Pages 1--58

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

Serving: The New York counties of Monroe, Livingston, Wayne, Ontario,
Seneca and Yates.

Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 5 for requirements.

Enrollment codes for this Plan:
MK1 Self Only MK2 Self and Family

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

For changes
in benefits
see page 7.

RI 73-510 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan
brochure for 2003. The brochure explains all the benefits this health plan offers to its
enrollees. Since benefits can vary from year to year, you should review your plan's brochure
every Open Season. Fundamentally, I believe that FEHB participants are wise enough to
determine the care options best suited for themselves and their families.

In keeping with the President's health care agenda, we remain committed to providing
FEHB members with affordable, quality health care choices. Our strategy to maintain quality
and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged
them to contain costs, maintain quality, and keep the FEHB Program a model of consumer
choice and on the cutting edge of employer-provided health benefits. I asked the plans for
their best ideas to help hold down premiums and promote quality. And, I encouraged them to
explore all reasonable options to constrain premium increases while maintaining a benefits
program that is highly valued by our employees and retirees, as well as attractive to
prospective Federal employees. Second, I met with our own FEHB negotiating team here at
OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM
initiated a comprehensive outside audit to review the potential costs of federal and state
mandates over the past decade, so that this agency is better prepared to tell you, the Congress
and others the true cost of mandated services. Fourth, we have maintained a respectful and
full engagement with the OPM Inspector General (IG) and have supported all of his efforts to
investigate fraud and waste within the FEHB and other programs. Positive relations with the
IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced
significant increases in health care cost trends in recent years. Despite its size, the FEHB
Program is not immune to such market forces. We have worked with this plan and all the
other plans in the Program to provide health plan choices that maintain competitive benefit
packages and yet keep health care affordable.

Now, it is your turn. We believe if you review this health plan brochure and the
FEHB Guide you will have what you need to make an informed decision on health care for
you and your family. We suggest you also visit our web site at www. opm. gov/ insure. 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

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

OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

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

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for
any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if
OPM has already acted based on your permission.

By law, you have the right to:

See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal
medical information.

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

you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a
disputed claim. 3.
3 Page 4 5
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also
call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the
change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
2003 Blue Choice 2 Table of Contents
Table of Contents
Introduction................................................................ 4
Plain Language............................................................... 4
Inspector General Advisory .......................................................................................................................................... 4
Section 1. Facts about this HMO plan.......................................................................................................................... 6
How we pay providers................................................................................................................................. 6
Who provides my health care? .................................................................................................................... 6
Your Rights ................................................................................................................................................. 6
Service Area ................................................................................................................................................ 7
Section 2. How we change for 2002.. ............................................................... 8
Program-wide changes ................................................................................................................................ 8
Changes to this Plan .................................................................................................................................... 8
Section 3. How you get care ........................................................................................................................ 9
Identification cards ...................................................................................................................................... 9
Where you get covered care ........................................................................................................................ 9

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

Primary care .......................................................................................................................................... 9
Specialty care ........................................................................................................................................ 9
Hospital care ....................................................................................................................................... 10
Circumstances beyond our control ............................................................................................................ 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services................................................................................................................. 12

Copayments......................................................................................................................................... 12
Coinsurance......................................................................................................................................... 12
Your catastrophic out-of-pocket protection maximum.............................................................................. 12
Section 5. Benefits.............................................................. 13
Overview................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 23
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 26
(d) Emergency services/ accidents ........................................................................................................ 28
(e) Mental health and substance abuse benefits ................................................................................... 30
(f) Prescription drug benefits ............................................................................................................... 32
(g) Special features............................................................................................................................... 34
Flexible benefit options................................................................................................................ 34 5.
5 Page 6 7
2003 Blue Choice 3 Table of Contents
(h) Dental benefits ................................................................................................................................ 35
(i) Non-FEHB benefits available to Plan members ............................................................................. 36
Section 6. General exclusions --things we don't cover ............................................................................................. 37
Section 7. Filing a claim for covered services............................................................................................................ 38
Section 8. The disputed claims process ...................................................................................................................... 39
Section 9. Coordinating benefits with other coverage................................................................................................ 41
When you have other health coverage....................................................................................................... 41

