Pages 1--64

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

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

Enrollment codes for this Plan:
DA1 Self Only
DA2 Self and Family

BlueCHiP, Coordinated Health Partners, Inc.
http: / / www. bcbsri. com 2003

RI 73-489
For changes
in

benefits see page 8. 1.
1 Page 2 3
2003 BlueCHiP, Coordinated Health Partners
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 it enrollees. Since bene-
fits 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 an 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 con-
strain premium increases while maintaining a benefits program that is highly valued by our employ-
ees 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 year. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with the 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 http: / / www. opm. gov/ insure

Sincerely,

Kay Coles James
Director 2.
2 Page 3 4
2003 BlueCHiP, Coordinated Health Partners
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 infor-
mation.
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. 3.
3 Page 4 5
2003 BlueCHiP, Coordinated Health Partners
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call
202-606-0191 and ask for OPM s FEHB Program privacy official for this purpose.

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change.
The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
2003 BlueCHiP, Coordinated Health Partners Table of Contents
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
We also have point-of service ( POS) benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2. How we change for 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 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

2 5.
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2003 BlueCHiP, Coordinated Health Partners Table of Contents
Flexible benefits option
Services for deaf and hearing impaired
Reciprocity benefit
High risk pregnancies
Centers of excellence
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
( i) Point of service product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
( j) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 6. General exclusions things we don t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
What is Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Worker Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Children s Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Long term care insurance is still available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

3 6.
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4 2003 BlueCHiP, Coordinated Health Partners Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of BlueCHiP, Coordinated Health Partners, Inc. under our contract ( CS2328) with the Office of
Personnel Management ( OPM) , as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by
Coordinated Health Partners, Inc. The address for Coordinated Health Partners administrative offices is:

BlueCHiP, Coordinated Health Partners, Inc.
15 LaSalle Square
Providence, RI 02903

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 summa-
rized on page 8. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; we
means BlueCHiP, Coordinated Health Partners, Inc.

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

Our brochure and other FEHB plans brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM s Rate Us
feedback area at www. opm. gov/ insure or e-mail 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.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits ( FEHB) Program premi-um.

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. 7.
7 Page 8 9
5 2003 BlueCHiP, Coordinated Health Partners Introduction/ Plain Language/ Advisory
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 401-274-3500 from within the State of Rhode Island or
1-800-564-0888 from outside Rhode Island and explain the situation.
If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United state 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.
8 Page 9 10
6 2003 BlueCHiP, Coordinated Health Partners Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments,
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.

We also have Point-of-Service ( POS) benefits:
Our HMO offers Point-of-Service ( POS) benefits. This means you can receive covered services from a participating provider with-
out a required referral, or from a non-participating provider. These out-of-network benefits have higher out-of-pocket costs than our
in-network benefits.

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. BlueCHiP, Coordinated
Health Partners is affiliated with Blue Cross and Blue Shield of Rhode Island. BlueCHiP, Coordinated Health Partners contracts
with over 1000 primary care doctors ( family and general practitioners, internists, pediatricians, and some obstetrician/ gynecologists
who have chosen to participate as a primary care doctor) and over 1700 specialists, along with a full range of hospitals across the
State of Rhode Island and Southeastern Massachusetts. All participating primary care doctors practice out of offices in the communi-
ty. Each member selects a primary care doctor who acts as a personal doctor working to coordinate all of your health care needs.
When specialist services are needed, your primary care doctor will refer you to a BlueCHiP, Coordinated Health Partners specialist.
You must receive a referral from your primary care doctor in order to receive maximum benefits.

BlueCHiP, Coordinated Health Partners has a POS product which offers members the flexibility of obtaining services without a
referral from their primary care doctor or from non-Plan providers. You will be subject to deductibles and coinsurance. For more
information regarding this benefit, see page 42.

Your Rights
OPM requires all FEHB Plans to provide certain information to their FEHB members. You may get information about us, our net-
works, 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.

Years in existence: 16 years
Profit status: For profit
If you want more information about us, call 401/ 274-3500 , or write to 15 LaSalle Square, Providence, RI 02903 . You may also
contact us by fax at 401-459-5089 or visit our website at www. bcbsri. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is the
State of Rhode Island and the following cities and towns in the state of Massachusetts: Acushnet, Attleboro, Bellingham, Blackstone,
Dartmouth, Dighton, Fall River, Fairhaven, Foxborough, Franklin, Mansfield, Medway, Mendon, Millville, New Bedford, North
Attleboro, Norton, Plainville, Raynham, Rehoboth, Seekonk, Somerset, Swansea, Taunton, Uxbridge, Wesport and Wrentham. 9.
9 Page 10 11
2003 BlueCHiP, Coordinated Health Partners Section 1
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 or Point of Service 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. BlueCHiP, Coordinated Health Partners, Inc. offers the HMO USA Guest
Membership Program. To enroll in this program, please contact Customer Service at 401-274-3500 from within Rhode Island or toll
free at 1-800-564-0888 from outside of Rhode Island. 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.

.

7 10.
10 Page 11 12
8 2003 BlueCHiP, Coordinated Health Partners Section 5
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not
change benefits.

