Coventry Health Care of Kansas, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--60

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

2
Coventry Health Care of Kansas, Inc.
(Wichita, Salina, and Central Kansas areas)
http:// www. chckansas. com
2003 A Health Maintenance Organization

For changes in benefits
see page 8.

Serving: Wichita, Salina and Central Kansas areas
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
7W1 Self Only 7W2 Self and Family

RI 73-275 1.
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2.
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Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), .
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected, . To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and

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

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

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

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

your request if the information is used to conduct operations in the manner described above. . Get a separate paper copy of this notice. 3.
3 Page 4 5

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
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Table of Contents
Introduction. ........................................................................................ 4
Plain Language........................................................................................ 4
Stop Health Care Fraud!.. ....................................................................................................................................................................... 4
Section 1. Facts about this HMO plan ................................................................................................................................................... 6
How we pay providers .......................................................................................................................................................... 6
Who provides my health care?............................................................................................................................................. 6
Your Rights........................................................................................................................................................................... 7
Service Area.......................................................................................................................................................................... 7
Section 2. How we change for 2003........................................................................................... 8
Program-wide changes.......................................................................................................................................................... 8
Changes to this Plan.............................................................................................................................................................. 8
Section 3. How you get care ... .............................................................................................................................................. 9
Identification cards................................................................................................................................................................ 9
Where you get covered care.................................................................................................................................................. 9
. Plan providers ................................................................................................................................................................. 9
. Plan facilities .................................................................................................................................................................. 9
What you must do to get covered care .................................................................................................................................. 9
. Primary care.................................................................................................................................................................... 9
. Specialty care.................................................................................................................................................................. 9
. Hospital care ................................................................................................................................................................. 10
Circumstances beyond our control ...................................................................................................................................... 11
Services requiring our prior approval.................................................................................................................................. 11
Section 4. Your costs for covered services .......................................................................................................................................... 12
. Copayments .................................................................................................................................................................. 12
. Deductible..................................................................................................................................................................... 12
. Coinsurance .................................................................................................................................................................. 12
Your catastrophic protection out-of-pocket maximum....................................................................................................... 12
Section 5. Benefits........................................................................................ 13
Overview............................................................................................................................................................................. 13
(a) Medical services and supplies provided by physicians and other health care professionals....................................... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................... 22
(c) Services provided by a hospital or other facility, and ambulance services................................................................. 26
(d) Emergency services/ accidents .................................................................................................................................... 28
(e) Mental health and substance abuse benefits ............................................................................................................... 30
(f) Prescription drug benefits ........................................................................................................................................... 32
(g) Special features........................................................................................................................................................... 34
. 24 hour nurse line ............................................................................................................................................. 34

2003 Coventry Health Care of Kansas, Inc. 2 Table of Contents 5.
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. Services for deaf and hearing impaired............................................................................................................. 34
. Transplant Network........................................................................................................................................... 34
. Flexible Benefits Option ................................................................................................................................... 34
(h) Dental benefits............................................................................................................................................................ 35
(j) Non-FEHB benefits available to Plan members......................................................................................................... 37
Section 6. General exclusions --things we don't cover....................................................................................................................... 38
Section 7. Filing a claim for covered services ..................................................................................................................................... 39
Section 8. The disputed claims process................................................................................................................................................ 40
Section 9. Coordinating benefits with other coverage ......................................................................................................................... 42
When you have other health coverage.. .............................................................................................................................. 42
. What is Medicare ....................................................................................................................................................... 42
. Medicare managed care plan...................................................................................................................................... 45
. TRICARE and CHAMPVA....................................................................................................................................... 46
. Worker's Compensation............................................................................................................................................. 46
. Medicaid .................................................................................................................................................................... 46
. Other Government agencies ....................................................................................................................................... 46
. When others are responsible for injuries.................................................................................................................... 46
Section 10. Definitions of terms we use in this brochure..................................................................................................................... 47
Section 11. FEHB facts........................................................................................................................................................................ 48

Coverage information ......................................................................................................................................................... 48
. No pre-existing condition limitation ........................................................................................................................... 48
. Where you can get information about enrolling in the FEHB Program...................................................................... 48
. Types of coverage available for you and your family................................................................................................. 48
. Children's Equity Act.. ............................................................................................................................................... 48
. When benefits and premiums start.............................................................................................................................. 49
. When you retire .......................................................................................................................................................... 49
When you lose benefits ....................................................................................................................................................... 49
. When FEHB coverage ends ........................................................................................................................................ 49
. Spouse equity coverage............................................................................................................................................... 49
. Temporary Continuation of Coverage (TCC) ............................................................................................................. 49
. Converting to individual coverage.............................................................................................................................. 50
. Getting a Certificate of Group Health Plan Coverage................................................................................................. 50
Long term care insurance is still available . .......................................................................................................................................... 51
Index ..................................................................................................................................................................................................... 52
Summary of benefits ............................................................................................................................................................................. 56
Rates ....................................................................................................................................................................................... Back cover

2003 Coventry Health Care of Kansas, Inc. 3 Table of Contents 6.
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2003 Coventry Health Care of Kansas, Inc. 4 Introduction / Plain Language / Advisory
Introduction
This brochure describes the benefits of Coventry Health Care of Kansas, Inc. under our contract (CS 2108) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Coventry Health Care
of Kansas, Inc. administrative offices is:
Coventry Health Care of Kansas, Inc. 8301 E. 21 st North, Suite 300
Wichita, Kansas 67206
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 54. Rates are shown at the end of this brochure.