What is Medicare ................................................................................................................................. 41
Medicare managed care plan................................................................................................................ 44
TRICARE and CHAMPVA................................................................................................................. 44
Worker's Compensation ....................................................................................................................... 45
Medicaid .............................................................................................................................................. 45
Other Government Agencies................................................................................................................ 45
When others are responsible for injuries.............................................................................................. 45
Section 10. Definitions of terms we use in this brochure ........................................................................................... 46
Section 11. FEHB facts .............................................................................................................................................. 47

Coverage information
No pre-existing condition limitation.................................................................................................. 47
Where you get information about enrolling in the FEHB Program................................................... 47
Types of coverage available for you and your family ....................................................................... 47
Children's Equity Act......................................................................................................................... 48
When benefits and premiums start .................................................................................................... 48
When you retire................................................................................................................................ 49
When you lose benefits ............................................................................................................................. 49

When FEHB coverage ends .............................................................................................................. 49
Spouse equity coverage .................................................................................................................... 49
Temporary Continuation of Coverage (TCC) .................................................................................. 49
Converting to individual coverage ................................................................................................... 50
Getting a Certificate of Group Health Plan Coverage ...................................................................... 50
Long term care insurance is still available ................................................................................................................. 51
Index ............................................................................................................................................................... 52
Summary of benefits ................................................................................................................................................... 53
Rates .......................................................................................................................................................................... 54 6.
6 Page 7 8
2003 Blue Choice 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Blue Choice under our contract (CS 2506) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. The address for Blue Choice administrative office is:

Blue Choice
165 Court Street
Rochester, NY 14647

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

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means Blue Choice.
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.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:

Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.
Carefully review explanations of benefits (EOB's) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service. 7.
7 Page 8 9
2003 Blue Choice 5 Introduction/ Plain Language
If you suspect that a physician, pharmacy, or hospital 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 585/ 238-4466 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy: Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
Your child over age 22 (unless he/ she is disabled and incapable of self support). If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or
with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the

Plan.

CALL --THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
OR WRITE TO:

The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10
2003 Blue Choice 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for
the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the
copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You
cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or
other provider will be available and/ or remain under contract with us.

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Your Rights
Blue Choice, a health care plan of Blue Cross and Blue Shield of the Rochester Area is a Health Maintenance
Organization( HMO) that emphasizes comprehensive medical, surgical and preventive care through an IPA network of more
than 2,500 area physicians in private offices and a multi-specialty group practice at the Plan's four health centers.

Each member selects their own primary care doctor from within the private office option or from the medical center option.
Members of the same family can select different delivery systems. To be eligible for coverage, all services, except for
emergency care, must be provided, arranged, or authorized in advance by the member's primary care physician.

A woman may see her Plan obstetrician/ gynecologist or certified nurse midwife directly with no need to be referred by her
primary care doctor. Routine exams are limited to two per year

Benefits for urgent care outside of this Plan's may be covered. This Plan is affiliated with HMO-USA, a network of BlueCross
and BlueShield HMOs that can coordinate your medical care. If you need more information, this Plan can tell you more about
its reciprocity benefits.

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us,
our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is listed below.

There are New York State laws that BlueCross BlueShield of the Rochester Area administers to protect your private health information.
BlueCross BlueShield of the Rochester Area has been serving the Rochester community for over 60 years, with products such as Blue Choice, the area's largest health care plan.
Blue Choice is a Non-Profit organization
If you want more information about us, call 800/ 462-0108, or write to Blue Choice Member Services, 165 Court Street,
Rochester, NY 14647. You may also contact us by fax at 585/ 238-3659 or visit our website at www. bcbsra. com. 9.
9 Page 10 11
2003 Blue Choice 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
the New York counties of Monroe, Livingston, Wayne, Ontario, Seneca and Yates.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live
out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait
until Open Season to change plans. Contact your employing or retirement office. 10.
10 Page 11 12
2003 Blue Choice 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits.
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does
not change benefits.

