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FIRSTCARE

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits OVERVIEW
Section 6. General exclusions
Section 7. Filing a claim
Section 8. The disputed claims process
Section 9. Coordinating benefits
- When you have other health coverage
Section 10. Definitions
Section 11. FEHB facts
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for FIRSTCARE
2003 Rate Information

Pages 1--63

Page 1


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

FIRSTCARE http:// www. firstcare. com
A Health Maintenance Organization

Serving: The entire Texas Panhandle and much of West Texas and the Central Texas area.
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See pages 6-7 for requirements.
West Texas
Enrollment codes for this Plan: CK1 Self Only

CK2 Self and Family

Central Texas
Enrollment codes for this Plan: 6U1 Self Only

6U2 Self and Family

RI 73-496

2003
For changes in benefits see
pages 8-9.

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

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected, To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

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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.

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2003 FIRSTCARE 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of FIRSTCARE under our contract (CS 2321) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address
for FIRSTCARE administrative offices is:
SHA, L. L. C. dba FIRSTCARE 12940 N. Highway 183
Austin, Texas 78750
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusion in this brochure. It is your responsibility to be informed about your
health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You
do not have a right to benefits that were available before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on pages 8-9. 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 FIRSTCARE.

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 premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

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2003 FIRSTCARE 5 Introduction/ Plain Language/ Advisory
Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800/ 884-4901 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

you can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits to try to obtain services for someone who is not an eligible
family member or who is no longer enrolled in the Plan.

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO:
The United States Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, NW, Room 6400 Washington, DC 20415

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2003 FIRSTCARE 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of our 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 and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about our networks, providers, our facilities, and us. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the required information is listed below:
We have been operational since June, 1986, and we have been providing quality healthcare to Federal employees since January 1, 1988.

As a state certified and federally qualified health plan, FIRSTCARE is in compliance with all the rules and regulations of these governing bodies.
FIRSTCARE is a limited liability company.
If you want more information about us, call 800/ 884-4901, or write to 12940 N. Highway 183, Austin, Texas 78750. You may also contact us by fax at 512/ 257-6037 or visit our website at www. firstcare. 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:

In West Texas, the counties of Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Carson, Castro, Childress, Cochran, Collingsworth, Cottle, Crane, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Ector, Floyd,
Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Hemphill, Hockley, Howard, Hutchinson, King, Lamb, Lipscomb, Loving, Lubbock, Lynn, Martin, Midland, Moore, Motley, Ochiltree, Oldham, Parmer, Pecos,
Potter, Randall, Reagan, Reeves, Roberts, Scurry, Sherman, Swisher, Terry, Upton, Ward, Wheeler, Winkler, and Yoakum.

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2003 FIRSTCARE 7 Section 1
In Central Texas, the counties of Bell, Bosque, Brazos, Burleson, Burnet, Coryell, Falls, Freestone, Grimes, Hamilton, Hill, Houston, Lampasas, Lee, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Navarro,
Robertson, San Saba, Somervell, Walker, and Washington.

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. We will not pay for any other health care services 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. FIRSTCARE will only provide coverage for emergency care outside our service area. 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.

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2003 FIRSTCARE 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5, Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
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 Do/ DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium for Enrollment Code CK will increase by 26. 1% for Self Only or 27. 8% for Self and Family. Enrollment Code 6U will decrease 19. 0% for Self Only or 19. 2% for Self and Family.

We now show "non-formulary" prescription drugs as "non-Preferred" prescription drugs. The following copayments apply:
Retail pharmacy copayment for non-Preferred Name Brand drug increases from $30 to $40 per unit or refill.
Mail order pharmacy copayment for non-Preferred Name Brand drug increases from $60 to $80 for a 90 day supply.
Insulin and other diabetic treatment medication copays change as follows:
Retail Pharmacy (up to a 30 day supply):
Generic drug copay will be $10 per unit or refill;
Preferred Name Brand drug copay will be $20 per unit or refill;
Non-Preferred Name Brand drug copay will be $40 per unit or refill;
When a Generic drug is available, the copay will be $10 plus the price difference in the cost of the Preferred Name Brand drug over the Generic drug.

Mail Order Pharmacy (up to a 90 day supply):
Generic drug copay will be $20 per unit or refill;
Preferred Name Brand drug copay will be $40 per unit or refill;
Non-Preferred Name Brand drug copay will be $80 per unit or refill;
When a Generic drug is available, the copay will be $20 plus the price difference in the cost of the Preferred Name Brand drug over the Generic drug.