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

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

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

. Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve this structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us 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 Coventry Health Care of Kansas, Inc. 5 Introduction / Plain Language / Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired

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

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

. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service. . If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
. Call the provider and ask for an explanation. There may be an error.

. If the provider does not resolve the matter, call us at 866/ 320-0697 and explain the situation. .
If we do not resolve the issue:

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

OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
. Do not maintain as a family member on your policy: .
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or . your child over age 22 (unless he/ she is disabled and incapable of self support).

. If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM
if you are retired. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to

obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan. 8.
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Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact 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.

Who provides my healthcare
Coventry Health Care provides you with a comprehensive benefit package that covers many kinds of health services for a fixed payroll deduction and minimal copayments. As a participant of Coventry Health Care, you will select a personal doctor for yourself
and each member of your family. Depending on where you live, you will be able to choose from a directory of more than 320 primary care doctors whose offices are located throughout the Plan's service areas.

The first and most important decision each member must make is the selection of a primary care doctor. Your primary care doctor will be the manager and coordinator of your health care. If you require additional care, your primary care doctor, with your input, will
select the specialist or hospital that best fits your needs. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization.

The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular
basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1-866-320-0697. You can also find out if your doctor participates by calling these numbers. The list is also on our website. Visit www. chckansas. com to
utilize our doctor search option. Our doctor search on the web is updated monthly.
If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in the Plan, services (except for
emergency benefits) are provided through the Plan's delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Should you decide to enroll, you will be asked to complete a primary care doctor selection and send it to the Plan, indicating the name of the primary care doctor( s) selected for you and each member of your family. Members may change their doctor selection by
notifying the Plan 30 days in advance.

2003 Coventry Health Care of Kansas, Inc. 6 Section 1 9.
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Your Rights
OPM requires that 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.
. State Insurance Department requirements for external quality review .
Years in existence . Profit status

If you want more information about us, call 866/ 320-0697, or write to Coventry Health Care of Kansas Inc., 8301 East 21 st North, Suite 300, Wichita, Kansas 67206. You may also contact us by fax at 316/ 634-1266 or visit our website at www. chckansas. com.
Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is: Butler, Harvey, McPherson, Pratt, Saline, Sedgwick, and Sumner Counties.

You may also enroll with us if you live or work in the following places: Cowley, Dickinson, Greenwood, Harper, Kingman, Lincoln, Marion, Ottawa, and Reno counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

2003 Coventry Health Care of Kansas, Inc. 7 Section 1 10.
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2003 Coventry Health Care of Kansas, Inc. 8 Section 2
Section 2. How we change for 2003
Do not rely on these changes descriptions; this page is not an official statement of benefits. For that go to Section 5 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 55. 7% for Self Only or 74. 4% for Self and Family.
. The primary care physicians and specialists' office visit copayments are now $15 instead of $10 per visit.
. The inpatient hospital admission copayment is $100 per day up to $300 maximum. Previously, you paid nothing.
. Outpatient X-rays, laboratory and other diagnostic tests NOT received during a doctor's office are subject to $15 per visit.
Previously, members paid no copayment for test not received during a doctors office visit. You will continue to pay no copayment for these test when received as part of the doctor's office visit

. The outpatient hospital or ambulatory surgery copayment is now $50 per surgery. Previously, you paid nothing.
. Under Rehabilitative therapies, we cover Physical, Speech, Occupational and Chiropractic. The copayment is now $15 per visit
instead of 20% of covered charges.

. The hospital emergency room visit copayment is now $75 instead of $50.
. The land ambulance coinsurance is now 30% of covered charges up to a maximum Plan benefit of $400 per trip. Previously, you
paid $25 per trip.

. The air ambulance coinsurance is now 30% of covered charge. Previously, you paid $25 per trip.
. Under prescription drugs, you now pay $5 for generic drugs, $15 for formulary brand name drugs and $45 for non-formulary
drugs. Previously, you paid $5 for generic drugs, $10 for formulary brand name drugs and $20 for non-formulary drugs.

. Under mail order prescription drugs, you now pay $10 for generic drugs and $30 for formulary brand name drugs. Previously, you paid $10 for generic drugs and $20 for formulary drugs.