Program-wide changes

We changed the address for sending disputed claims to OPM (Section 8).
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

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

Changes to this Plan
Your share of the non-Postal premium will decrease by 0. 7% for Self Only or 16. 8% for Self and Family.
Skilled nursing facility will be provided for up to 120 days for each single confinement in a skilled nursing facility.
Rehabilitation Hospital coverage for up to 90 days of inpatient care in a Rehabilitation Hospital for comprehensive physical medicine and rehabilitation. This does not affect Mental Health and Substance Abuse Parity.

Durable Medical Equipment are now covered at 80% at a participating provider, subject to a 20% member copayment. Previously it was covered in full, subject to a $10 office visit copayment.
External Prosthetics are now covered with a 20% member copayment up to a $15,000 maximum. Previously it was covered in full, subject to a $10 member copayment.
Internal Prosthetics are now covered in full. Previously, it was subject to a $10 member copayment. 11.
11 Page 12 13
2003 Blue Choice 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you
receive your ID card, use your copy of the Health Benefits Election Form, SF-2809,
your health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at
585/ 454-4810 or write to us at 165 Court Street, Rochester, NY 14647. You may
also request replacement cards through our website at www. bcbsra. com

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

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

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is important since
your primary care physician provides or arranges for most of your health care. To
determine if a physician is a participating provider and accepting new patients,
you can refer to our Provider Directory or contact us at 585/ 454-4810

Primary care Your primary care physician can be a family practitioner, internal medicine, pediatrician, general medicine or obstetrician/ gynecologist. Your primary care
physician will provide most of your health care, or give you a referral to see a
specialist.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care physician
authorized a certain number of visits without additional referrals. The primary
care physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives you a referral.
However, you may see your eye doctor once every 24 months or an acupuncturist
without a referral. 12.
12 Page 13 14
2003 Blue Choice 10 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number of
visits without additional referrals. Your primary care physician will use our
criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you

need. If he or she decides to refer you to a specialist, ask if you can see your
current specialist. If your current specialist does not participate with us, you
must receive treatment from a specialist who does. Generally, we will not pay
for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist.
You may receive services from your current specialist until we can make
arrangements for you to see someone else.

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

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

reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you
receive notice of the change. Contact us or, if we drop out of the program,
contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 585/ 454-4810. 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.. 13.
13 Page 14 15
2003 Blue Choice 11 Section 3
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 pre-certification. Your physician must
obtain pre-certification for the following services:

1. Air ambulance,
2. All inpatient admissions,
3. All referrals to non-participating providers,
4. Ambulatory surgery,
5. Chemotherapy & radiation treatment,
6. Colonoscopy & endoscopy procedures,
7. Diabetic equipment,
8. Home health care,
9. Home infusion therapy,
10. Inpatient physical rehabilitation,
11. Kidney dialysis,
12. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA),
13. Mental health services,
14. Nutritional counseling,
15. Organ & bone marrow transplants,
16. Outpatient alcohol or drug abuse,
17. Pain management,
18. Short term therapy,
19. Skilled nursing facility care, and
20. Sleep apnea studies. 14.
14 Page 15 16
2003 Blue Choice 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go in the hospital, you pay nothing.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care
Example: In our Plan, you pay 50% of our allowance for acupuncture services
and 20% for Prosthetic and Orthopedic Devices

Your catastrophic out-of-pocket protection maximum We do not have an out-of-pocket maximum. 15.
15 Page 16 17
2003 Blue Choice 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 52 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 (585) 454-4810 or at our website at www. bcbsra. com.
(a) Medical services and supplies provided by physicians and other health care professionals ........................... 13-21

Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................ 22-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services...................................................... 26-27

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

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

(e) Mental health and substance abuse benefits ............................................................................................. 30-31
(f) Prescription drug benefits..................................................................................................................................... 32
(g) Special features..................................................................................................................................................... 34
Flexible benefit option