Program-wide changes
A Notice of the Office of Personnel Management s Privacy Practices is included.
A section on the Children s Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB
Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 58.2% for Self Only or 47.0% for Self and Family.
Office visits to the member s primary care physician will require a $ 15 copayment. Office visits to a specialist will require a $ 25
copayment. Previously, you paid a $ 10 copayment for office visits to your primary care physician or to a participating specialist
with a referral from your primary care physician. ( Section 5a)
Inpatient admissions for acute care, maternity, mental health, substance abuse, transplants and hospice care will require a $ 500
per admission copayment, with a $ 1,000 individual/ $ 2,000 family out-of-pocket maximum per calendar year. This will also apply
to admissions that result as part of an emergency room visit. Previously, you paid nothing. ( Section 5c)
You will pay $ 7 per prescription unit or refill for generic drugs, $ 25 per prescription unit or refill for brand name drugs on the
Plan s formulary and $ 40 per prescription unit or refill for brand name drugs not listed on the Plan s formulary. Prescriptions
filled at a non-Plan pharmacy will be covered at 80% of the Plan s allowance less a $ 40 copayment. Previously, you paid $ 5 per
prescription unit or refill for generic drugs, $ 15 per prescription unit or refill for brand name drugs on the Plan s formulary and
$ 30 per prescription unit or refill for brand name drugs not listed on the Plan s formulary. Prescriptions filled at a non-Plan phar-
macy were covered at 80% of the Plan s allowance less a $ 30 copayment. ( Section 5f)
Prescription drugs prescribed by a physician will be dispensed for up to a 30-day supply for non-maintenance drugs and mainte-
nance drugs. Previously, prescription drugs prescribed by a physician were dispensed for up to a 34-day supply for non-mainte-
nance drugs or the greater of a 34-day supply or 100 units for maintenance drugs. ( Section 5f)
Members utilizing the mail service prescription drug service will pay two copayments for a 90-day supply. For example, a
generic drug available through the mail service program will cost $ 14 for a 90-day supply. Previously, you paid three copay-
ments for a 90-day supply. ( Section 5f)
Fertility drugs purchased at the pharmacy require a 20% copayment. Previously, fertility drugs purchased at the pharmacy were
covered with the applicable pharmacy copayment. ( Section 5f)
Infertility treatment, including artificial insemination, intrauterine insemination and assisted reproductive technology procedures
require a 20% copayment.
If you utilize the Point-of-Service benefit, the Plan will pay 70% of it s allowance after you meet the calendar year deductible of
$ 500 per individual/ $ 1,000 per family. You are protected by an out-of-pocket maximum of $ 5,000 per individual and $ 10,000 per
family per calendar year. Previously, the Plan paid 80% of it s allowance after a $ 250 individual/ $ 500 family deductible, with an
out-of-pocket calendar year maximum of $ 3,000 per individual/ $ 6,000 per family. ( Section 5i)
Members are now covered for up to twelve ( 12) chiropractic visits per calendar year. Previously, you were covered up to six ( 6)
visits per year. ( Section 5a)
Emergency care as an outpatient at a hospital, including doctor s services will require a $ 50 copayment. If the emergency results
in an admission to the hospital, the copayment is waived. Previously, you paid a $ 25 copayment for emergency room visits.
( Section 5d)
Emergency/ urgent care at an urgent care center, including doctor s services, will require a $ 25 copayment. Previously, you paid a
$ 20 copayment for urgent care center visits. ( section 5d) 11.
11 Page 12 13
9 2003 BlueCHiP, Coordinated Health Partners Introduction/ Plain Language
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 enroll-
ment 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 enroll-
ment, or if you need replacement cards, call us at 401-274-3500 from within the State of
Rhode Island or 1-800-564-0888 from outside of Rhode Island.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copay-ments, deductibles, and/ or coinsurance, and you will not have to file claims. If you use
our point-of-service program, you can also get care from non-Plan providers, or from
participating providers without a required referral, but it will cost you more.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list
is also on our website.

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

What you must It depends on the type of care you need. First, you and each family member must do to get care choose a primary care physician. This decision is important since your primary care
physician provides or arranges for most of your health care. You will select a primary
care physician for you and each covered member of your family when you enroll by
completing the primary care physician selection card provided by the Plan. If you want
to change your primary care physician at any time, you must contact Customer Service
at 401-274-3500 from within the State of Rhode Island and 1-800-564-0888 from out-
side of Rhode Island prior to receiving any services. The change will not be effective
until the first day of the following month.

Primary care Your primary care physician can be a family practitioner, general practitioner, internist,
or pediatrician. In addition, some OB/ GYNs are also primary care physicians. Your pri-
mary care physician will provide most of your health care, or give you a referral to see a
specialist.

If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you
receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician has authorized a
certain number of visits. The primary care physician must provide or authorize all fol-
low-up care. Do not go to the specialist for return visits unless your primary care physi-
cian gives you a referral. However, you may see your OB-GYN for annual exams, go
for your annual eye exam and receive up to twelve ( 12) chiropractic visits per year with-
out a referral. In addition, you do not need a referral from your primary care doctor for
mental health or substance abuse services, however, you must receive authorization for
these services from the Plan s mental health administrator. Here are other things you
should know about specialty care: 12.
12 Page 13 14
10 2003 BlueCHiP, Coordinated Health Partners Section 3
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with your 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 crite-
ria when creating your treatment plan ( the physician may have to get an authoriza-
tion 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 spe-
cialist 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 arrange-ments 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 401-274-3500 from within Rhode Island or toll
free at 1-800-564-0888 from outside of Rhode Island. If you are new to the FEHB
Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospi-
tal stay until:

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

These provisions apply only to the benefits of the hospitalized person. 13.
13 Page 14 15
2003 BlueCHiP, Coordinated Health Partners Section 3 11
Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may have to our control delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services Requiring Your primary care physician has authority to refer you for most services. For certain Prior Medical Review services, however, it is recommended that your physician obtain prior approval from us.
Before giving approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

We call this review and approval process the Prospective Medical Review process. It is
recommended that your physician obtain prior medical review for the following services
to ensure that they will be covered: inpatient admissions, home health care/ home IV
therapy, home physical, speech and occupational therapy, speech therapy, durable med-
ical equipment, inpatient and outpatient hospice care, skilled nursing care, inpatient
rehabilitation, pulmonary rehabilitation, human growth hormone therapy and organ
transplants. Mental health and substance abuse services require authorization from the
Plan s Behavioral Care Administrator. You may be responsible for payment of these
services if they are determined to not be medically necessary.