. The out-of-pocket maximum is now $2, 000 for Self Only enrollment and $4, 000 for Self and Family enrollment. Previously, the out-of-pocket maximum was $1, 000 for Self Only enrollment and $3, 000 for Self and Family
enrollment.
. We now cover a more comprehensive list of dental benefits. See Section 5( h) Dental benefits for details. 11.
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Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-866-320-0697 or write us at
Coventry Health Care of Kansas, Inc., 8301 E. 21 st St. North, Ste. 300 Wichita, KS 67206. You may also request replacement cards through our website at
www. chckansas. com.

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

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

We list Plan providers in the provider directory, which we update periodically. The list is also on our website. Visit www. chckansas. com to utilize our doctor search option. Our
doctor search on the web is updated monthly.
. 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 www. chckansas. com.

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. The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with
their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of
enrollment or upon request by calling the Customer Service Department at 1-866-320-0697. You can also find out if your doctor participates by calling these numbers.

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is
accepting new patients.
. Primary care Your primary care physician will generally be a family practitioner, internist or
pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
. Specialty care Your primary care physician will refer you to a specialist for needed care. You must
receive a referral from your primary care doctor before seeing or obtaining special services, with the following exceptions:, (1) Female members may visit a participating

gynecologist without a referral from their primary care doctor; (2) All members may visit the Plan's mental health providers for mental conditions and substance benefits without a
referral from their primary care doctor (See "Mental Conditions /Substance Abuse Benefits").

2003 Coventry Health Care of Kansas, Inc. 9 Section 3 12.
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Referral to a participating specialist is given at your primary care doctor's discretion; if specialists or consultants are required beyond those participating in the Plan, your
primary care doctor will make arrangements for appropriate referrals.
When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow-up care must be provided or
arranged by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If the consultant
suggests additional services or visits, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan
has issued an authorization for the referral in advance.
Here are other things you should know about specialty care:
. If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will work with the specialist to develop a treatment plan that allows you to see your specialist for a certain number of

visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or
approval beforehand).
. If you are seeing a specialist when you enroll in our Plan, talk to your primary care
physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If

your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.
. If you are seeing a specialist and your specialist leaves the Plan, call your primary
care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see

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

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

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

. Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements
and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-866-320-0697. If you are new to the FEHB
Program, we will arrange for you to receive care.

2003 Coventry Health Care of Kansas, Inc. 10 Section 3 13.
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If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
. You are discharged, not merely moved to an alternative care center; or
. The day your benefits from your former plan run out; or
. The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the hospital benefits of the hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Your primary care physician has authority to refer you for most services. For certain services, 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.
Services requiring our prior approval

We call this review and approval process prior authorization. Your physician must obtain, for example, prior authorization from the Plan for outpatient surgeries or inpatient
hospitalization. You may call customer service at 1-866-320-0697 to find out if a specific procedure treatment requires prior authorization.

2003 Coventry Health Care of Kansas, Inc. 11 Section 3 14.
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Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
. Copayments A copayment is a fixed amount of money you pay to provider, facility, pharmacy, etc.,
when you receive services.

Example: When you see your primary care physician, you pay a copayment of $15 per office visit. When you go in the hospital, you pay $100 copay per day up to a $300
maximum per admission.
. Deductible A deductible is a fixed expense you must incur for certain covered services and supplies
before we start paying benefits for them. We have no deductible.

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

After your copayments and coinsurance total $ 2,000 per person or $ 4,000 per family enrollment in any calendar year, you do not have to pay any more for covered services.
However, copayments for prescription drugs do not count toward your out-of-pocket maximum, and you must continue to pay copayments for prescription drugs.

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

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

2003 Coventry Health Care of Kansas, Inc. 12 Section 4 15.
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Section 5. Benefits OVERVIEW (See page 8 for how our benefits changed this year and page 56 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 866-320-0697 or at our website at www. chckansas. com.

(a) Medical services and supplies provided by physicians and other health care professionals.................................................... 14-21
. Diagnostic and treatment services .
Lab, X-ray, and other diagnostic tests . Preventive care, adult

. Preventive care, children .
Maternity care . Family planning

. Infertility services .
Allergy care . Treatment therapies

. Physical and occupational therapies

. Speech therapy .
Hearing services (testing, treatment, and supplies)

. Vision services (testing, treatment, and
supplies) . Foot care

. Orthopedic and prosthetic devices .
Durable medical equipment (DME) . Home health services

. Chiropractic .
Alternative treatments . Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................................ 22-25
. Surgical procedures .
Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue transplants . Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services.............................................................................. 26-27
. Inpatient hospital .
Outpatient hospital or ambulatory surgical center . Extended care benefits/ skilled nursing care facility benefits . Hospice care

. Ambulance
(d) Emergency services/ accidents .......................................................................................................................................... 28-29 . Medical emergency . Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................... 30-31
(f) Prescription drug benefits ........................................................................................................................................................... 32-33
(g) Special features ................................................................................................................................................................................ 34 . 24 hour nurse line . Services for deaf and hearing impaired . Transplant Network . Flexible Benefits Option

(h) Dental benefits .......................................................................................................................................................................... 35-36
(i) Non-FEHB benefits available to Plan members............................................................................................................................... 37

Summary of benefits ............................................................................................................................................................................. 53

2003 Coventry Health Care of Kansas, Inc. 13 Section 5 16.
16 Page 17 18
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.