Dental benefits............................................................................................................................................................. 35
(h) Non-FEHB benefits available to Plan members ................................................................................................... 36
Summary of benefits.................................................................................................................................................... 49 16.
16 Page 17 18
2003 Blue Choice 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
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
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T

Benefit Description You pay
2. Diagnostic and treatment services
Professional services of physicians
In physician's office

$10 per office visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

$10 per office visit

At home $10 per visit
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology

Nothing

X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

$10 per visit 17.
17 Page 18 19
2003 Blue Choice 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test

Nothing

Sigmoidoscopy, screening every five years starting at age 50 Nothing
Routine Prostate Specific Antigen (PSA) test one annually for men age 40
and older
Nothing

Routine pap test Nothing
Physical Exams Nothing
Allergy Injections Nothing
Vision Exams
The exam, once every 2 years may include physical exam of the eyes, refraction tests and assessment of binocular vision.
$10 per visit

Hearing Exams $10 per visit
Routine mammogram covered for women age 35 and older, as
follows:

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

Nothing

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

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

$10 per visit

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of pediatrics

Well-child care charges for routine examinations, immunizations and care (under age 19)
Examinations, such as:
Eye exams through age 18 to determine the need for vision
correction.

Ear exams through age 18 to determine the need for hearing
correction

Examinations done on the day of immunizations (under age 19)

Nothing
Nothing
$10 per visit 18.
18 Page 19 20
2003 Blue Choice 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page xx 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

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization (see surgical procedures section 5( b))
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug
benefit.

Nothing

Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges.

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

Fertility drugs

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

$10 per visit
Copayment dependent on if the
drug is generic, preferred brand
name or non-preferred brand name. 19.
19 Page 20 21
2003 Blue Choice 17 Section 5( a)
Infertility services continued You pay
Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm

Cost of donor egg

All charges.

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

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

Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.

Respiratory and inhalation therapy
Inhalers are covered under pharmacy benefit, see page 30

Inhalation therapy equipment is covered under DME, see page 19
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Note: We will only cover GHT when we preauthorize the treatment.
Call (585) 454-4810 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
physician to have us authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date you submit
the information. If you do 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.

$10 per visit 20.
20 Page 21 22
2003 Blue Choice 18 Section 5( a)
Physical and occupational therapies You pay
Up to two consecutive months per condition which in the judgement of the Plan's Medical Director can be expected to result in a
significant improvement through short term therapy
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 any cardial infarction.

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

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy You pay
60 visits per condition $10 per visit

Hearing services (testing, treatment, and supplies) You pay
Hearing testing
Hearing Aids for children
Hearing testing for children through age 17 (see Preventive Care, children)

$10 per visit
Balance after $600 every three years

Not covered:
all other hearing testing hearing aids, testing and examinations for them
All charges. 21.
21 Page 22 23
2003 Blue Choice 19 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Bi-annual exam (see Preventive Care) $10 per office visit

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

Nothing

Eye exam to determine the need for vision correction for children through age 18 (see Preventive Care)
Annual eye refractions
$60 toward the purchase of one pair of either prescription eyeglasses or contact lenses once every 24 months. Prescription eyeglasses or

contact lenses covered annually for children to age 19.

$10 per office visit
Balance after $60 every 2 years

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

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

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

$10 per office visit

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

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges. 22.
22 Page 23 24
2003 Blue Choice 20 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

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

Note: There is a $15,000 maximum on external prosthetics.

20%
20%

Nothing

Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

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

All charges.

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

hospital beds;
wheelchairs;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Call us at 585/ 454-4810 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

20%

Not covered:
Motorized wheel chairs All charges. 23.
23 Page 24 25
2003 Blue Choice 21 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide. Services include
oxygen therapy, intravenous therapy and medications.

