covered services are limited to:
Oral Examination, twice per calendar year.
Prophylaxis (cleaning), twice per calendar year.
X-rays (bitewings, twice per calendar year; and full mouth, once per 5 year
period).
Fluoride application (through age 18), twice per calendar year.
Sealants for enrolled dependents through age 15 for permanent molars,
once per three year period per molar.
Space maintainers (through age 15).
Emergency treatment for pain relief.

50% of charges

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

VOLUNTARY BUY-UP DENTAL PLAN
You may elect Delta's Buy-Up plan for more coverage. You must enroll in Cimarron's HMO for the 2002 plan year to be eligible. Your enrollment of "self only" or "self and family" must match in both Cimarron's HMO and Delta's Buy-Up plan.

You are responsible for the monthly premium payable by automatic bank draft as authorized by you.
DEDUCTIBLE: $50 deductible per enrolled person, $150 per family each contract term. MAXIMUM: The maximum amount payable by Delta is $1000 per enrolled person each contract term.

The Delta Buy-Up Plan is Delta's Advantage, a PPO plan with its own list of participating providers. Percentages listed are applied to Delta's Advantage maximum allowable fee schedule or billed charges, whichever is less. Dentists who do not
participate in Delta's Advantage network may charge more; the difference is the patient's responsibility.
Diagnostic & Preventive Services oral exams (twice per year), cleanings (twice per year), x-rays (full-mouth once per five years/ bitewings twice per

calendar year), emergency treatment for relief of pain, topical flouride (twice per
year through age 18), space maintainers (through age 15), sealants (for dependent children through age 15, permanent molars only).

100% of Delta's Advantage Plan fee schedule (no deductible applies)

Restorative Services amalgam fillings on posterior teeth, composite fillings on anterior teeth, stainless steel crowns. 80% of Delta's Advantage Plan fee schedule (deductible applies)
Basic Services extractions (simple or surgical), oral surgery, endodontics (root canal and pulp therapy), periodontics (non-surgical and surgical), general
anesthesia (when dentally necessary and administered by a licensed provider for a
covered oral surgery procedure).

80% of Delta's Advantage Plan fee schedule (deductible applies)

Major Services Crowns and Cast Restorations--when teeth cannot be restored with amalgam, composite resin, or plastic restorations. Prosthodontics--
procedures for construction or repair of fixed bridges, partial, or complete
dentures.

50% of Delta's Advantage Plan fee schedule (deductible applies)

AVAILABLE AFTER A 12 MONTH WAITING PERIOD FOR NEW ENROLLEES BEGINNING JANUARY 1, 2002
Orthodontic Services coverage is for adults and children, subject to $1000 lifetime maximum per enrolled person 50% of Delta's Advantage Plan fee schedule (no deductible applies)

AVAILABLE AFTER A 12 MONTH WAITING PERIOD FOR NEW ENROLLEES BEGINNING JANUARY 1, 2002
For a complete listing of Delta's Buy-Up Plan Benefits and Delta's Advantage Providers, call (505) 855-7111 or toll-free at (877) 395-9420. Applications will only be accepted during Federal Open Season for active or retired employees. New hires are eligible after the
probationary period. Disenrollment mid-year precludes any future enrollment in this Voluntary Buy-Up plan. This is only a summary of benefits, please refer to the contract documents for specific information on benefits and eligibility.

VISION BENEFITS (You are NOT required to pay any additional premium for this benefit.)

Your vision exam and eyewear purchase are covered by Cimarron Health Plan through the Vision Service Plan. No referral is necessary, just call the participating provider and schedule your appointment. Your copayment for your eye exam is $10.
(Note: If an exam is done for contact lenses, an additional copayment applies.) You and your covered family members may
each have one exam every 12 months.

Eyewear is available in most Plan provider offices. You will receive a 20% discount off the VSP doctor's usual and
customary fee for a complete pair of prescription glasses. You can also save 15% off the cost of the contact lens exam when you receive services from a VSP doctor (this discount does not apply to the contact lenses). Additionally, you are

entitled to a $55.00 allowance toward those materials after the discount has been applied.
Remember! This benefit is for routine eye care. Medically necessary diagnostic eye care is available by referral under your FEHB Medical and Surgical Benefits. Refer to the Medical directory for these providers.