We continue to recommend that you obtain prior medical review for these same services
when utilizing the POS benefit. When utilizing non-Plan participating providers, it is
recommended that you advise your provider to contact the Plan for prior medical review
in advance of such services to ensure they will be covered. 14.
14 Page 15 16
2003 BlueCHiP, Coordinated Health Partners Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

Copayments A copayment is a fixed amount of money you pay to a provider, facility, pharmacy, etc. , when you receive services.

Example: When you see your primary care physician you pay a copayment of $ 15 per
primary care office visit, $ 25 per specialist office visit and when you go in the hospital,
you pay $ 500 per admission.

Deductible We do not have a deductible except as noted under the POS benefit.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 20% of our allowance for infertility services and diabet-
ic supplies. Coinsurance also applies when you use the POS benefit.

Your catastrophic protection After your in-network inpatient copayments per admission reach $ 1000 per person or
out-of-pocket maximum for $ 2000 per family per calendar year, you do not have to pay any more for covered
deductibles, coinsurance and inpatient services for that year. There are no other out-of-pocket maximums except as
copayments noted under the POS benefit.

12 15.
15 Page 16 17
2003 BlueCHiP, Coordinated Health Partners Section 5 13
Section 5. Benefits OVERVIEW
( See page 8 for how our benefits changed this year and page 55 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
claims forms, claims filing advice, or more information about our benefits, contact us at 401-274-3500 from within Rhode Island or
toll free at 1-800-564-0888 from outside of Rhode Island. or at our website at www. bcbsri. 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
nfertility services
Allergy care
Treatment therapies
Physical and occupational therapies

( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . 22-25

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

( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27

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

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

( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-31
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-33
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Reciprocity benefit; High Risk Pregnancies

( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
( i) Point of service benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-37
( j) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

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 16.
16 Page 17 18
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2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 14

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

Plan physicians must provide or arrange your care.
We have no calendar year deductible for services received from Plan participating providers. Please see
Section 5( i) regarding your Point-of-Service benefits.

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.

Benefit Description You pay After the calendar year deductible
Diagnostic and treatment services
Professional services of physicians
In physician s office $ 15 per visit to your primary care physician

At home $ 25 per visit to a specialist
Office medical consultations
Second surgical opinion

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

Professional services of physicians
During a hospital stay Nothing

In a skilled nursing facility

Lab, X-ray and other diagnostic tests

Tests, such as: Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG 17.
17 Page 18 19
2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 15
Preventive care, adult You pay
Routine screenings, such as: Nothing.
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including:

Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50
Routine Prostate Specific Antigen ( PSA ) test one annually for men
age 40 and older

Routine pap test

Note: The office visit copay applies if test is received on the same day;
see Diagnosis and T eatment , above.

Routine mammogram covered for women age 35 and older, as follows: Nothing.
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 year

Not covered: All charges.

Physical exams equired for obtaining or continuing employment or
insurance, attending schools or camp, or travel.

Weight eduction programs, including laboratory tests elated to
programs designed for the purposes or weight eduction All charges.

Routine immunizations, limited to: Nothing.
Tetanus-diphtheria ( Td) booster once every 10 years, ages19 and over
( except as provided for under Childhood immunizations)

Influenza
Pneumococcal vaccine, age 65 and over

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Nothing.
Pediatrics

Well-child care charges for routine examinations, immunizations and care $ 15 per office visit
( through age 22)

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)

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

Weight eduction programs, including laboratory tests elated to programs
designed for the purposes or weight eduction

Examination, evaluations, or services performed solely for educational or
developmental purposes. 18.
18 Page 19 20
2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 16
Maternity care You pay
Complete maternity ( obstetrical) care, such as: $ 15 for initial office visit at Member s
Prenatal care PCP, otherwise, $ 25 for initial office visit
Delivery Specialist; covered in full thereafter
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 31 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. In addition, coverage of injury or
illness or sickness including necessary care and treatment of medically
diagnosed congenital defects and birth abnormalities will be covered for
the first 31 days of a newborn s life; all care after the first 31 days will be
covered only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services ( delivery) the same as for
illness and injury. See Hospital benefits ( Section 5c) and Surgery benefits

( Section 5b) .

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

Family planning
A range of voluntary family planning services, limited to: Nothing.
Voluntary sterilization ( See Surgical procedures Section 5( b) )
Surgically implanted contraceptives
Intrauterine devices ( IUDs)
Diaphragms

Injectable contraceptive drugs ( such as Depo provera) 20%
NOTE: Pharmacy purchased contraceptives are covered under the prescription
drug benefit with the applicable prescription drug copay.

Medically necessary genetic counseling $ 25 per visit
Not covered: All charges.

Reversal of voluntary surgical sterilization
T eatment for infertility when the cause of infertility was a previous
sterilization 19.
19 Page 20 21
2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 17
Infertility services You pay
Diagnosis and treatment of infertility, such as: 20%
Artificial insemination:
Intravaginal insemination ( IVI)
Intracervical insemination ( ICI)
Intrauterine insemination ( IUI)

Assisted eproductive technology ( ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT

Zygote transfer 20%
Fertility drugs 20%
Note: Fertility drugs purchased at the pharmacy also have a 20% copayment.