Service 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 You pay
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$10 per office visit

Alternative treatments You pay
Chiropractic Services

Acupuncture Up to 10 visits per calendar year

$10 per visit
50%

Not covered:
naturopathic services
hypnotherapy
biofeedback

All charges. 24.
24 Page 25 26
2003 Blue Choice 22 Section 5( a)
Educational classes and programs You pay
Coverage is limited to:
Member Rewards includes:

Smoking Cessation
Nutrition counseling
First aid/ safety
Back care
Stress Management
General Wellness
Family Life

Copayment or balance after
discount 25.
25 Page 26 27
2003 Blue Choice 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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.

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 for charges associated with the facility (i. e. hospital, surgical
center, etc.).

I M
P O
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A N
T

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

Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal weight
according to current underwriting standards; eligible members must
be age 18 or over

Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

$10 per office visit; nothing for
hospital visits

Voluntary sterilization (e. g. Tubal ligation, Vasectomy) Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.
All charges. 26.
26 Page 27 28
2003 Blue Choice 24 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance
and

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

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

$10 per visit

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

Note: We pay for internal breast prostheses as hospital benefits.
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.

See above.

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 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;

$10 per visit

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.
TMJ surgery and other non-dental treatment.

$10 per visit

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

the periodontal membrane, gingiva, and alveolar bone)

All charges. 27.
27 Page 28 29
2003 Blue Choice 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

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

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the Plan's protocols.

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

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

Nothing

Anesthesia You pay
Professional services provided in

Hospital (inpatient)

Nothing

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

Nothing 28.
28 Page 29 30
2003 Blue Choice 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

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

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

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

I M
P O
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A N
T

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

meals and special diets.
Note: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines

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

Nothing

Not covered:
Custodial care Non-covered facilities, such as nursing homes, extended care

facilities, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

All charges. 29.
29 Page 30 31
2003 Blue Choice 27 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

$10 per visit

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: The Plan provides a comprehensive range
of benefits with no dollar limit for 120 days per member 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. Lifetime
maximum of 360 days

Nothing

Not covered: custodial care All charges
Rehabilitation Hospital You pay
The Plan provides up to 90 days per calendar year of inpatient care
in a Rehabilitation Hospital for comprehensive physical medicine
and rehabilitation. The hospitalization must be primarily for
rehabilitation (alcohol and substance abuse program are excluded)
and only for a condition which, in the sole judgement of your Plan
doctor and the Plan Medical Director, can be expected to result in
significant improvement of your condition.

Nothing

Hospice care You pay
Supportive and palliative care for a terminally ill member is covered
in the home or hospice facility for up to 210 days. Services include
inpatient and outpatient care, and family counseling; these services
are provided under the direction of a Plan doctor who certifies that
the patient is in the terminal stage of illness, with a life ecpectancy of
approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate $25 per emergency 30.
30 Page 31 32
2003 Blue Choice 28 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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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.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan
member so they can notify the Plan. You or a family member must notify the Plan within 48 hours. It is your responsibility
to ensure that the Plan has been timely notified.

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

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

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

If the emergency results in admission to a hospital, the emergency care copay is waived.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

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

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

If the emergency results in admission to a hospital, the emergency care copay is waived. 31.
31 Page 32 33
2003 Blue Choice 29 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center

$10 per visit
$25 per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area You pay

Emergency care at a doctor's office Emergency care at an urgent care center $10 per visit
$25 per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

All charges.

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

$25 per emergency 32.
32 Page 33 34
2003 Blue Choice 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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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 and are payable 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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after
the benefits description below.

I M
P O
R T
A N
T

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

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

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

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

Medication management

$10 per visit

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

Nothing

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. 33.
33 Page 34 35
2003 Blue Choice 31 Section 5( e)
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
The Pre-authorization procedure must be followed regardless whether the Member is
within The Plan's Service Area or not. Pre-authorization need not be obtained for Emergency care. In making the determination to issue Pre-authorization The Plan

will examine the circumstances surrounding the Member's condition and the care provided; including reasons for providing or prescribing the care; and any unusual
circumstances. However, the fact that the Member's Doctor prescribed the care does not automatically mean that the care qualifies for The Plan's payments under
this Certificate. The provider, prior to recommending or ordering any pre-authorized services, must call Blue Choice at (585) 454-4591. For obtaining provider directories,
call Member Service Department at (585) 454-4810.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2003 Blue Choice 32 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 licensed physician must write the prescription or A plan physician or licensed dentist must write the prescription.