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

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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office
$15 per office visit

In an urgent care center
. During a hospital stay
. In a skilled nursing facility
. Initial examination of a newborn child covered under a family
enrollment

. Office medical consultations
. Second surgical opinion

$15 per office visit

. At home $25 per office visit
Lab, X-ray and other diagnostic tests
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. C. A. T. Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

$15 when the test is not performed during your office visit. You only pay the office
visit copayment when the test is performed during your office visit.

2003 Coventry Health Care of Kansas, Inc. 14 Section 5( a) 17.
17 Page 18 19
Preventive care, adult You pay
Routine screenings, such as:
. Blood lead level One annually
. Total Blood Cholesterol once every three years, ages 19 through 64
. Colorectal Cancer Screening, including
. Fecal occult blood test
. Sigmoidoscopy, screening every five years starting at age 50

$15 per office visit

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $15 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnostic and Treatment, above.
$15 per office visit

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

$15 per office visit.

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel All charges
Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood Immunizations)

. Influenza vaccines, annually,
. Pneumococal vaccine, age 65 and over

$15 per office visit

Preventive care, children
. Childhood immunizations recommended by the American Academy
of Pediatrics $15 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)

$15 per office visit

2003 Coventry Health Care of Kansas, Inc. 15 Section 5( a) 18.
18 Page 19 20
Maternity care You pay
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. You do not need to precertify your normal delivery; see page 11 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).

$15 for initial office visit to confirm pregnancy. All other copayments for
prenatal visits during the course of pregnancy are waived.

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:

. Voluntary sterilization (See Surgical procedures Section 5 (b))
. Surgically implanted contraceptives (implant only; not removal)
. Intrauterine devices (IUDs implant only, not removal)
. Injectable contraceptive drugs (such as Depo provera)
. Diaphragms (insertion only)
NOTE: We cover oral contraceptives under the prescription drug benefit.

$100 per sterilization procedure
$15 for office visit applies to implanted contraceptive devices. Benefit does NOT

cover removal of devices.
$15 office visit copay applies to the injectable contraceptive drugs.

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
. intravaginal insemination (IVI)
. intracervical insemination (ICI)
. intrauterine insemination (IUI)

50% of charges up to a $2, 000 annual out-of-pocket maximum for an individual and
$4, 000 out of pocket maximum for family. The Plan pays remaining charges.

Infertility services --continued on next page
2003 Coventry Health Care of Kansas, Inc. 16 Section 5( a) 19.
19 Page 20 21
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
Allergy injection
50% of cost of testing; you pay $15 copayment for treatment visits, including

allergy serum.

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

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 24.
. Respiratory and inhalation therapy
. Dialysis hemodialysis and peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy Home IV and antibiotic
therapy

. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the medical benefit.
Note: We will only cover GHT when the treatment is prior authorized by your Primary Care Physician. It is a good idea to call us at 1-866-320-

0697 to confirm that prior authorization has been done before starting treatment. If we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services requiring our prior authorization in Section 3.

$15 per office visit

2003 Coventry Health Care of Kansas, Inc. 17 Section 5( a) 20.
20 Page 21 22
Physical, occupational therapies and chiropractic You pay
60 days per condition for the services of each of the following:
. qualified physical therapists
. occupational therapists and
. chiropractors (coverage limited to subluxation and manipulation)
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

. Cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, is provided for up to 60 days per condition.

$15 copay for each outpatient session; Nothing per visit during covered inpatient
admission

Not covered:
. Long-term rehabilitative therapy
. Exercise programs

All charges.

Speech therapy
60 days per condition $15 copay for each outpatient session.
Nothing per visit during covered inpatient admission

Hearing services (testing, treatment, and supplies)
. First hearing aid and testing only when necessitated by accidental
injury

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

$15 per office visit

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

Vision services (testing, treatment, and supplies)
. Eye refraction every two years $10 per office visit

. One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery (such as for cataracts) $15 per office visit

. Eye exam to determine the need for vision correction for children
through age 17 (see preventive care) $15 per office visit

Vision services --continued on next page

2003 Coventry Health Care of Kansas, Inc. 18 Section 5( a) 21.
21 Page 22 23
Vision services (testing, treatment, and supplies) (continued) You pay
Not covered:
. Eyeglasses or contact lenses and, after age 17, examinations for
them

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

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$15 per office visit

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

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

All charges.