The cost of diabetic equipment and supplies changes from 20% of all charges to 20% coinsurance and applies a 30-day limit to diabetic supplies.
Growth hormone is now covered in the cost of growth hormone therapy at no charge. See Treatment Therapy, Section 5( a).

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2003 FIRSTCARE 9 Section 2
Infertility drugs are not covered.
The primary care physician office visit copay increases from $10 to $15 per office visit.
The specialist office visit copay increases from $15 to $25 per office visit.
The physician home visit copay increases from $20 to $25 per visit.
The emergency care urgent care center copay increases from $25 to $40 per visit, in or outside the service area.
The emergency care outpatient hospital copay will increase from $75 to $100 per visit, in or outside the service area.
A $100 copay per inpatient hospital admission now applies.
A $50 copay per visit for outpatient surgery now applies.

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2003 FIRSTCARE 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800/ 884-4901
or write to us at 12940 N. Highway 183, Austin, Texas 78750. You may also request replacement cards through our website at www. firstcare. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
FIRSTCARE services are provided through 775 primary care physicians, 1280 Specialists, 62 contracted hospitals and many other health
professionals and facilities. FIRSTCARE has been serving FEHB employees and eligible dependents since 1988.

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

What you must do It depends on the type of care you need. First, you and each family member to get covered care must choose a primary care physician. This decision is important since
your primary care physician provides or arranges for most of your health care.

Each female member may select an obstetrician-gynecologist (OB/ GYN) in addition to her primary care physician. She may go directly to him/ her for
an annual well-woman examination, care for pregnancy and all gynecological conditions. The OB/ GYN may diagnose, treat and refer for
any disease or condition within the scope of professional practice of a credentialed obstetrician or gynecologist. Remember, you must choose
your OB/ GYN and notify the Plan of your choice prior to your first visit.
Services of other providers are covered only when your primary care physician has referred you.

Primary care Your primary care physician can be a family practitioner or an internist and you may select a pediatrician for your children. Your primary care
physician will provide most of your health care, or give you a referral to see a specialist.

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2003 FIRSTCARE 11 Section 3
If you want to change your primary care physician 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. However, you may see your designated obstetrician/ gynecologist
(OB/ GYN) or seek emergency care without a referral. Your primary care physician will arrange your referral to a specialist. Referral to a
participating specialist is given at the primary care physician's discretion, if non-Plan specialists or consultants are required, the primary care physician
will arrange appropriate referrals.
When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation unless your
doctor authorizes additional visits. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for a
return visit unless your primary care physician gives you a referral, and the Plan has issued an authorization for the referral in advance.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with
us to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

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

specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

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

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

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

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2003 FIRSTCARE 12 Section 3
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer Services Department immediately at 800/ 884-4901. If you are
new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the necessary care.

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

We call this review and approval process preauthorization. Your physician must obtain preauthorization for certain services, such as outpatient surgery,
inpatient hospital admissions, growth hormone therapy (GHT) in children with documented growth hormone deficiency disease, certain prescription
drugs, and durable medical equipment (DME) e. g., oxygen and monitoring devices.

In some cases, charges for medical procedures may not be covered without proper authorization. If you have any questions, call our Customer Services
Department at 800/ 884-4901. Remember, when in doubt, CALL!

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2003 FIRSTCARE 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment of $15 per office visit.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for certain services.
Example: In our Plan, you pay 50% of our allowance for infertility services; and 20% of charges for durable medical
equipment.
Your catastrophic protection After your copayments and coinsurance total 200% of annual catastrophic protection premium per Self Only enrollment or 200% of annual premium
out-of-pocket maximum for per Self and Family enrollment in any calendar year, you do copayments and coinsurance not have to pay any more for covered services. However,
copayments and coinsurance for prescription drugs and Durable Medical Equipment (DME) do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for prescription
drug and DME.
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when
you reach the maximum.

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2003 FIRSTCARE 14 Section 5
Section 5. Benefits OVERVIEW (See pages 8-9 for how our benefits changed this year and page 59 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 800/ 884-4901 or at our website www. firstcare. com.

(a) Medical services and supplies provided by physicians and other health care professionals............................... 15-24
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies
Speech therapy

Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............... 25-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 29-31
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ....................................................................................................................... 32-34 Medical emergency ! Ambulance
(e) Mental health and substance abuse benefits ....................................................................................................... 35
(f) Prescription drug benefits ............................................................................................................................... 36-39
(g) Special features .................................................................................................................................................... 40
Services for deaf and hearing impaired
Centers of excellence for transplants/ heart surgery/ etc.
(h) Dental benefits ..................................................................................................................................................... 41
Summary of benefits ................................................................................................................................................... 59

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2003 FIRSTCARE 15 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

including with Medicare.