Where you can obtain them. You may fill the prescription at a participating pharmacy or by mail. 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
difference in cost between the name brand drug and the generic.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of

name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To
order a prescription drug brochure, call (585) 454-4810.

These are the dispensing limitations. Retail and Mail Order Prescription drugs are dispensed per 30 day supply, maximum 90-day supply. You will pay either a $5, $15 or $30 copayment for each for each

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

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

You can save money by using generic drugs. However, you and your physician have the option to
request a brand name if a generic option is available. Using the most cost-effective medication saves
money.

When generic substitution is permissible, (i. e., a generic is available and the prescribing doctor does not
require the use of a brand name drug), but you request the name brand drug. You pay the $5 copay for
prescription drugs plus the price difference between the generic and the name brand drug.

When you have to file a claim. You will have no claims to file unless you use a non-participating pharmacy..

Prescription drug benefits begin on the next page. 35.
35 Page 36 37
2003 Blue Choice 33 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded below.

Insulin $10 per 30 day supply Disposable needles and syringes for the administration of covered
medications $10 per 30 day supply
Diabetic supplies including blood glucose monitors, insulin pumps, insulin infusion devices, oral agents for controlling blood sugar, and

diabetes self-management education $10 per 30 day supply.
Drugs for sexual dysfunction (see Prior authorization below) Contraceptive drugs and devices

Growth hormones Oral fertility drugs

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

Retail and Mail Order
$5 copayment per generic (tier 1)
prescription or refill .

$15 copayment per preferred brand
name (tier 2) prescription or refill .

$30 copayment per non preferred
brand name (tier 3) prescription or
refill .

for each 30 day supply

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-plan pharmacy; except for out-of-area emergencies.

Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines

All Charges 36.
36 Page 37 38
2003 Blue Choice 34 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

Reciprocity benefit HMOBlue USA Urgent Care & Guest Membership
From BlueCross BlueShield of the Rochester Area

The HMO that stays with you whenever you're away from home. Should you ever come down with an unexpected illness or injury while
traveling, which can't wait to be treated at home, you can rest assured
knowing that you have a place to turn. We call it Urgent Care, because it
delivers just that: the help you need, whenever you need it.

No paperwork whatsoever. You're not feeling well to begin with. The last thing you need is a big
expense to make things worse. You can take comfort knowing you'll have
no claims to file, no paperwork and no payment at the time of service.

Guest Membership Coverage at an affiliated HMO when living away from home for at least 90
consecutive days. Guest membership is only available for members under
age 65.

Centers of excellence BlueCross BlueShield of the Rochester Area works with other
BlueCross plans to identify centers of excellence which offer quality
care in specialized areas. When necessary the plan's Medical
Director will recommend, members with diseases and conditions that
can not be handled by our providers, to be sent to centers of
excellence. 37.
37 Page 38 39
2003 Blue Choice 35 Section 5( h)
Section 5 (h). Dental benefits
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.

We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See section 5 for inpatient hospital
benefits. We do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

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

$10 copay per office visit

Dental benefits
We have no other dental benefits. 38.
38 Page 39 40
2003 Blue Choice 36 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic out-of-pocket
protection maximums.

Member Rewards has been developed by Blue Choice to introduce you to selected local resources that will help you get into
shape, have more energy, deal more effectively with life's problems and increase your chances of preventing heart disease,
cancer or stroke. Take advantage of the health and wellness programs offered to Blue Choice members.

Private office option Member Rewards offers most health and wellness programs for just $5 a session. Topics include nutrition,
smoking cessation, first aid/ safety, back care, stress management, general wellness and family life.

Choice discounts Member Rewards offers Choice Discounts that provide savings on health and fitness club membership,
exercise programs, and sports equipment, ranging from footwear to cardiovascular exercise machines. To obtain a list of
Member Rewards and Choice Discounts, call 585/ 454-4810.