Orthopedic and prosthetic devices
. Orthopedic devices such as braces
. Artificial limbs and eyes
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy. External prosthetic devices, except those associated with reconstructive

surgery after a mastectomy, are limited to one per member per lifetime.

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

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

20% of charges limited to a maximum Plan benefit of $1, 000 per member per calendar
year.

Orthopedic and prostetic devices --continued on next page
2003 Coventry Health Care of Kansas, Inc. 19 Section 5( a) 22.
22 Page 23 24
Orthopedic and prosthetic devices (continued) You pay
Not covered:
. orthopedic and corrective shoes
. arch supports
. foot orthotics
. heel pads and heel cups
. lumbosacral supports
. corsets, trusses, elastic stockings, support hose, and other supportive
devices

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

All charges.

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

oxygen and dialysis equipment. Under this benefit, we also cover:
. hospital beds;
. wheelchairs;
. crutches;
. walkers;
. insulin pumps; and
. blood glucose monitors for those members with diabetes.

Note: Call us at 1-866-795-3995 as soon as your Plan physician prescribes this equipment. We will arrange with a contracting health

care provider to provide you with the necessary equipment, according to the benefit.

20% of charges limited to a maximum Plan benefit of $1, 000 benefit per member per
calendar year.

Nothing.
Not covered:
. Motorized wheel chairs
All charges.

2003 Coventry Health Care of Kansas, Inc. 20 Section 5( a) 23.
23 Page 24 25
Home health services You pay
. Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.

. Services include oxygen therapy, intravenous therapy and
medications.

Nothing.

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

. Home care primarily for personal asssistance that does not include
medical component and is not diagnositc, therapeutic, or rehabilitative.

All charges

Chiropractic
See Physical and Occupational therapies

Alternative treatments
No benefit All charges.

Educational classes and programs
Coverage is limited to:

. Diabetes Self-Management educational classes, as referred by your
Plan physician

. Prenatal education classes

Nothing

2003 Coventry Health Care of Kansas, Inc. 21 Section 5( a) 24.
24 Page 25 26
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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. Plan physicians must provide or arrange your care.
. We have no calendar year deductible.
. Be sure to read Section 4, Your costs for covered services, for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

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

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting
. Normal pre-and post-operative care by the surgeon
. Correction of amblyopia and strabismus
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and cysts
. Correction of congenital anomalies (see reconstructive surgery)
. Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible

members must be age 18 or over
. Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.

. Treatment of burns

$15 per office visit;

. Voluntary sterilization (e. g. Tubal ligation, Vasectomy) $100 copayment per procedure
Not covered: . Reversal of voluntary sterilization
. Routine treatment of conditions of the foot; see foot care.
All charges

2003 Coventry Health Care of Kansas, Inc 22 Section 5( b) 25.
25 Page 26 27
Reconstructive surgery You pay
. Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if:
. the condition produced a major effect on the member's
appearance and

. the condition can reasonably be expected to be corrected by
such surgery

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

palate; birth marks; webbed fingers; and webbed toes.
. All stages of breast reconstruction surgery following a mastectomy,
such as:

. surgery to produce a symmetrical appearance on the other
breast;

. treatment of any physical complications, such as
lymphedemas;

. breast prostheses and surgical bras and replacements (see
Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48

hours after the procedure.

$15 per office visit

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. . Treatment of TMJ

$15 per office visit

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

. TMJ related dental work

All charges.

2003 Coventry Health Care of Kansas, Inc 23 Section 5( b) 26.
26 Page 27 28
Organ/ tissue transplants You pay
Limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Lung: Single Double
. Pancreas
. Allogeneic (donor) bone marrow transplants

. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's

lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

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

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

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

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

Nothing

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

. Transplants not listed as covered

All charges

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

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

. Office

$15 per office visit

2003 Coventry Health Care of Kansas, Inc 25 Section 5( b) 28.
28 Page 29 30
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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Here are some important things to remember about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.

. Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
. 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 the facility (i. e., hospital or surgical center) or
ambulance service for your surgery or care. Any costs associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

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

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

. general nursing care; and .
meals and special diets.

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

$100 per day up to a maximum of $300 per admission

Other hospital services and supplies, such as: . Operating, recovery, maternity, and other treatment rooms
. Prescribed drugs and medicines .
Diagnostic laboratory tests and X-rays . Administration of blood and blood products

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

. Anesthetics, including nurse anesthetist services .
Take-home items

. Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

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

. Private nursing care

All charges.

2003 Coventry Health Care of Kansas, Inc 26 Section 5( c) 29.
29 Page 30 31
Outpatient hospital or ambulatory surgical center You pay
. Operating, recovery, and other treatment rooms .
Prescribed drugs and medicines . Diagnostic laboratory tests, X-rays, and pathology services

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

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

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

$50 per surgery

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
A comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary and confinement in a skilled

nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered,
including:
. Bed, board, and general nursing care
. Drugs, biologicals, supplies, and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by a Plan doctor.