Not covered: All charges.
Freezing ( i. e. , cryo-preservation) and storage of gametes, sperm, embryos
or other specimens for future use;

sperm bank ( i. e. , storage) ;
donor stipend;
donor oocytes for non-infertile couples ( e. g. , member has genetic disorder,
HIV+ status, etc. ) ;

Allergy care
Testing and treatment $ 25 per office visit
Allergy serum Nothing
Allergy injection

Not covered: p ovocative food testing and sublingual allergy desensitization All charges.

Treatment therapies You pay
Chemotherapy and radiation therapy Nothing.
Note: High dose chemotherapy in association with autologous bone marrow
transplants are limited to those transplants listed under Organ/ Tissue
Transplants on page 29.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)

Note: Growth hormone is covered under the medical benefit.
Note: We will only cover GHT when we preauthorize the treatment.
Benefits for treatment will be continued as long as there has been a
satisfactory response to growth hormone of at least 5 cm a year after
the first year. 20.
20 Page 21 22
2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 18
Physical and occupational therapies
Physical and occupational therapy for services by each of the following: $ 25 per office visit
Qualified physical therapists and $ 25 per outpatient visit
Occupational therapists. Nothing per visit during covered inpatient
admission

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. You must
show significant improvement within sixty ( 60) days to receive authorization
for additional treatment.

Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to eighteen ( 18) weeks or thirty
six ( 36) visits, whichever comes first.

Not covered: All charges.
long-term ehabilitative therapy
exercise programs
massage therapy
ecreational therapy

Speech therapy

Speech services by a speech therapist $ 25 per office visit
$ 25 per outpatient visit

Note: You must show significant improvement within sixty ( 60) days Nothing per visit during covered
to receive authorization for additional treatment. $ 25 per office visit inpatient admission

Hearing services ( testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury $ 25 per office visit
Hearing testing for children through age 17 ( see Preventive care, children )

Not covered: All charges.
all other hearing testing

hearing aids, testing and examinations for them

Vision services ( testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly Nothing
caused by accidental ocular injury or intraocular surgery
( such as for cataracts)

Annual eye refractions
Note: See Preventive care, children for eye exams for children $ 25 per office visit

Not covered: All charges.
Eyeglasses or contact lenses
Eye exercises and orthoptics

Radial keratotomy and other efractive surgery 21.
21 Page 22 23
2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 19
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or $ 25 per office visit
peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.

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

T eatment 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 other outine foot care

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose $ 20 per item.
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices as hospital benefits;
see Section 5( c) for payment information. See 5( b) for coverage of the
surgery to insert the device.

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

Not covered: All charges.
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

Durable medical equipment ( DME)
Rental or purchase, at our option, including repair and adjustment, of durable $ 20 per item
medical equipment prescribed by your Plan physician, such as oxygen and
dialysis equipment. Under this benefit, we also cover:

hospital beds;
wheelchairs; ( the type of wheelchair we allow will depend on your
medical condition) ;

crutches;
walkers;
blood glucose monitors; and
insulin pumps. 22.
22 Page 23 24
2003 BlueCHiP, Coordinated Health Partners Section 5 (a) 20
Durable medical equipment ( DME) ( Continued) You pay
Not covered: All charges.
Motorized wheel chairs

Equipment that serves as a comfort or convenience item. Electrical or
mechanical features which enhance basic equipment usually serve a
convenience function. Determination of medical necessity should be made
egarding the coverage of these features.

Equipment used for environmental control or to enhance the environmental
setting or surroundings of an individual should not be considered durable
medical equipment. Examples of these include air conditioners, air filters,
portable jacuzzi pumps, humidifiers, etc.

Repairs to patient owned equipment

Home health services You pay
Home health care ordered by a Plan physician and provided by a Nothing.
registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.

Services including oxygen therpay, intravenous therapy and medications

Not covered: All charges.
Nursing care equested by, or for the convenience of, the patient or
the patient s family;

Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or ehabilitative.

Chiropractic
Manipulation of the spine and extremities up to twelve ( 12) self-referred $ 25 per office visit
visits per calendar year

One set of x-rays of the spine every three ( 3) years

Not covered:
Other imaging studies or laboratory work ordered by a chiropractor All charges
. 23.
23 Page 24 25
21 2003 BlueCHiP, Coordinated Health Partners Section 5( a)
Alternative treatments You pay
No benefit. All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation Coverage is limited to primary care visits and $ 15 per office visit
individual counseling for smoking cessation.

Prescription nicotine substitutes, including transdermal patches, are
covered under the prescription drug benefit up to a maximum of a three
( 3) month supply ( see Section 5( f) ) . Member must submit proof of being
smoke free for a one-year period for reimbursement.

Diabetes self-management -Diabetes education, when medically $ 15 per visit.
necessary and prescribed by a physician, may be provided only by
the physician or, upon his or her referral to, an appropriately licensed
and State certified diabetes educator. Coverage is limited to five

( 5) individual sessions or seven ( 7) group sessions.

Asthma self-management Nothing
. 24.
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22 2003 BlueCHiP, Coordinated Health Partners Section 5( b)
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Section 5 ( b) . Surgical and anesthesia services provided by physicians
and other health care professionals

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and
are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible for services received from Plan participating providers. Please see Section
5( i) regarding your Point-of-Service benefits.
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 sur-
gical care. Look in Section 5( c) for charges associated with the facility ( i. e. hospital, surgical center, etc. ) .
YOUR PHYSICIAN SHOULD GET PRIOR MEDICAL REVIEW OF SOME SURGICAL PROCEDURES.
Please refer to the precertification information shown in Section 3 to be sure which services require precertifica-
tion and identify which surgeries require precertification.