To further promote wellness and preventive care, members may enroll in health education programs at the health centers.
These programs are professionally led courses on nutrition, back care, smoking cessation, stress management and many other
topics. Most programs cost just $5. 39.
39 Page 40 41
2003 Blue Choice 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.

We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2003 Blue Choice 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at (585) 454-4810.
When you must file a claim --such as for services you receive outside of this
Plan's service area --submit it on the HCFA-1500 or a claim form that includes the
information shown below. Bills and receipts should be itemized and show:

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

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

Receipts, if you paid for your services.
Submit your claims to: Blue Choice 165 Court Street
Rochester, NY 14647

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. 41.
41 Page 42 43
2003 Blue Choice 39 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. Write to us at: 165 Court Street, Rochester NY, 14647. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 165 Court Street, Rochester NY, 14647; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and

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

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

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

We will write to you with our decision.

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

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

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

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim. 42.
42 Page 43 44
2003 Blue Choice 40 Section 8
The Disputed Claim process continued
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the review
request.

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

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

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

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

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
(585) 454-4810 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 43.
43 Page 44 45
2003 Blue Choice 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage".
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer.
We, like other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners' guidelines.

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

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

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

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

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

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

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

When you are enrolled in Original Medicare, along with this plan you still need to
follow the rules in this brochure for us to cover your care. Your care must continue
to be authorized by your Plan PCP. 44.
44 Page 45 46
2003 Blue Choice 42 Section 9
Claims process when you have the Original Medicare Plan --You probably will
never have to file a claim form when you have both our Plan and the Original
Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your claims will be coordinated automatically and we will
then provide secondary benefits for covered charges. You will not need to do
anything. To find out if you need to do something to file your claims, call us at
(585) 454-4810 or on the web at: www. bcbsra. com.

We waive some costs when you have the Original Medicare Plan --When
Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:

Medical services and supplies provided by physicians and other health care
professionals. 45.
45 Page 46 47
2003 Blue Choice 43 Section 9
The following chart illustrates whether the Original Medicare plan or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability), .

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

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

.

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

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

.
(for other
services)

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

.
(except for claims
related to Workers'
Compensation.)

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

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, .

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, .

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, .

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

b) Are an active employee .

c) Are a former spouse or an annuitant, or .
d) Are a former spouse of an active employee . 46.
46 Page 47 48
2003 Blue Choice 44 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like
HMOs) in some areas of the country. In most Medicare managed care plans, you
can only go to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available
to you:

This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In this
case, we do not waive any of our copayments, coinsurance, or deductibles for your
FEHB coverage.

This Plan and another plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB
plan. We will still provide benefits when your Medicare managed care plan is
primary, even out of the managed care plan's network and/ or service area (if you
use our Plan providers), but we will not waive any of our copayments, coinsurance,
or deductibles. If you enroll in a Medicare managed care plan, tell us. We will
need to know whether you are in the Original Medicare Plan or in a Medicare
managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage and a Medicare managed care plan: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
Medicare managed care plan, eliminating your FEHB premium. (OPM does not
contribute to your Medicare managed care plan premium.) For information on
suspending your FEHB enrollment, contact your retirement office. If you later
want to re-enroll in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the Managed
Care Plan service area.

If you do not enrollment in If you do not have one or both Parts of Medicare, you can still be covered under the Medicare Part A or Part B FEHB Program. We will not require you to enroll in Medicare Part B and, if you
can't get premium-free Part A, we will not ask you to enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program.
CHAMPVA provides health coverage to disabled Veterans and their eligible
dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first.
See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions
about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
one of these programs, eliminating your FEHB premium. (OPM does not
contribute to any applicable plan premiums.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-enroll in
the FEHB Program, generally you may do so only at the next Open Season unless
you involuntarily lose coverage under the program. 47.
47 Page 48 49
2003 Blue Choice 45 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency
determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these State programs, eliminating
your FEHB premium. For information on suspending your FEHB Program, contact
your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the State program.