Nothing

Not covered: custodial care All charges
Hospice care
Supportive and Palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient

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

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
. Land ambulance service when medically appropriate. We limit
coverage to $400 per transport.

. Air ambulance when medically appropriate

30% of covered charges per transport up to our $400 coverage limit.

30% of covered charges

2003 Coventry Health Care of Kansas, Inc 27 Section 5( c) 30.
30 Page 31 32
Section 5 (d). Emergency services/ accidents
I M
P O
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T

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

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

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

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor, for First Help, the Plan's 24-hour advice line at 1-800-622-9528. In extreme emergencies, if you are unable to contact your doctor,

contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must
notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

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

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

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

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

2003 Coventry Health Care of Kansas, Inc. 28 Section 5( d) 31.
31 Page 32 33
Benefit Description You pay
Emergency within our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital,
including doctors' services

$15 per office visit
$25 per office visit
$75 per visit; waived if admitted to hospital

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services

$15 per office visit
$25 per office visit
$75 per ER visit; waived if admitted to hospital

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
. Land ambulance service when medically appropriate. We limit
coverage to $400 per transport

. Air ambulance when medically appropriate
See 5( c) for non-emergency service.

30% coinsurance per transport up to our $400 coverage limit.
30% of covered charges

2003 Coventry Health Care of Kansas, Inc. 29 Section 5( d) 32.
32 Page 33 34
2003 Coventry Health Care of Kansas, Inc 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.

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

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

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

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

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

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

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

. Medication management

$15 per visit

. Diagnostic tests $15 when the test is not performed during
your office visit. You only pay the office visit copayment when the test is performed

during your office visit.

Mental health and substance abuse benefits -Continued on next page 33.
33 Page 34 35
2003 Coventry Health Care of Kansas, Inc 31 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
. Services provided by a hospital or other facility
. Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing
$100 copay per day up to a maximum of $300 per admission

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

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

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
Call 1-800-752-7242. When you call, be prepared to give your name and member I. D. number. You will be asked some general questions about why you are seeking services,
and you will be referred to a provider for treatment.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2003 Coventry Health Care of Kansas, Inc. 32 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the next page.
. All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when
we determine they are medically necessary.

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There are important features you should be aware of. These include:
. Who can write your prescription. A plan physician or licensed dentist must write the prescription.

. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication.

. We use a formulary. We cover non-formulary drugs prescribed by a Plan doctor. Prescription drugs
prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31-day supply or 100-unit dosage, whichever is less. You pay a $5 copay per prescription unit or refill for formulary

generic drugs or a $15 copay for formulary name brand drugs or a $45 copay for non-formulary prescription drugs requested by the prescribing doctor.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name
brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-866-320-0697. When generic substitution is permissible (i. e., a generic
drug is available and the prescribing doctor does not require the use of a name brand drug), but you request the name brand drug, you pay the price difference between the average wholesale prices of the generic and
name brand drug as well as the $15 copay per prescription unit or refill.
. You can obtain through Mail Order covered "maintenance" prescription drugs used to treat chronic or long-term
health conditions (such as high blood pressure or diabetes) for a 93-day supply. You pay $10 copay per prescription unit or refill for formulary generic drugs, and $30 copay for formulary name brand drugs. Note:

Our mail order benefit is limited to two tiers. Non formulary prescription drugs are not covered under the maintenance mail order.

. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's
formulary is based on effectiveness and cost of drugs. Nonformulary drugs under the retail pharmacy benefit will be covered when prescribed by a Plan doctor.

. These are dispensing limitations. Retail Pharmacy Prescription drugs prescribed by a Plan or referral doctor
and obtained at a Plan pharmacy will be dispensed for up to a 31-day supply or 100-unit dosage, whichever is less. If a 90-day supply is prescribed, you will be able to pick up a 31-day supply at the pharmacy. The

balance of the script will be dispensed on a 31-day basis. Mail Order-Covered Mail Order "maintenance" prescription drugs use to treat chronic or long-term health conditions (such as high blood pressure or
diabetes) for a 93-day supply. 35.
35 Page 36 37
2003 Coventry Health Care of Kansas, Inc. 33 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

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

. Insulin
. Diabetic supplies, including insulin syringes, needles, glucose test
tablets and test tape, Benedict's solution, or equivalent, and acetone test tablets are each available for the $10 copay.

. Disposable needles and syringes for the administration of covered
medications.

. Drugs for sexual dysfunction
. Contraceptive drugs. (Contraceptive devices, see Section 5 (a) )

Retail Pharmacy
$5 per generic formulary drug
$15 per brand name formulary drug
$45 per non formulary drug

Mail Order (93-day supply)
$10 per generic formulary drug
$30 per brand name formulary drug
Note: Our mail order benefit is limited to the two tiers listed above.