I M
P O
R T
A N
T
Benefit Description You pay

Diagnostic and treatment services
Professional services of physicians
In physician's office $15perofficevisit toyourprimarycare physician
$25peroffice visittoaspecialist

In an urgent care center $25 per visit
During a hospital stay
In a skilled nursing facility
Nothing
Nothing

Office medical consultations

Second surgical opinion
$15perofficevisit toyourprimarycare physician
$25peroffice visittoaspecialist
At home $25 per visit

Lab, X-ray and other diagnostic tests
Such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

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2003 FIRSTCARE 16 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Fasting lipoprotein profile (total cholesterol, LDL, HDL and triglycerides) once every 3 years for adults age 20 or over; and

Colorectal Cancer Screening, including:
-Fecal occult blood test
-Sigmoidoscopy, screening everyfive years starting at age 50
-Colonoscopy once every10 years at age 50; or
-Double contrast barium enema (DCBE) once every 5-10 years at age 50

Nothing if you receive these services during your office
visit.

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older
Routine PAP test
Routine mammogram covered for women age 35 and older, as follows:

From age 35 to 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Routine immunizations according to generally accepted medical practice standards and the U. S. Public Health Service for people in
the United States, including immunizations for travel outside the United States.

Annual influenza vaccines
Pneumococcal vaccine, age 65 and over
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood

immunizations)
Eye screenings, biennially, for members age 19 and older for the purpose of determining vision loss

Hearing screenings, biennially, for members age 19 and older for the purpose of determining hearing loss
Speech screenings, biennially, for members age 19 and older for the purpose of determining speech impairment
Not Covered: Physical exams, health reports and/ or treatments required for employment, insurance, school, camp, travel, flight clearance, sports
or legal proceedings
All charges

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2003 FIRSTCARE 17 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics and those required by the Texas

Department of Health
Nothing

Well-child care charges for routine examinations, immunizations and care (through age 22). $15 per office visit to your primary care physician; $25 to a specialist.
Examinations, such as:
-Eye screenings, annually, through age 18 to determine vision loss.
-Ear screenings, annually, through age 18 to determine hearing loss.

-Speech screenings, annually, through age 18 to determine speech impairment

Nothing if you receive these services during your office visit

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
Your physician will pre-authorize your normal delivery; see page 12 for other circumstances, such as extended stays for you or your

baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover

other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

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

Nothing for pre-and post-natal care; $100 inpatient copay applies.

Not covered: Sonograms to determine fetal sex All charges

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2003 FIRSTCARE 18 Section 5( a)
Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures, Section 5 (b))
Surgically implanted contraceptives (such as, Norplant).
Injectable contraceptive drugs (such as, Depo Provera)
Diaphragms

Intrauterine devices (IUDs)
Note: We cover oral contraceptives under the prescription drug benefit. There is no charge when Norplant is implanted during a covered

hospitalization. We will not refund any portion of the coinsurance if the implanted time-release medication is removed before the end of its
expected life.

$15 per visit to your primary care physician
$25 per visit to a specialist
20% of charges for all services and procedures related to

Family Planning, in addition to the appropriate office visit
copayment, if applicable.

Not covered: reversal of voluntary surgical sterilization, genetic counseling and testing, except for medically necessary prenatal genetic
testing.
All charges

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

50% of charges

Not Covered:
Assisted reproductive technology (ART) procedures, such as:
-In vitro fertilization
-Fertility drugs
-Embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer
Services and supplies related to excluded ART procedures
Surrogate parenting fees
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment $25 per office visit to a specialist
Allergy injection, when administered without an office visit. 50% of charges
Allergy serum Nothing
Not Covered: provocative food testing and sublingual allergy desensitization All charges

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2003 FIRSTCARE 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/ Tissue Transplants

on page 27.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

$15 copay per primary care office visit; $25 copay per specialist
office visit; $50 copay per outpatient facility visit or $100
copay per inpatient admission.