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

If you do not seek damages you must agree to let us try. This is called subrogation.
If you need more information, contact us for our subrogation procedures. 48.
48 Page 49 50
2003 Blue Choice 46 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of
the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Custodial care that lasts 90 days or more is sometimes known as long term care.
Experimental or Blue Choice uses published peer-reviewed medical literature about the efficiency
Investigational and improvement outcomes of technology, along with the United States Food and Drug Administration approval for marketing of medical devices, drugs or

biologicals for a particular diagnosis or condition.

Medical necessity Medically Necessary Care is care which, according to The Plan's criteria is: (a) Consistent with the symptoms or diagnosis and treatment of the Member's condition,
disease, ailment or injury, (b) in accordance with standards of acceptable medical
practice, (c) not solely for the Member's convenience, or that of the Member's Doctor
or other Provider, (d) the most appropriate supply, place of service, or level of service
which can safely be provided to the Member, (e) provided for the diagnosis or the direct
care and treatment of the Member's condition, illness, disease or injury, and (f) when
applied to hospitalization, the Member requires acute care as a bed patient due to the
nature of the services rendered, or the Member's condition, and the Member could not
have received safe or adequate care in any other setting (e. g. as an outpatient).

Us/ We Us and we refer to Blue Choice

You You refers to the enrollee and each covered family member. 49.
49 Page 50 51
2003 Blue Choice 47 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials will tell
you:

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

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change
your enrollment status without information from your employing or retirement
office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including
any foster children or stepchildren your employing or retirement office authorizes
coverage for. Under certain circumstances, you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may change
your enrollment 31 days before to 60 days after that event. The Self and Family
enrollment begins on the first day of the pay period in which the child is born or
becomes an eligible family member. When you change to Self and Family because
you marry, the change is effective on the first day of the pay period that begins
after your employing office receives your enrollment form; benefits will not be
available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is
no longer eligible to receive health benefits, nor will we. Please tell us
immediately when you add or remove family members from your coverage for any
reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person
may not be enrolled in or covered as a family member by another FEHB plan. 50.
50 Page 51 52
2003 Blue Choice 48 Section 11
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for self and family coverage
in the Federal Employees Health Benefits (FEHB) Program, if you are an employee
subject to a court or administrative order requiring you to provide health benefits
for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a health
plan that provides full benefits in the area where your children live or provide
documentation to your employing office that you have obtained other health
benefits coverage for your children. If you do not do so, your employing office
will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the option of the Blue Cross and Blue Shield Service
Benefit Plan that provides the lower level of coverage;
if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change

your enrollment to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in

the lower option of the Blue Cross and Blue Shield Service Benefit Plan.
As long as the court/ administrative order is in effect, and you have at least one
child identified in the order who is still eligible under the FEHB Program, you
cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't
serve the area in which your children live, unless you provide documentation that
you have other coverage for the children. If the court/ administrative order is still in
effect when you retire, and you have at least one child still eligible for FEHB
coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact your employing office for
further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay period
that starts on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing office
will tell you the effective date of coverage 51.
51 Page 52 53
2003 Blue Choice 49 Section 11
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do
not meet this requirement, you may be eligible for other forms of coverage, such as
temporary continuation of coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is the case

even when the court has ordered your former spouse to supply health coverage to
you. But, you may be eligible for your own FEHB coverage under the spouse
equity law or Temporary Continuation of Coverage (TCC). If you are recently
divorced or are anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices. You can also download the guide
from OPM's website, www. opm. gov/ insure.

Temporary continuation If you leave Federal service, or if you lose coverage because you no longer qualify of coverage (TCC) as a family member, you may be eligible for Temporary Continuation of Coverage
(TCC). For example, you can receive TCC if you are not able to continue your
FEHB enrollment after you retire, if you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross
misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement office
or from www. opm. gov/ insure. It explains what you have to do to enroll. 52.
52 Page 53 54
2003 Blue Choice 50 Section 11
Converting to You may convert to a non-FEHB individual policy if: individual coverage