For a complete listing of the Vision Service Plan benefits and providers, please call Cimarron Health Plan at (800) 473-0391 or (505) 342-4680. 39.
39 Page 40 41
2003 Cimarron Health Plan 37 Section 6
Section 6. General exclusions: things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease,
injury or condition and we agree, as discussed in What Services Require Our Prior Approval on page 10.
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. 40.
40 Page 41 42
2003 Cimarron Health Plan 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers
bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on
the UB-92 form. For claims questions and assistance, call us at (800) 473-0391
or (505) 342-4680.

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:
Cimarron Health Plan, Box 3887, Albuquerque, NM 87190

Prescription drugs Call Customer Service at (800) 473-0391 or (505) 342-4680 for a Prescription Drug Reimbursement form.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by 90 days following the date 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. 41.
41 Page 42 43
2003 Cimarron Health Plan 39 Section 8
Disputed claims process continued on next page.

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 prior authorization:

Step Description
1 Ask us in writing to reconsider our initial decision. Write to us at: Cimarron Health Plan, P. O. Box 3887, Albuquerque, NM 87190. You must:
(a) Write to us within 6 months from the date of our decision; and (b) Send your request to us at: Cimarron Health Plan, P. O. Box 3887, Albuquerque, NM 87190.
(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, Contracts Division 3,
1900 E Street NW, Washington, D. C. 20415-3630.

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. 42.
42 Page 43 44
2003 Cimarron Health Plan 40 Section 8
Section 8. The disputed claims process continued
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 (505) 342-4680 or 800-473-0391 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited
treatment too, or
You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 43.
43 Page 44 45
2003 Cimarron Health Plan 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We,
like other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular
benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:

People 65 years of age and older
Some people with disabilities, under 65 years of age
People with End-Stage-Renal Disease (permanent kidney failure requiring dialysis
or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or
your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a

Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise,
if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

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

If you are eligible for Medicare, you may have choices in how you get your health
care. Medicare + Choice is the term used to describe the various health plan choices available to Medicare beneficiaries. The information in the next few pages shows

how we coordinate benefits with Medicare, depending on the type of Medicare
managed care plan you have.

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue
to be authorized by the Plan PCP, or prior authorized as required.
We will waive most copayments, coinsurance, and deductibles. We will coordinate benefits with Medicare as we coordinate benefits with any other Plan.

Coordinating benefits with other coverage continued on next page 44.
44 Page 45 46
2003 Cimarron Health Plan 42 Section 9
.
Claims process when you have the Original Medicare Plan (Part A or Part B)
You probably will never have to file a claim form when you both our Plan and the
Original Medicare Plan.

When we are the primary payers, 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 (800) 473-0391 or (505) 342-4680

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

followed.

(Primary Payer Chart begins on next page)

Section 9. Coordinating benefits with other coverage Continued 45.
45 Page 46 47
2003 Cimarron Health Plan 43 Section 9
The following chart illustrates whether The Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you or your covered spouse are age 65 or over and Then the primary payer is
Original Medicare This Plan
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, (forPartBservices) (forotherservices)

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that you are
unable to return to duty,

(exceptforclaimsrelated toWorkers'

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and a) Are an annuitant, or

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

Coordinating benefits with other coverage continued on next page 46.
46 Page 47 48

2003 Cimarron Health Plan 44 Section 9
Coordinating benefits with other coverage continued on next page

Section 9. Coordinating benefits with other coverage continued
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 does not offer a Medicare managed care plan.
This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB
plan. We will still provide benefits when your Medicare managed care plan is
primary and you have utilized our Plan providers and followed our Plan procedures, and we will waive deductibles and 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 and enroll in a Medicare managed care plan, eliminating your FEHB premium (OPM does not

contribute to your Medicare managed care plan premium). For information on
suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open

season unless you involuntarily lose coverage or move out of the Medicare managed
care plan's service area.

If you do not enroll in Medicare Part A or Part B If you do not have one or both Parts of Medicare, you can still be covered under the FEHP Program. We will not require you to enroll in Medicare Part B and, if you
can't get premium-free Part A, 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 Veterands 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 yu are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to

any applicable plan premiums.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you

involuntarily lose coverage under the program. 47.
47 Page 48 49
2003 Cimarron Health Plan 45 Section 9
Section 9. Coordinating benefits with other coverage continued
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency

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

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

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 are responsible for

you