Document Outline

• Introduction
• Plain Language
• Stop Health Care Fraud
• Section 1.
  • Facts about this HMO plan
  • Who provides my health care
  • How we pay providers
  • Your Rights
  • Service Area
• Section 2.
  • How we change for 2003
  • Changes to this plan
• Section 3
  • How you get care
  • Identification cards
  • Where you get covered care
  • What you must do to get care
    • Primary care
    • Specialty care
    • Hospital care
  • Circumstances beyond our control
• Section 4.
  • Your cost for covered services
  • Your catastrophic protection out of pocket maximum
• Section 5.
  • Benefits overview
    • Medical services and supplies provided by physicans and other health care professionals
    • Medical services and supplies provided by physicians and other health care professionals
    • Medical services and supplies provided by physicians and other health care professionals
    • Medical services and supplies provided by physicians and other health care professionals
    • Medical services and supplies provided by physicians and other health care professionals
    • Medical services and supplies provided by physicians and other health care professionals
    • Medical services and supplies provided by physicians and other health care professionals
    • Surgical and anesthesia services provided by physicians and other health care professionals
    • Surgical and anesthesia services provided by physicians and other health care professionals
    • Surgical and anesthesia services provided by physicians and other health care professionals
    • Services provided by a hospital or other facility and ambulance services
    • Services provided by a hospital or other facility, and ambulance services
    • Services provided by a hospital or other facility, and ambulance services
    • Services provided by a hospital or other facility, and ambulance services
    • Emergency services
    • Emergency services
    • Mental Health and substance abuse benefits
    • Mental Health and substance abuse benefits
    • Mental Health and substance abuse benefits
    • Mental Health and substance abuse
    • Prescription drug benefits
    • Prescription drug benefits
    • Prescription drug benefits
    • Prescription drug benefits
    • Special Features
    • Dental benefits
    • Non-FEHB benefits available to Plan members
• Section 6
  • General exclusions-things we dont cover
• Section 7
  • Filing a claim for covered services
• Section 8
  • The disputed claims process
  • The disputed claims process
  • The disputed claims process
• Section 9
  • Coordinating benefits with other coverage
  • What is Medicare
  • The original Medicare Plan
  • Medicare managed care plan
  • Medicare managed care plan
  • Private contract
  • If you dont enroll in Medicare Part A or Part B
  • TRICARE and CHAMPVA
  • Workers' Compensation
  • Medicaid
  • When other Government agencies are responsible for your care
  • When others are responsible for injuries
• Section 10
  • Definitions of terms we use in this brochure
  • Definitions of terms we use in this brochure
• Section 11.
  • FEHB facts
  • no pre-existing condition limitation
  • Where you get information about enrolling in the FEHB Program
  • Types of coverage available for you and your family
  • Children's Equity Act
  • When benefits and premium start
  • When you retire
  • When you lose benefits
    • When FEHB coverage ends
    • Spouse equity coverage
    • Temporary Continuation of Coverage (TCC)
    • Converting to individual coverage
  • Getting a Certificate of Group Health Plan Coverage
• Long Term Care Insurance Is Still Available
• Index
• Summary of benefits
• Rates

Pages 1--68

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: Most of California
Enrollment in this Plan is limited. You must live or work in our geographic area to
enroll. See page 7 for requirements.

This Plan has a commendable rating from the NCQA. See the 2003 Guide
for more information on accreditation.

RI 73-517

For changes
in benefits,
see page 8.

Enrollment Code:
M51 Self Only
M52 Self and Family 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits
(FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held
by OPM.

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

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

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For
example:

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

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

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission. 3.
3 Page 4 5
By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement

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

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

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
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
5.
5 Page 6 7