Growth hormone therapy (GHT) for children with growth hormone deficiency disease.
We will only cover GHT and growth hormone when we authorize the treatment of documented growth hormone deficiency in children. We will ask your
physician to submit information that establishes that the GHT is medically necessary. Your physician needs to authorize GHT before treatment begins;
otherwise, we will only cover GHT services from the date your physician submits the information. If your physician does not ask or if we determine
GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Nothing

Physical and occupational therapies
Physical therapy and occupational therapy services for each of the following:

-Qualified physical therapists; and
-Occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction must be provided at a Plan facility, and is covered
for up to two months per condition, or for up to 60 days per condition per calendar year, whichever is greater, if significant improvement can be
expected within that time.
Note: Your coverage is limited to services that continue to meet or exceed the treatment goals established for you. For a physically disabled

person, treatment goals may include maintenance of functioning or prevention of or slowing of other deterioration.

$25 per office visit; $50 per outpatient visit; included in the
$100 inpatient admission copay.

Not Covered: long-term rehabilitative therapy
exercise programs
All charges

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2003 FIRSTCARE 20 Section 5( a)
Speech therapy You pay
Speech therapy services provided by a speech therapist $25 per office visit; $50 outpatient visit; included in the $100 inpatient
admission copay.
Hearing services (testing, treatment, and supplies)
Hearing screenings, annually, for children through age 18 (see Preventive care, children)

Hearing screenings, biennially, for members age 19 and older (see Preventive care, adult)
$15 per office visit to your primary care physician
$25 per office visit to a specialist

Hearing aids
Note: Must be medically necessary as determined by a Plan physician, authorized in advance by the Plan, and obtained from a

Plan provider.

Nothing up to Plan maximum of $500 per ear once every 36
months; all charges over $500 per ear.

Not covered:
Repair or replacement of hearing aids due to normal wear and tear and loss or damage
All charges

Vision services (testing, treatment, and supplies)
Eye screenings, annually, for children through age 18 to determine vision loss (see Preventive care, children)

Eye screenings, biennially, for members age 19 and older to determine vision loss (see Preventive care, adult)
Nothing if you receive these services during your primary care
physician office visit

Not Covered:
Eyeglasses, frames, or contact lenses (including the fitting of contact lenses), except as necessary for the first pair of corrective

lenses following cataract removal
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Refractions, including lens prescriptions, to determine the need for glasses or contacts.

All charges

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2003 FIRSTCARE 21 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

See Orthopedic and prosthetic devices for information on podiatric shoe inserts.
$15 per visit to your primary care physician
$25 per visit to a specialist
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except

as stated above
Treatment of weak, strained or flat feet, spurs, and of any instability, imbalance or subluxation of the foot (unless the treatment is by open

cutting surgery.

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Foot orthotics
Podiatric appliances for the prevention of complications associated with diabetes.

Braces (limb or back only)

20% of charges

Internal prosthetic devices, such as artificial joints, pacemakers, surgically implanted breast implant following mastectomy, and
implanted lenses during cataract surgery. Note: See 5( b) for coverage of the surgery to insert the device.
Nothing

Not Covered:
Orthopedic and corrective shoes Arch supports

Heel pads and heel cups Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices
Prosthetic repairs, maintenance or replacements, except for breast prostheses; and standard replacements needed because of physical
growth by dependents under 18 years of age.
Cochlear implanted device Wigs or prosthetic hair

Implanted neurological stimulators, including but not limited to spinal or dorsal column stimulators for relief of pain, Parkinson's,
movement disorders or seizures.

All charges

Orthopedic and prosthetic devices continued on next page

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2003 FIRSTCARE 22 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen (see below) and dialysis equipment. Under this benefit, we also cover:

Manual hospital beds
Manual wheelchairs
Crutches
Canes
Walkers

20% of charges

Braces (limb or back only)
Traction devices
Nebulizers
Indwelling urinary catheters
C-PAP monitoring device (when there is a diagnosis of documented obstructive sleep apnea)

Oxygen, oxygen concentrators, rental of equipment for administration of oxygen, and mechanical equipment necessary for the treatment of
chronic or acute respiratory failure.
Note: Oxygen and equipment must be prescribed and directed by a Plan provider, and approved in advance by the Plan.

Monitoring devices, such as apnea monitors and uterine monitors for use in the home, when prescribed and directed by a Plan provider

Ostomy supplies
Sterile dressing change kits, i. e., tracheostomy suction and dressing kits, and central line dressing kits

Note: DME must be pre-authorized, unless it is provided by your physician's office.

Not covered:
Motorized, deluxe, and custom wheelchairs and hospital beds; auto tilt chairs

Comfort or convenience items, such as bathtub chairs, whirlpool tubs, safety grab bars, stair gliders or elevators, over-the-bed tables,
bed boards, saunas, and exercise equipment.
Environmental control equipment, such as air conditioners, purifiers, humidifiers, de-humidifiers, electrostatic machines and heat lamps

Institutional equipment, such as fluidized beds and diathermy machines.
Consumable medical supplies, such as over-the-counter bandages, dressings and other disposable supplies and skin preparations.
Foam cervical collars.
Stethoscopes, sphygmomanometers, reading oximeters.