Benefit Description You pay
After the calendar year deductible

Surgical procedures
A comprehensive range of services, such as: $ 25 per office visit; Nothing for surgery
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.

Surgical procedures continued on next page. 25.
25 Page 26 27
2003 BlueCHiP, Coordinated Health Partners Section 5 (b) 23
Surgical procedures ( continued) You pay
Voluntary sterilization ( e. g. , Tubal ligation, Vasectomy) $ 25 per office visit; Nothing for surgery
Treatment of burns

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

Not covered: All charges.
Blood Storage
Reversal of voluntary sterilization

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

Reconstructive surgery
Surgery to correct a functional defect Nothing.
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: Nothing.
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements ( see
Prosthetic devices)

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

after the procedure.

Not covered All charges.
Cosmetic surgery any surgical procedure ( or any portion of a procedure)
performed primarily to improve physical appearance through change in
bodily form, except epair of accidental injury
Surgeries elated to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Nothing.
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.

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

periodontal membrane, gingiva, and alveolar bone) 26.
26 Page 27 28
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea

Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogenetic ( 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.

Medications directly related to the transplant for a one-year period after the
transplant.

All transplants must be performed at a Plan-designated center of excellence.
Contact

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.

Transportation/ lodging when performed at a Plan-designated center of Up to $ 5,000
excellence

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

Implants of artificial organs
Transplants not listed as covered

2003 BlueCHiP, Coordinated Health Partners Section 5 (b) 24 27.
27 Page 28 29
2003 BlueCHiP, Coordinated Health Partners Section 5 (b) 25
` Anesthesia You pay
` Professional services provided in Nothing
Hospital ( inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 28.
28 Page 29 30
26 2003 BlueCHiP, Coordinated Health Partners Section 5( c)
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Section 5 ( c) . Services provided by a hospital or other facility,
And ambulance services

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 for services received from Plan participating providers. Please see
Section 5( i) regarding your Point-of-Service benefits.

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.

Benefit Description You pay
Inpatient hospital
Room and board, such as $ 500 per admission ward, semiprivate, or intensive care accommodations; $ 1000 individual/ $ 2000 family out-of-pocket
general nursing care; and maximum for admission copays per calendar
meals and special diets. year.

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

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home ( Note: calendar year deductible applies. )

Not covered: All charges
Custodial care

Non-covered facilities, such as nursing homes schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds

Private nursing care ( unless medically necessary) 29.
29 Page 30 31
27 2003 BlueCHiP, Coordinated Health Partners Section 5( c)
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Nothing
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.

Not covered: blood and blood derivatives not eplaced by the member All charges.

Extended care benefits/ skilled nursing care facility benefits You pay

Extended care/ skilled nursing facility ( SNF) : Nothing
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or
arranged by a skilled nursing facility when prescribed by a Plan doctor

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.

Inpatient care ( limited to 21 days per calendar year) $ 500 per admission
Family counseling $ 1000 individual/ $ 2000 family out-of-
pocket maximum per calendar year
Hospice 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 ( 6) months or less.

Outpatient care Nothing

Not covered:
independent nursing All charges.
homemaker services

Ambulance
Local professional ambulance service when medically appropriate Nothing 30.
30 Page 31 32
28 2003 BlueCHiP, Coordinated Health Partners Section 5 (d)
Section 5 ( d) . Emergency services/ accidents
Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden
inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have

in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area:

Please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, call 911 or go to the
nearest emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan.
You or your family member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your
responsibility to ensure that the Plan has been notified timely.

If you need to be hospitalized in a non-Plan facility, the Plan must notified within forty-eight ( 48) hours or on the first working
day following you admission , unless it is not reasonably possible to notify the Plan within that timeframe.

To be covered by this Plan, any follow-up care recommended by a non-Plan provider must be approved by a Plan providers
except as covered under the POS benefits.

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 was 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 a non-Plan provider must be approved by a Plan provider
except as covered under the POS benefits.

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29 2003 BlueCHiP, Coordinated Health Partners Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor s office $ 15 per PCP visit
$ 25 per Specialist visit

Emergency care at an urgent care center $ 25 per visit
Emergency care as an outpatient or inpatient at a hospital, including $ 50 per hospital emergency room visit.
doctors services If emergency results in an admission to

the hospital, the copay is waived.

Not covered: Elective care or non-emergency care All charges.

Emergency outside our service area
Emergency care at a doctor s office $ 25 per visit
Emergency care at an urgent care center $ 25 per visit

Emergency care as an outpatient or inpatient at a hospital, including $ 50 per hospital emergency. If emergency
doctors services results in an admission to a hospital, the

copay is waived.
Not covered: All charges.
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 esulting from a normal full-term delivery
of a baby outside the service area.

Ambulance
Professional ambulance service when medically appropriate. Nothing.
See 5( c) for non-emergency service. 32.
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30 2003 BlueCHiP, Coordinated Health Partners Section 5( e)
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Section 5 ( e) . Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for
Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and
conditions.

Here are some important things to keep in mind about these benefits:

All benefits are subject to the definitions, limitations, and exclusions in this brochure.
The inpatient copayment applies to inpatient hospital and some alternative care settings.
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 bene-fits description below

Benefit Description You pay
After the calendar year deductibe. . .

Mental health and substance abuse benefits

All diagnostic and treatment services recommended by a Plan provider Your cost sharing responsibilities are no
and contained in a treatment plan that we approve. The treatment plan may greater than for other illness or conditions.
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.