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

the brand name copay plus the difference in the average wholesale price between the
generic and the brand name drug. This applies to both the formulary and non-formulary
drugs.
Not covered:
. Drugs available without a prescription or for which a non-prescription
equivalent is available.

. Drugs and supplies for cosmetic purposes
. Vitamins, nutrients, and food supplements even if a physician
prescribes or administers them

. Non-prescription medicines
. 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 smoking cessation, include nicotine patches
. Fertility drugs
. Appetite suppressants and other drugs to assist in weight control
(except for the treatment of morbid obesity when authorized by the Plan and your primary care physicians).

All charges. 36.
36 Page 37 38
Section 5 (g). Special features
Feature Description

24 hour nurse line Call FirstHelp anytime you or a family member experience health symptoms that need attention. Nurses are available to you and your family 24 a day, 7 days a week and are trained to handle your questions. Any member who visits an
emergency room or urgent care center as a result of advice from FirstHelp will automatically have associated claims approved. With FirstHelp authorization, you
will know in advance if medical services will be covered. You may call 1-800-622-9528 or for the hearing impaired call 1-800-735-2966.

Services for deaf and hearing impaired The Kansas TDD relay number is 1-800-766-3777.

Transplant Network In order to provide members requiring a transplant the opportunity for the best outcomes and experiences, We have contracted with United Resource Networks for access to a network of transplant programs with proven expertise. United
Resource Networks evaluates transplant programs throughout the United States, and has built a nationally-recognized network of programs called the United
Resource Networks Transplant Network.

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

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

. The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.

. Our decision to offer or withdraw alternative benefits is not subject to OPM
review under the disputed claims process.

2003 Coventry Health Care of Kansas, Inc. 34 Section 5( g) 37.
37 Page 38 39

2003 Coventry Health Care of Kansas, Inc.. 35 Section 5 (h)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and
are payable only when we determine they are dentally necessary.

. Members may contact National Dental Plans (NDP) a CompDent company toll free at (800) 456-5500 or visit
their website at www. compdent. com, for a complete listing of services and associated costs.

. We have no calendar year deductible. There are no out-of-network benefits.
. The member must pay the dentist the listed copay at the time of service. The member is not limited to a specific
number of visits per year. Member does not have to be assigned to a certain provider office. Member may visit any dentist in the plan. A plan dentist must provide or arrange your care.

. We coverhospitalization for dental procedures only when a non-dental physical impairment exist which makes
hospitalization necessary to safeguard the health of the patient. See section 5 ( c ) for inpatient benefits.

. This is not a complete list of our Dental benefits. For a complete list of our Dental
benefits, contact National Dental Plans (NDP) a CompDent company toll free at (800) 456-5500 or visit NDP's website at www. compdent. com.

. Important Note: Prior to treatment, always discuss all fees with the dentist. Some of
our benefits list the amount you pay for the service. For other covered benefits, you pay a percentage of the dentist's usual and customary fee. IT IS YOUR

RESPONSIBILITY TO BE INFORMED ABOUT YOUR DENTAL COVERAGE.

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

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Accidental injury benefit You pay
We cover emergency restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these

services must result from an accidental injury.
The remaining cost after 20% reduction of participating specialist fees

Dental benefits
Service You pay
General dentist (you pay restorative services)
Amalgam (fillings silver, plastic or composite)
Crowns (Stainless steel, cast or porcelain/ metal)
$33 55
$431 458

Periodontic services
Root planning (per quadrant) $44 114

Orthodontic services
Standard fully banded case (available to members age 19 and under)
The remaining cost after a 20% reduction of the participating specialist usual &

customary fees for services provided

Endodontic services
Root canals
The remaining cost after a 20% reduction of the participating specialist usual &

customary fees for services provided
Dental benefits continued on next page 38.
38 Page 39 40
2003 Coventry Health Care of Kansas, Inc.. 36 Section 5 (h)
Dental benefits (continued) You pay
Oral surgery
Simple extraction
Extractions (each additional tooth)
Surgical removal of erupted tooth

$45
$39
$85

Prosthetic services
Dentures (complete upper or lower)
Partial dentures
$540
$455

. Any treatment provided by a participating specialist (advanced degree)
will be charged at a 20% reduction of participating specialist fees for that particular case.

Note: Some specialists may require a consultation visit before treatment is initiated.

The remining cost after a 20% reduction of the participating specialist usual &
customary fees for services provided

Not covered:
. Services for injuries or conditions that are covered under Workman's
Compensation or Employer Liability Laws.

. Services which are provided without cost to the member by any
municipality, county, or other political subdivision.

. Cost of dental care that is covered under automobile medical, no fault,
or similar type insurance.

. General anesthesia, IV sedation, nitrous oxide, hospitalization or
hospital medical charges of any kind.