All charges

Durable Medical Equipment continued on next page

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2003 FIRSTCARE 23 Section 5( a)
Durable medical equipment (DME) (Continued) You pay
Hygienic or self help items or equipment.
Sports cords.
TENS units.
Repair or replacement resulting from misuse or abuse

All charges

Diabetic Equipment and Supplies
Equipment as follows:
-Blood glucose monitors, including monitors designed to be used by blind individuals

-Insulin pumps and associated appurtenances
-Insulin infusion devices
-Podiatric appliances for the prevention of complications associated with diabetes

-Injection aids
-Insulin cartridges
-Infusion sets
Supplies, including:
-Test strips for blood glucose monitors
-Visual reading and urine test strips
-Lancets and lancet devices
-Injection aids
-Syringes
-Needles
-Glucose test tablets and test tape
-Benedict's solution or equivalent
-Acetone test tablets

20% co-insurance

Note: Supplies limited to 30 day supply All charges

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26 Page 27 28

2003 FIRSTCARE 24 Section 5( a)
Home health services You pay
Home health care visits ordered by a Plan physician and provided by a skilled home health care professional or home health aide.

Services include oxygen therapy, intravenous therapy and medications.
Nothing

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

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

All charges

Chiropractic
No benefit All charges

Alternative treatments
Telemedicine to deliver health care, which includes use of interactive audio, video, or other electronic media for diagnosis, consultation,

treatment, transfer of medical data, and medical education, but excludes services performed using a telephone or facsimile (FAX) machine.
Nothing

Not covered:
Naturopathic services
Hypnotherapy
Biofeedback
Acupuncture
Equine or Hippo therapy
Massage therapy, unless associated with a physical therapy modality provided by a licensed physical therapist

All charges

Educational classes and programs
Coverage is limited to:
Diabetes self-management training, including counseling and use of diabetic equipment and supplies.

Nutritional counseling for morbid obesity.

$15 per office visit to your primary care physician
$25 per office visit to a specialist

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27 Page 28 29

2003 FIRSTCARE 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits

with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated

with the facility (i. e., hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the preauthorization information

shown in Section 3 to be sure which services require preauthorization and identify which surgeries require preauthorization.

Assistant surgeon services will be covered for those surgeries which require an assistant surgeon and when we pre-approve them.

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

Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Treatment of burns
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
Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

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

$15 when performed in primary care office;
$25 when performed in specialist office
$50 when performed in outpatient surgical facility
Included in the $100 inpatient admission copay

Voluntary sterilization (e. g. tubal ligation, vasectomy) 20% of charges
Surgical procedures continued on next page

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2003 FIRSTCARE 26 Section 5( b)
Surgical procedures (Continued) You pay
Not Covered:
Reversal of voluntary sterilization
Any surgical procedures related to snoring and sleep apnea
Routine treatment of conditions of the foot; see Foot Care

All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

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

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

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

$15 when performed in primary care office;
$25 when performed in specialist office
$50 when performed in outpatient surgical facility
Included in the $100 inpatient admission copay

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Not Covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through

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

All charges

Oral and maxillofacial surgery continued on next page

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29 Page 30 31

2003 FIRSTCARE 27 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

Treatment of temporomandibular joint (TMJ), including surgical and non-surgical intervention, corrective orthopedic appliances and
physical therapy and other surgical procedures that do not involve the teeth or their supporting structures.

$15 when performed in primary care office;
$25 when performed in specialist office
$50 when performed in outpatient surgical facility
Included in the $100 inpatient admission copay

Not Covered:
Oral implants and transplants
Procedures or related dental work that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and

alveolar bone)

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogenic (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; testicular, mediastinal;, retroperitoneal and ovarian germ cell
tumors
Autologous tandem transplants for testicular cancer and other germ cells 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.

Nothing

Organ/ tissue transplants continued on next page

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2003 FIRSTCARE 28 Section 5( b)
Organ/ tissue transplants (Continued) You pay
Note: Immuno-suppressive medications necessary to prevent rejection of any transplanted organ listed above are covered subject to no copay while

hospitalized. After discharge, these medications are covered under the Prescription drug benefit and subject to the applicable prescription drug
copay per 30-day supply. They are not available through the Mail Order Pharmacy.