Professional services, including individual or group therapy by providers $ 25 per visit
such as psychiatrists, psychologists, or clinical social workers

Services in approved alternative care settings residential treatment,
full-day hospitalization, facility based intensive outpatient treatment

Mental health and substance abuse benefits -continued on next page 33.
33 Page 34 35
31 2003 BlueCHiP, Coordinated Health Partners Section 5( e)
Mental health and substance abuse benefits ( continued) You pay
Medication management $ 25 per visit
Diagnostic tests Nothing
Services provided by a hospital or other facility $ 500 per admission
Services in approved alternative care settings such as partial hospitalization $ 1000 individual/ $ 2000 family out-of-pocket
maximum per admission per calendar year

Services in approved alternative care settings such as facility based intensive $ 25 per visit
outpatient treatment, residential treatment

Not covered: All charges.
Services not coordinated through our Administrator
Methodone treatment programs

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

Treatment for mental health conditions and substance abuse may be obtained directly by contacting BlueCHiP s Mental
Health Administrator at 1-800-544-5977 or 401-276-4052 prior to services being rendered. Our Administrator will determine and
authorize the appropriate number of visits and determine the appropriate specialist. A referral from your PCP is not required.

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

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.

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy. Plan pharmacies include CVS and Brooks
pharmacies as well as additional independent pharmacies. Prescriptions filled at non-Plan pharmacies will be covered at 80% of
BlueCHiP, Coordinated Health Partners allowance after a $ 40 copay. In addition, most prescription drugs are available through
the participating mail order pharmacy. Contact Customer Service at 401-274-3500 from within Rhode Island and 1-800-564-
0888 from outside of Rhode Island for more information or to obtain a mail services enrollment form directly logon to
www. pharmacare. com.

We use a formulary. BlueCHiP, Coordinated Health Partners uses a drug formulary, which is a listing of quality, cost effec-
tive medications that are covered under your prescription drug benefit for a lower copay. We cover non-formulary drugs pre-
scribed by a physician; however, you will be responsible for a higher copay.

These are the dispensing limitations. Prescription drugs prescribed by a physician will be dispensed for up to a 30-day sup-ply for non-maintenance drugs and maintenance drugs. If there is no generic equivalent available, you will still have to pay the

brand name copayment. A generic equivalent will be dispensed if it is available, unless your physician specifically requires a
name brand or if you specifically ask and sign for a brand name medication.

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

brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets
quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name
drugs.
You can save money by using generic drugs. However, you and your physician have the option to request a name-brand if a
generic option is available. Using the most cost-effective medication saves money.

When you have to file a claim. You will be required to submit a claim for prescriptions purchased from a non-Plan pharma-cy. You will be required to pay the non-Plan pharmacy directly and the Plan will reimburse you once you have submitted the
receipt, your name, Plan identification number to Basic Claims Administration, 444 Westminster Street, Providence, RI 02903.

2003 BlueCHiP, Coordinated Health Partners Section 5 (f)

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2003 BlueCHiP, Coordinated Health Partners Section 5 (f) 33
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan $ 7 per prescription unit or refill for generic
physician and obtained from a Plan pharmacy or through our mail order program: drugs

Drugs and medicines that by Federal law of the United States require a $ 25 per prescription unit or refill for brand physician s prescription for their purchase, except those listed as Not covered . name drugs on the Plan s formulary

Insulin $ 40 per prescription unit or refill for brand name drugs not listed on the Plan s formulary
Disposable needles and syringes for the administration of covered medications Prescriptions filled at non-Plan pharmacy will be covered at 80% of the Plan s
allowance less a $ 40 copayment
Drugs for sexual dysfunction ( contact Customer Service for limitations) Mail order: $ 14 for formulary generic; $ 50 for formulary brand drugs; $ 80 for non-for-

mulary drugs for a 90-day supply.
Contraceptive drugs and devices purchased at the pharmacy Note: If there is no generic equivalent avail-able, you will still have to pay the brand

name copay. In addition, if a brand name
drug becomes available as a generic, you will
be required to pay the highest copayment.

Injectible drugs purchased at the pharmacy
Prenatal vitamins

NOTE: Fertility drugs purchased at the pharmacy require a 20% copayment.
Not covered:
Over-the-counter drugs ( even if prescribed) All charges.
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Compound medications not made up of at least one Legend drug
Prescription drugs prescribed or dispensed outside our guidelines
Drugs which have not been proven effective according to the Food and Drug Administration

Vitamins ( excluding prenatal) , nutrients and food supplements even if a physician prescribes or administers them
Drugs and supplies for the purpose of weight eduction 36.
36 Page 37 38
Section 5 ( g) . Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate
other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may withdraw it at
any time and resume regular contract benefits.

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

.
Services for deaf and For the deaf or hearing impaired, please call our TDD Number. From outside hearing impaired Rhode Island dial 1-877-232-8432 and from within the State of Rhode Island

dial ( 401) 459-5505.
Reciprocity benefit When you or a covered member are traveling throughout the United States, and need urgent medical care before you return home, call 1-800-810-BLUE to locate a Blue Cross
and Blue Shield traditional provider or log on to www. bcbs. com. In addition, you must
contact Customer Service before or after you receive care ( within 48 hours) to ensure that
your claim is paid appropriately. Please remember to coordinate all follow-up care
through your primary care physician.

High risk pregnancies If you are pregnant, you will be part of our Little Steps prenatal program. Little Steps is designed to work with you and your physician to help you heave the healthiest baby pos-
sible. Little Steps includes free classes on parenting, newborn care and breast-feeding.
The classes are held at participating hospitals throughout Rhode Island. For more infor-
mation contact Customer Service.