. Osseointegrated implants
. Member's dental fees apply only when treatment is performed at a
participating dental office. If the services of a non-participating specialist or non-participating general dentist are required, these

dental fees do not apply, and the patient will be responsible for the non-participating dentist's usual, customary and reasonable fee.

. Reduced fees will not be honored if the dental treatment is already in
progress or if the patient's membership is no longer valid.

. Any member accepted for orthodontics must remain a member of the
dental plan for the full duration of their treatment or risk additional charges from their participating Orthodontist.

. A patient's existing dental or medical condition may necessitate extra
precautionary procedures and require additional charges.

Please discuss all fees with the dentist prior to treatment.

All charges. 39.
39 Page 40 41
2003 Coventry Health Care of Kansas, Inc.. 37 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.

Vision One Discount Program: Contact Vision One for a participating Vision One Provider near you, 1-800-804-4384

Vision One You pay
Frames-Retail
Priced up to $60.99 Priced $61. 00-$ 80. 99

Priced $81. 00-$ 100. 99 Priced $101.00 and over
$25.00 $35.00
$45.00 65%

Lenses (uncoated plastic)
Single Vision Bifocal

Trifocal Lenticular
$30.00 $50.00
$60.00 $100.00

Lens Options (add to lens cost)
Standard Progressive (no line) Polycarbonate

Scratch Resistant Coating Anti-Reflective Coating
Ultraviolet Coating Solid Tint
Gradient Tint Photochromic
Glass

$50.00 $30.00
$12.00 $35.00
$12.00 $8. 00
$8. 00 $30.00
$15.00
Eye Examinations
Note: Your medical plan may already cover eye exams. This fee is for subsequent eye exams once your existing eye exam benefit is

exhausted.

$35.00 (Fixed eye exam rate)

Contact Lenses
Use the Vision One Contact Lens Replacement program for additional savings and convenience.
20% off regular retail prices; 10% discount on disposables

All Other Materials (sunglasses, accessories, etc.) 20% discount off regular retail prices
Prices are effective as of 8/ 1/ 02 and subject to change without notice. 40.
40 Page 41 42
2003 Coventry Health Care of Kansas, Inc.. 38 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.

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

. Services, drugs, or supplies related to sex transformations;
. 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. 41.
41 Page 42 43
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

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

Medical, hospital and drug 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 1-866-320-0697.
When you must file a claim --such as for services you receive outside of the Plan's service --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:
. Covered member's name and ID number;
. Name and address of the physician or facility that provided the service or supply;
. Dates you received the services or supplies;
. Diagnosis;
. Type of each service or supply;
. The charge for each service or supply;
. A copy of the explanation of benefits, payments, or denial from any primary payer
--such as the Medicare Summary Notice (MSN); and

. Receipts, if you paid for your services.

Submit your claims to: Coventry Health Care of Kansas
P. O. Box 7124
London, KY 40742

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

2003 Coventry Health Care of Kansas, Inc.. 39 Section 7 42.
42 Page 43 44
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 90 days from the date of our decision; and
(b) Send your request to us at: Coventry Health Care of Kansas, Inc., Attn: Member Appeals, 1001 East 101 st Terrace, Suite 300, Kansas City, MO 64131; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, 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.

2003 Coventry Health Care of Kansas, Inc.. 40 Section 8 43.
43 Page 44 45
The Disputed Claims process (continued)
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-866-320-0697 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 III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time.

2003 Coventry Health Care of Kansas, Inc.. 41 Section 8 44.
44 Page 45 46
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 or have automobile insurance that pays health care expenses without regard
to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

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

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

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

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

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

. The Original Medicare Plan
(Part A or Part B)

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or precertified as required.
We will waive some copayments, coinsurance, and deductibles, as follows: When Original Medicare is the primary payor, we will waive your out of pocket costs including
copayments and coinsurance. 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.

2003 Coventry Health Care of Kansas, Inc.. 42 Section 9 45.
45 Page 46 47

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

out if you need to do something to file your claims, call us at 1-866-320-0697 or visit us at www. chckansas. com.

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 your out-of-pocket costs including copayments and coinsurance. 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.

(Primary payer chart begins on next page)

2003 Coventry Health Care of Kansas, Inc.. 43 Section 9 46.
46 Page 47 48
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and
OriginalMedicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability),

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

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

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

covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, (for Part B services) (for other services)

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

(except for claims related to Workers'

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

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

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

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

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

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

This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary and we will waive your out-of pocket costs like copayments and coinsurance, up to our allowed
amount. 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 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. 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 If you do not have one or both Parts of Medicare, you can still be covered under the
Medicare Part A or B FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it.

2003 Coventry Health Care of Kansas, Inc.. 45 Section 9 48.
48 Page 49 50
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.

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

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

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

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

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

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

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

2003 Coventry Health Care of Kansas, Inc.. 46 Section 9 49.
49 Page 50 51
Section 10. Definitions of terms we use in this