Note: All covered transplants must be evaluated by a nationally recognized medical facility designated by FIRSTCARE and they must
agree that the proposed transplant is appropriate for the treatment of your condition. Also, they must agree to perform the transplant.

The FIRSTCARE Medical Director must approve all covered transplants. All related medical and hospital expenses of the donor are covered when
the recipient is covered by this Plan.
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)

Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing

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2003 FIRSTCARE 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL STAYS. Please refer to the preauthorization information shown in Section 3 to
be sure which services require preauthorization and identify which surgeries require preauthorization.

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Benefit Description You pay
Inpatient hospital
Room and board, such as:
Ward, semiprivate room or intensive care accommodations;
Private rooms and/ or special duty nursing when medically necessary
General nursing care; and
Meals and special diets.

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

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

$100 per admission

Inpatient Hospital continued on next page

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2003 FIRSTCARE 30 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered:
Custodial care, rest cures, domiciliary or convalescent 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
Take-home drugs

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We

do not cover the dental procedures.

$50 per visit

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit:
A comprehensive range of benefits to a maximum of 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a

skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

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

doctor.

$100 per admission

Not Covered:
Custodial care
Rest cures
Domiciliary or convalescent care

All charges

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2003 FIRSTCARE 31 Section 5( c)
Hospice care You pay
We cover supportive and palliative care in the home or a hospice facility
Services include:
-Inpatient and outpatient care, and
-Family counseling.
Note: A Plan physician must certify that the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

Nothing

Not covered:
Independent nursing

Homemaker services

All charges

Ambulance
Local professional ambulance service when medically appropriate $75 per trip

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2003 FIRSTCARE 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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.
Our Plan's allowance of Usual, Customary and Reasonable (UCR) charges will apply to emergency care received at any doctor's office, outside our Plan's services

area, for the services rendered. (See next page and Section 10 for the definition of our Plan's allowance of UCR charges).

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

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

What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care physician right away. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (such as, the 911-

telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a FIRSTCARE member so they can notify us. You or a family member should notify FIRSTCARE
within 24 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that we have been notified in a timely manner.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
Emergency care includes the following services:
An initial medical screening examination by the facility providing the emergency care or other evaluation required by state or federal law that is necessary to determine whether an emergency medical condition

exists.
Services for the treatment and stabilization of an emergency condition.
Post-stabilization care originating in a hospital emergency room or comparable facility, if approved by us, provided that we must approve or deny coverage within one hour of a request for approval by the treating

physician or the hospital emergency room.
Requirements for All Emergency Care. To be covered, emergency care must meet all of these conditions:
You must obtain the services immediately, or as soon as possible, after the emergency condition occurs.
As soon as possible after the emergency occurs and you seek treatment, you (or someone acting for you) must contact your primary care physician for advice and instructions. In any event, you must contact the

Plan within 24 hours, unless it is impossible to do so.
You must be transferred to the care of Plan providers as soon as this can be done without harming your condition. We do not cover services provided by non-Plan providers after the point at which you can be safely

transferred to the care of a Plan provider.

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2003 FIRSTCARE 33 Section 5( d)
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, FIRSTCARE must be notified within 24 hours or on the first working day following your admission, unless it was not reasonably possible to notify Us 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.

Any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $15 per office visit to your primary care physician
$25 per office visit to a specialist

Emergency care at an urgent care center $40 per visit
Emergency care as an outpatient, including doctors' services $100 per visit; if admitted, the copay is waived. However, if
admitted for an observation period of less than 24 hours,
the copay is not 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 office visit, plus all amounts over the Usual,
Customary and Reasonable (UCR) charges for the services
rendered.
Emergency care at an urgent care center $40 per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services $100 per visit; if admitted, the copay is waived. However, if
admitted for an observation period of less than 24 hours,
the copay is not waived.
Emergency outside our service area continued next page

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2003 FIRSTCARE 34 Section 5( d)
Emergency outside our service area (Continued) You pay
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Charges for the normal delivery of a baby (vaginal or cesarean section) outside our Plan's Service Area, if the delivery is within 30
days of your due date specified by your participating physician, except in case of emergency; however, complications of pregnancy or
premature delivery are covered.

All charges

Ambulance
Professional ambulance service, including air ambulance, when medically appropriate.

See 5( c) for non-emergency service.
$75 per trip

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37 Page 38 39

2003 FIRSTCARE 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
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.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

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

include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the

care as part of a treatment plan that we approve.

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

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

$25 per office visit

Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, full-day hospitalization, facility based intensive

outpatient treatment.