Centers of excellence To ensure you receive quality care, we selectively choose medical facilities that specialize in various transplants to participate in our network. The facilities are chosen based on the
duration of their transplant program, volume of transplants performed each year, patient
outcomes, and qualifications of their transplant program medical staff. Each facility is
well known and respected throughout the country, and is designated a Center of
Excellence for its commitment to quality care and positive patient outcomes. By utiliz-
ing one of our network facilities, you will receive quality care and can better manage
your costs. For more information, contact Customer Service.

2003 BlueCHiP, Coordinated Health Partners Section 5 (g) 34 37.
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2003 BlueCHiP, Coordinated Health Partners Section 5 (H) 35
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Section 5 ( h) . Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists ehich makes hospitalization necessary to safeguard the health of the patient. See section 5 for inpatient hospital benefits.

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

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair $ 50 per hospital emergency room visit
( but not replace) sound natural teeth. The need for these services must result
from an accidental injury caused by an unexpected or unintentional means $ 25 per office visit
and must occur within seventy-two ( 72) hours of injury.

Only the following services are covered:

Extraction of teeth needed to avoid infection of teeth damaged in the injury
Suturing and suture removal
Re-implanting and stabilization of dislodged teeth
Medication received from the provider
Not covered:
Injuries incurred as a esult of biting and/ or chewing

Dental benefits
We have no other dental benefits. 38.
38 Page 39 40
36 2003 BlueCHiP, Coordinated Health Partners Section 5 (i)
Section 5 ( i) . Point of service benefits
Facts about this Plan s POS option
At your option, you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need
care, except for the benefits listed below under What is not covered. Benefits not covered under Point of Service must either be
received from or arranged by Plan doctors to be covered. When you obtain covered non-emergency medical treatment from a non-
Plan doctor without a referral from a Plan doctor, you are subject to the deductibles, coinsurance and maximum benefit stated below.

What is covered
Under the point-of-service benefit, you are covered for medically necessary, covered health services when you self-refer to a non-
Plan provider or to a BlueCHiP provider without a referral from your PCP. You may receive medically necessary covered health ser-
vices listed in this brochure, except for the services listed under what is not covered. Once you use the point-of-service benefit, all
services associated with the episode of care ( i. e. , lab, x-ray, hospitalization) will be paid according to your point-of-service benefit. If
you choose to use the point-of-service benefit, you will receive a lower allowance than when the standard HMO benefit is utilized.

You are able to self-refer to a non-Plan provider either inside or outside of our service area. You must call BlueCHiP for authoriza-
tion for hospitalization.

Plan Authorization
When utilizing the POS benefit, we continue to recommend that you obtain prior medical review for the same services that we rec-
ommend you do so under the Standard HMO benefit. When utilizing non-Plan participating providers, it is recommended that you
advise your provider to contact the Plan for prior medical review in advance of such services to ensure they will be covered.

Deductible
When the point-of-service benefit is utilized, you pay a $ 500 deductible per member per calendar year or a $ 1000 deductible per
family per calendar year for doctor s visits, other outpatient services, and hospital services. The deductible is not reimbursable by
the Plan. If you decide to use non-Plan providers or self refer to a Plan provider, this deductible applies to all covered benefits.
Copayments under the BlueCHiP, Coordinated Health Partners point-of-service benefit cannot be used to meet your calendar year
deductible.

Coinsurance
Members are able to self-refer to a provider either inside or outside the Service Area. If the self-referral is to a provider who does not
participate with the BlueCHiP network, but who is part of the Blue Cross and Blue Shield national traditional network ( Host Blue) ,
you will only be responsible for your deductible and the 30% coinsurance. To check if the provider participates with this program,
please call 1-800-810-BLUE or log on to www. bcbs. com. These providers will file the claim directly. This feature is referred to as
the BlueCard program.

If you self-refer to a provider who is neither part of the BlueCHiP network, nor part of the BlueCard program, you will be responsi-
ble for any amount over our allowance, in addition to your deductible and coinsurance amount.

When you use the Flex Plan Rider to self-refer for services to a BlueCHiP participating provider, BlueCHiP will pay 70% of the
BlueCHiP fee schedule based on existing contractual relationships with the provider. BlueCHiP providers cannot charge the member
more than the contracted fee.

When you obtain health care services through the BlueCard program outside the BlueCHiP network, you will pay 30% of the
amount for the covered services. The amount charged for a covered service is calculated on the lower of:

The billed charges for your Covered Health Care Services, or
The negotiated price that the on-site Blue Cross and/ or Blue Shield Plan ( Host Blue ) passes on to us.
Often, this negotiated price will consist of a simple discount, which reflects the actual price paid by the Host Blue. However,
sometimes it is an estimated price that factors into the actual price expected settlements, withholds, any other contingent payment
arrangements and non-claims transactions with your health care provider or with a specified group of providers. The negotiated
price may also be billed charges reduced to reflect an average expected savings with your health care provider or with a specified
group of providers. The price that reflects average savings may result in greater variation ( more or less) from the actual price paid
than will the estimated price. The negotiated price will also be adjusted in the future to correct for over-or underestimation of past
prices. However, the amount you pay is considered a final price. 39.
39 Page 40 41
37 2003 BlueCHiP, Coordinated Health Partners Section 5( i)
Statutes in a small number of states may require the Host Blue to use a basis for calculating your liability for covered services that
does not reflect the entire savings realized, or expected to be realized, on a particular claim or to add a surcharge. Should any state
statutes mandate your liability calculation methods that differ from the usual BlueCard method noted above in this section or require
a surcharge, We would then calculate your liability for any Covered Health Care Services in accordance with the applicable state
statute in effect at the time you received your care.