2003 Blue Cross-HMO Plan 2 Table of Contents
Table of Contents
Introduction .......................................................................................................................................................... 4
Plain Language ...................................................................................................................................................... 4
Stop Health Care Fraud .......................................................................................................................................... 5
Section 1. Facts about this HMO plan .................................................................................................................... 6
Who provides my health care? .............................................................................................................. 6
How we pay providers .......................................................................................................................... 6
Your Rights .......................................................................................................................................... 7
Service Area ......................................................................................................................................... 7
Section 2. How we change for 2003 ...................................................................................................................... 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 care ................................................................................................................ 9
Primary care ................................................................................................................................... 9
Specialty care ............................................................................................................................... 10
Hospital care ................................................................................................................................. 13
Circumstances beyond our control ....................................................................................................... 13
Section 4. Your costs for covered services ........................................................................................................... 14
Copayments .................................................................................................................................. 14
Deductible .................................................................................................................................... 14
Coinsurance .................................................................................................................................. 14
Your catastrophic protection out-of-pocket maximum ......................................................................... 14
Section 5. Benefits .............................................................................................................................................. 15
Overview ............................................................................................................................................ 15
(a) Medical services and supplies provided by physicians and other health care professionals........... 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 25
(c) Services provided by a hospital or other facility, and ambulance services.................................... 28
(d) Emergency services .................................................................................................................. 32
(e) Mental health and substance abuse benefits ................................................................................ 34
(f) Prescription drug benefits ......................................................................................................... 38
(g) Special features ........................................................................................................................ 42
(h) Dental benefits .......................................................................................................................... 43
(i) Non-FEHB benefits available to Plan members ......................................................................... 44
Section 6. General exclusions --things we don't cover ........................................................................................ 45 6.
6 Page 7 8
2003 Blue Cross-HMO Plan 3 Table of Contents
Section 7. Filing a claim for covered services ...................................................................................................... 46
Section 8. The disputed claims process ............................................................................................................... 47
Section 9. Coordinating benefits with other coverage .......................................................................................... 50
When you have other health coverage ................................................................................................. 50
What is Medicare .......................................................................................................................... 50
The Original Medicare Plan .......................................................................................................... 51
Medicare managed care plan ......................................................................................................... 53
Private contract ............................................................................................................................. 53
If you do not enroll in Medicare Part A or Part B ........................................................................... 53
TRICARE and CHAMPVA ................................................................................................................ 54
Workers' Compensation ..................................................................................................................... 54
Medicaid ............................................................................................................................................ 54
When other Government agencies are responsible for your care .......................................................... 54
When others are responsible for injuries ............................................................................................. 54
Section 10. Definitions of terms we use in this brochure....................................................................................... 55
Section 11. FEHB facts ...................................................................................................................................... 57
No pre-existing condition limitation .................................................................................................. 57
Where you get information about enrolling in the FEHB Program ..................................................... 57
Types of coverage available for you and your family ......................................................................... 57
Children's Equity Act........................................................................................................................ 58
When benefits and premium start ..................................................................................................... .58
When you retire ................................................................................................................................ 59
When you lose benefits ..................................................................................................................... 59
When FEHB coverage ends ...................................................................................................... 59
Spouse equity coverage ............................................................................................................ 59
Temporary Continuation of Coverage (TCC) ........................................................................... 59
Converting to individual coverage ............................................................................................ 59
Getting a Certificate of Group Health Plan Coverage ......................................................................... 60

Long Term Care Insurance Is Still Available......................................................................................................... 61
Index... ..................................................................................................................................................... 62
Summary of benefits ........................................................................................................................................... 63
Rates ..................................................................................................................................................... Back cover 7.
7 Page 8 9
2003 Blue Cross-HMO Plan 4 Introduction/ Plain Language
Introduction
Blue Cross of California, P. O. Box 4089, Woodland Hills, Ca. 91365
This brochure describes the benefits of the Blue Cross HMO under our contract (CS 2514) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. 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 8. Rates are shown at the end of this brochure.

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

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

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

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650. 8.
8 Page 9 10
2003 Blue Cross-HMO Plan 5 Stop Health Care Fraud
Stop Health Care Fraud
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium.

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

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 records or recommend services.
Avoid using health care providers who say that an item is not usually covered, but they know how to bill us to get it paid.

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

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800-235-8631and explain the
situation.
If we do not resolve the issue:

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

OR WRITE TO: The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court 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 of 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. 9.
9 Page 10 11
2003 Blue Cross-HMO Plan 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. Blue Cross is solely
responsible for the selection of these providers in your area. Contact Blue Cross for a copy of our most recent provider
directory.

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

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

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

Who provides my health care?
When you enroll you should choose a primary care physician. Your primary care physician will be the first doctor
you see for all your health care needs. If you need special kinds of care, this physician will refer you to other kinds of
health care providers.

Your primary care physician will be part of a Blue Cross HMO contracting medical group. There are two types of
Blue Cross HMO medical groups.

A primary medical group (PMG) is a group practice staffed by a team of doctors, nurses, and other health care providers.