$100 per admission

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

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

All charges

Preauthorization To be eligible to receive these benefits you must obtain your treatment plan and follow all of our network authorization processes. These
include:
Mental health and substance abuse services are provided through these behavioral health benefit managers:

In the Amarillo and Lubbock regions (which includes
Midland/ Odessa) -Comprehensive Behavioral Care 800/ 541-3647

In the Central Texas area MHNet, Inc. 800/ 336-2030

Your primary care physician may refer you, or you may contact the benefit manager for your region without a referral.

Limitation If you do not obtain an approved treatment plan, we may limit your benefits.

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38 Page 39 40

2003 FIRSTCARE 36 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.

I M
P O
R T
A N
T

There are important features you should be aware of. These include:
Who can write your prescription.
A Plan physician or dentist, or an out-of-Plan doctor when you have been referred must write the prescription.

Where you can obtain them.
-Retail Pharmacy
You may fill your prescriptions at a retail Plan pharmacy, or
-Mail Order Pharmacy
You may obtain a medication for chronic conditions through the Plan mail order pharmacy. Medications for chronic conditions are defined as those that you have taken for at least six

months. Our mail order pharmacy is Express Scripts 888/ 202-4560.
We use a Preferred Drug List (PDL)

Our Preferred Drug List includes all generic drugs and a comprehensive list of Preferred Name Brand drugs approved by our Pharmacy and Therapeutics (P& T) Committee, and

used by Plan physicians to be dispensed through our Plan pharmacies to meet patient needs at a lower cost. You must use drugs included on the Preferred Drug List to take advantage
of the best combination of safety, effectiveness and cost savings. Drugs not included in the PDL are called "non-Preferred" drugs and you must pay a higher copayment for these drugs.
If you need to order a Preferred Drug List or have any questions, please call our Customer Services Department at 800/ 884-4901 or visit our website at www. firstcare. com

These are the dispensing limitations.
FIRSTCARE requires prior authorization and imposes dispensing limitations on certain drugs, due to specific therapeutic indications or requirements for closer monitoring to help

insure appropriate dispensing. The criteria used in administering these programs follow FDA approved dosing guidelines. For specific information about your prescription
coverage, please consult a Customer Services Representative at 800/ 884-4901.
Prescriptions are limited to a 30-day supply, except medications for chronic conditions that may be filled up to a 90-day supply, but only when filled through a Participating Mail

Service Pharmacy.
If you or your physician request a Name Brand drug when a Generic equivalent is available, you will be responsible for the Generic Drug Copayment plus the difference between the

cost of the Generic Drug and the cost of the Name Brand Drug.
Why use generic drugs?
Generic drugs are lower-priced drugs that are pharmaceutically and therapeutically equivalent in strength and dosage to the more expensive original Name Brand product. The

U. S. Food and Drug Administration closely regulates both generic and Name Brand drugs to ensure they meet the same standards for safety, purity, strength and effectiveness. Generic
drugs are less expensive for you and us and can reduce your out-of-pocket expenses.

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2003 FIRSTCARE 37 Section 5( f)
When you have to file a claim.
You may have to file a claim for reimbursement if you are out of the service area and have to pay for an emergency prescription filled at an out-of-network pharmacy. To obtain these

forms, call our Customer Services Department at 800/ 884-4901.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician, or dentist and obtained from a Plan retail pharmacy or through

our mail order program:
Drugs and medicines that by Federal law require a physician's prescription for their purchase except those listed as Not Covered.

Formulas necessary for the treatment of a heritable disease, such as phenylketonuria (PKU).
Drugs for sexual dysfunction are subject to dosage limits set by the Plan. Contact the Plan for details.
Oral contraceptive drugs.
Prescription and non-prescription oral agents for controlling blood sugar levels.

Insulin, insulin analogs, and glucagon emergency kits

Retail Pharmacy, for a 30-day supply per prescription
unit or refill: A $10 copay for generic
drugs;
A $20 copay for Preferred Name Brand

drugs when a generic equivalent is not
available;
A $40 copay for non-Preferred drugs; and

A $10 copay for Preferred Name Brand
drugs when a generic equivalent is available,
plus the difference between the cost of the
generic drug and the cost of the Preferred Name
Brand drug.
Mail Order Pharmacy, for up to a 90-day supply per

prescription unit or refill:
A $20 copay for generic drugs;

A $40 copay for Preferred Name Brand
drugs when a generic equivalent is not
available;
A $80 copay for non-Preferred drugs; and

A $20 copay for Preferred Name Brand
drugs when a generic equivalent is available,
plus the difference between the cost of the
generic drug and the cost of the Preferred Name
Brand drug.
Covered medications and supplies continued on the next page