When you receive services from providers that are not contracted with BlueCHiP or a Host Blue Plan, we will pay 70% of the fee
schedule, as determined by BlueCHiP. The member is responsible for the remaining balance of the non-network provider s charges if
they are greater than the fee schedule. Payment for these services will be made directly to the member. The member is responsible to
pay the provider directly for the services.

All payments made by BlueCHiP for services through the Point of Service benefit will be subject to a deductible as outlined above.

Out-of-Pocket Maximum
You are protected by an out-of-pocket maximum of $ 5,000 per person per calendar year and $ 10,000 per family per calendar year.
This includes deductibles and copayments. Charges over the fee allowance cannot be applied to the out-of-pocket maximum.

Emergency Benefits
True, medically necessary emergency care ( even if received from a non-participating provider) is always covered as a standard HMO
benefit.

Prescription Drugs
You may have prescriptions filled when utilizing the point-of-service benefit. You will be covered at 80% of the BlueCHiP,
Coordinated Health Partners after a $ 40 copay. The benefits and requirements are the same as those for the standard HMO
Prescription Drug Benefit.

What is Not Covered
Anesthesia consultations
Chiropractic care
Diagnostic procedures, such as laboratory tests and x-rays
Durable Medical Equipment ( DME) and medical supplies
Emergency room visits
Home health services
Infertility services
Mental conditions/ substance abuse benefits
Outpatient physical, speech and occupational therapies, cardiac rehabilitation
Rehabilitation hospitalizations
Skilled nursing facility care
Transplant coverage
Vision care benefits

How to Obtain Benefits
If you receive services from a non-participating provider, you may be required to pay up front and submit to us for reimbursement.
Please call Customer Service at 401-274-3500 from within the State of Rhode Island or toll free at 1-800-564-0888 from outside of
Rhode Island for a claim form. We will provide you with a form within 15 days of your request. Submit the claim to Basic Claims
Administration, 444 Westminster Street, Providence, RI 02903 as soon as possible. You must submit a complete claim form by
December 31 of the year after the year you received the service. Either OPM or we can extend this deadline if you show that cir-
cumstances beyond your control prevented you from filing on time. 40.
40 Page 41 42
38 2003 BlueCHiP, Coordinated Health Partners Section 5 (j)
Section 5 ( j) . 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 a FEHB
disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
out-of-pocket maximums.

Medicare prepaid plan

Enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 46, annuitants and former spouses with
FEHBP coverage and Medicare Part B may elect to drop their FEHBP coverage
and enroll in a Medicare prepaid plan when one is available in their area. They
may then later re-enroll in the FEHBP Program. Most federal annuitants have
Medicare Part A. Those without Medicare Part A may join this Medicare pre-
paid plan but will probably have to pay for hospital coverage in addition to the
Part B premium. Before you join the plan, ask whether the plan covers hospital
benefits and, if so, what you will have to pay. Contact your retirement system
for information on dropping your FEHBP enrollment and changing to a
Medicare prepaid plan. Contact us at 1-800-505-2583 for information on the
Medicare prepaid plan and the cost of that enrollment.

If you are Medicare eligible and are interested in enrolling in a Medicare HMO
sponsored by this Plan without dropping your enrollment in this Plan s FEHB
plan, call 1-800-505-2583 for information on the benefits available under the
Medicare HMO.

The benefits on this page are not part of the FEHB contract or premium, and you canot file an FEHB
disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-
of-pocket maximum. 41.
41 Page 42 43
39 2003 BlueCHiP, Coordinated Health Partners Section 6
Section 6. General exclusions things we don t cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover
it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease,
injury, or condition and we agree, as discussed under What Services Require Our Prior Approval on page 11.

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; or
Services, drugs, or supplies you receive without charge while in active military service. 42.
42 Page 43 44
40 2003 BlueCHiP, Coordinated Health Partners Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment, 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 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 401-274-3500 from within the
State of Rhode Island or toll-free at 1-800-564-0888 from outside of Rhode Island.

When you must file a claim such as for services you receive outside of the Plan s
service area submit it on the HCFA-1500 or a claim form that includes the informa-
tion 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: Basic Claims Administration
444 Westminster Street
Providence, Rhode Island 02903

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. 43.
43 Page 44 45
2003 BlueCHiP, Coordinated Health Partners Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: ( a) Write to us within 6 months from the date of our decision; and

( b) Send your request to us at: 15 LaSalle Square, Providence, RI 02903; and
( c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this
brochure; and

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

2 We have 30 days from the date we receive your request to: ( a) Pay the claim ( or, if applicable, arrange for the health care provider to give you the care) ; or

( b) Write to you and maintain our denial go to step 4; or
( c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request go to
step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We
will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days; or

120 days after we asked for additional information. Write to OPM at: Office of Personnel Management, Office of
Insurance Programs, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians letters, operative reports, bills, medical records, and
explanation of benefits ( EOB) forms;

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

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

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

41 44.
44 Page 45 46
2003 BlueCHiP, Coordinated Health Partners Section 8
The Disputed Claims process ( Continued)
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM s decision, your only recourse is to sue. If you decide to sue, you must file the suit against
OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not
be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This infor-
mation 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 401-274-3500
from within the State of Rhode Island or toll-free at 1-800-564-0888 from outside Rhode Island and we will expedite our
review; or

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

You may call OPM s Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time.

42 45.
45 Page 46 47
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member has coverage under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called double coverage.
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according
to the National Association of Insurance Commissioners guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

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

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

Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not have to pay for Part A.
If you or your spo