An independent practice association (IPA) is a group of doctors in private offices who usually have ties to the same hospital.
You and your family members can enroll in whatever medical group is best for you.
You must live or work within 30 miles of the medical group.
You and your family members do not have to enroll in the same medical group.

How we pay providers
Your medical group is paid a set amount for each member per month. Your medical group may also get added money
for some types of special care or for overall efficiency, and for managing services and referrals. Hospitals and other
health care facilities are paid a set amount for the kind of service they provide to you or an amount based on a
negotiated discount from their standard rates. If you want more information, please call us at 800-235-8631, or you
may call your medical group.

You do not have to pay any Blue Cross HMO provider for what we owe them, even if we don't pay them. But you
may have to pay a non-Plan provider any amounts not paid to them by us. 10.
10 Page 11 12

2003 Blue Cross-HMO Plan 7 Section 1
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about your health plan, its networks, providers, and facilities. You can also find out about care management, which
includes medical practice guidelines, disease management programs and how we determine if procedures are
experimental or investigational. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you.

If you want specific information about us, call 800-235-8631, or write to P. O. Box 4089, Woodland Hills, CA 91365.
You may also contact us by fax at 818-234-6401, or visit our website at www. bluecrossca. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice.
Our service area is:

Northern California --Amador --Fresno --Marin --Plumas --Santa Cruz

--Alameda --Humboldt --Mendocino --Sacramento --Solano
--Butte --Kings --Merced --San Benito --Sonoma
--Contra Costa --Lake --Modoc --Santa Clara --Stanislaus
--Del Norte --Lassen --Nevada --San Francisco --Tulare
--El Dorado --Madera --Placer --San Joaquin --Tuolumne
--San Mateo --Yolo

Southern California --Imperial --Los Angeles --Orange --San Diego --San Louis Obispo
--Santa Barbara --Ventura
You may also enroll with us if you live in or work in the Zip Codes of the following counties:
KERN: 93203, 93205-06, 93215-17, 93220, 93222, 93224-26, 93238, 93240-41, 93243, 93249-52, 93255, 93263,
93276, 93280, 93283, 93285, 93287, 93300-09, 93311-13, 93380-89, 93399, 93504-05, 93516, 93518-19, 93523-24,
93528, 93531, 93554, 93555, 93556, 93560-61, 93570, 93581-82, 93596

RIVERSIDE: 91718-20, 91752, 91753, 91760, 92201-03, 92210, 92211, 92220, 92223, 92230, 92234-36, 92240,
92241, 92253-55, 92258, 92260-64, 92270, 92276, 92282, 92292, 92303, 92320, 92330-31, 92343-44, 92348, 92353,
92355, 92360-62, 92367, 92370, 92379-81, 92383, 92387-88, 92390, 92395-96, 92500-09, 92513-19, 92521-23,
92530-32, 92542-46, 92548, 92550, 92552-57, 92562-64, 92567, 92570-72, 92581-87, 92589-93, 92595-96, 92599

SAN BERNARDINO: 91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758, 91761-64, 91784-86, 91798,
92337, 92252, 92256, 92268, 92277-78, 92284-86, 92301, 92305, 92307-08, 92311-13, 92314-18, 92321-22,
92324-27, 92329, 92333-37, 92339-42, 92345-47, 92350, 92352, 92354, 92356-59, 92365, 92368-69, 92371-78,
92382, 92385-86, 92391-94, 92397, 92398, 92399, 92400-18, 92420, 92423-24, 92427

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 or urgent care services. 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 you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 11.
11 Page 12 13
2003 Blue Cross-HMO Plan 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 26.7% for Self Only or 35% for Self and Family.
Coverage will be provided for certain routine patient care costs for a member who has been accepted into an approved clinical trial for cancer and whose personal physician has obtained prior authorization from the plan.

Coverage will be provided for hospice care when a member's terminal illness has a prognosis of life of one year, if the disease follows its normal course.
The brochure has been clarified to show that coverage is not provided for scalp/ hair prosthesis or any form of hair replacement. 12.
12 Page 13 14
2003 Blue Cross-HMO Plan 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 participating pharmacy. Until you receive your ID card, use your
copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 800/ 235-
8631 or write to us at Blue Cross of California, P. O. Box 4089,
Woodland Hills, Ca. 91365. You may also request replacement cards
through our website at www. bluecrossca. 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.
For treatment of a mental health or substance abuse condition you may
request an authorized referral to a non-Plan provider. See Mental Health
and Substance Abuse Benefits (Section 5e) for details.