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2003 FIRSTCARE 38 Section 5( f)
Covered medications and supplies (Continued) You pay
Contraceptive drugs and devices, such as:
-Diaphragms
-Intrauterine devices (IUDs)
-Implantable drugs, such as Norplant
-Injectable drugs, such as Depo Provera
Disposable needles and syringes for the administration of covered medications

Allergy syringes

20% of all charges

Here are some things to keep in mind about our prescription drug program:
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a Name Brand. If you receive a
Name Brand drug when a Federally approved generic drug is available, and your physician has not specified Dispense as Written
for the Name Brand drug, you have to pay the Generic copay plus the difference in cost between the Name Brand and the Generic
drug.
Prescribing Generic drugs is encouraged. Prescribing Preferred Name Brand drugs is encouraged over non-Preferred Name Brand

drugs.
A Generic (1 st -tier) or Preferred Name Brand (2 nd -tier) drug may not always be available or appropriate to treat a condition. In that case,

a non-Preferred Name Brand drug is covered at the non-Preferred (3 rd -tier) Copayment when used to treat a covered medical condition.

A non-Preferred drug is a prescription medication that is not in the Preferred Drug List. Non-Preferred drugs require a higher
copayment.
Prescriptions will not be refilled until 70% of the prescription has been used.

Not Covered:
Drugs and supplies for cosmetic purposes, including medications such as Lamisil or Sporanox for the treatment of uncomplicated

nail fungus, and drugs for hair growth or removal.
Vitamins, and nutritional substances that can be purchased without a prescription, except for pre-natal vitamins

Nonprescription medicines, except for the treatment of diabetes
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Fertility drugs
Smoking cessation drugs and medication, including nicotine patches

All Charges

Covered medications and supplies continued on the next page

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41 Page 42 43

2003 FIRSTCARE 39 Section 5( f)
Covered medications and supplies (Continued) You pay
Not Covered (continued):
Drugs prescribed for weight loss and appetite suppressants, except for medications prescribed for morbid obesity

Prescription refills in excess of the number specified by the Physician and any refill dispensed more than one year after the
Physician's order
Any prescription drug for which the actual cost is less than the required copayment is not covered and you will be responsible for

the cost of the drug
Prescriptions or refills that replace lost, stolen, spoiled, expired, spilled or are otherwise misplaced or mishandled by the Member.

All Charges
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42 Page 43 44

2003 FIRSTCARE 40 Section 5( g)
Section 5 (g). Special Features
Feature Description

Services for deaf and hearing impaired TDD LINE 1-800/ 562-5259

Centers of excellence for transplants/ heart
surgery/ etc.

FIRSTCARE coordinates with nationally recognized medical facilities to evaluate the Member's case; to determine that the proposed transplant
or treatment is appropriate for the Member's condition; and to perform the transplant or treatment.

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43 Page 44 45

2003 FIRSTCARE 41 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient

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

Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
No benefit All charges

Dental benefits
No benefit All charges

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44 Page 45 46

2003 FIRSTCARE 42 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 12.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

Services, drugs, supplies you receive without charge while in active military service.

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45 Page 46 47

2003 FIRSTCARE 43 Section 7
Section 7. Filing a claim for Medical, Hospital and Drug benefits
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your
copayment or coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is

the process:

Medical, hospital and In most cases, providers and facilities file claims for you. drug benefits Physicians must file on the form HCFA-1500, Health Insurance
Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call us at 800/ 884-4901.

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

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary

Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to: FIRSTCARE 12940 N Highway 183

Austin, Texas 78750

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.

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2003 FIRSTCARE 44 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 our Complaints and Appeals Department at 12940 N. Highway 183, Austin 78750; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.

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2003 FIRSTCARE 45 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year, in which you received
the disputed services, drugs, or supplies or from the year in which you were denied preauthorization. This is the only deadline that may not be extended.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call our Customer Services Department at 800/ 884-4901 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time.

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2003 FIRSTCARE 46 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays
health care expenses without regard to fault. This is called "double coverage."

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

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

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

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

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

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

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

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is a plan that is (Part A or Part B) available everywhere in the United States. It is the way everyone
used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits. You may go to any doctor,

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2003 FIRSTCARE 47 Section 9
specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover you. Your
care must continue to be authorized by your Plan PCP, or pre-certified as required. We will not waive any of our copayments or coinsurance.

Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare
processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the balance of covered

charges. You will not need to do anything. To find out if you need to do some