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

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

What you must do to get care It depends on the type of care you need. First, you and each family member must choose a primary care physician. Your primary care
physician will be the first doctor you see for all your health care needs.
If you need special kinds of care, this doctor will refer you to other kinds
of health care providers. This decision is important since your primary
care physician provides or arranges for most of your health care. Your
primary care physician will be part of a Blue Cross HMO contracting
medical group. There are two types of Blue Cross HMO medical groups:
A primary medical group (PMG) is a group practice staffed by a team of doctors, nurses, and other health care providers.

An independent practice association (IPA) is a group of doctors in private offices who usually have ties to the same hospital.

You and your family members can enroll in whatever medical group is
best for you.
You must live or work within 30 miles of the medical group. You and your family members do not have to enroll in the same

medical group.
Primary care Your primary care physician can be a general or family practitioner, internist or pediatrician. Certain specialists we may approve may also be

designated primary care physician. Your primary care physician will
provide most of your health care, or give you a referral to see a specialist. 13.
13 Page 14 15
2003 Blue Cross-HMO Plan 10 Section 3
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 doctor may refer you to another physician if you need special care. Your primary care physician must approve all the care you get except
when you have an emergency or need urgent care.
Your doctor's medical group has to agree that the service or care you will
be getting from the other health care provider is medically necessary.
Otherwise it won't be covered.

You will need to make the appointment at the other doctor's office.
Your primary care physician will give you a referral form to take with you to your appointment. This form gives you the approval to get this

care. If you don't get this form, ask for it or talk to your Blue Cross
HMO coordinator.
You may have to pay a copayment. You shouldn't get a bill, unless it is for a copayment, for this service. If you do, send it to your Blue

Cross HMO coordinator at your primary medical group right away.
The medical group will see that the bill is paid. If you need additional
help you can call our customer service department.

Standing Referrals. If you have a condition or disease that:
Requires continuing care from a specialist; or is
Life-threatening;
Degenerative; or
Disabling; your primary care physician may give you a standing referral to a

specialist or specialty care center. The referral will be made if your
primary care physician, in consultation with you, and a specialist or
specialty care center, if any, determine that continuing specialized care is
medically necessary for your condition or disease.

If it is determined that you need a standing referral for your condition or
disease, a treatment plan will be set up for you. The treatment plan:

Will describe the specialized care you will receive;
May limit the number of visits to the specialist; or
May limit the period of time that visits may be made to the specialist.

If a standing referral is authorized, your primary care physician will
determine which specialist or specialty care center to send you to in the
following order:

First, a Blue Cross HMO contracting specialist or specialty care center which is associated with your medical group;

Second, any Blue Cross HMO contracting specialist or specialty care center; and
Last, any specialist or specialty care center;
that has the expertise to provide the care you need for your condition or
disease.

After the referral is made, the specialist or specialty care center will be
authorized to provide you health care services that are within the
specialist's area of expertise and training in the same manner as your
primary care physician, subject to the terms of the treatment plan. 14.
14 Page 15 16
2003 Blue Cross-HMO Plan 11 Section 3
Remember: We only pay for the number of visits and the type of special care that your primary care physician approves. Call your
physician if you need more care. If your care isn't approved ahead of
time, you will have to pay for it (except for emergencies or urgent
care.)

Ready Access. There are two ways you may get special care without getting an approval from you medical group. These two ways are the

"Direct Access" and "Speedy Referral" programs. Not all medical
groups take part in the Ready Access program. See your Blue Cross
HMO Directory for those that do.

Direct Access. You may be able to get some special care without an approval from your primary care physician. We have a program called
"Direct Access", which lets you get special care, without an approval
from your primary care physician for:

Allergy Dermatology

Ear/ Nose/ Throat
Ask your Blue Cross HMO coordinator if your medical group takes part
in the "Direct Access" program. If your medical group participates in the
Direct Access program, you must still get your care from a physician
who works with your medical group. The Blue Cross HMO coordinator
will give you a list of those doctors.

Speedy Referral. If you need special care, your primary care physician may be able to refer you for it without getting an approval from your

medical group first. The types of special care you can get through
Speedy Referral depend on your medical group.

If You Are A Woman You can get OB-GYN services from a doctor who specializes in caring

for women (OB-GYN) or family practice doctor who does OB-GYN and
works with your medical group.

You can get these services without an approval from your primary care physician.

Ask your Blue Cross HMO coordinator for the list of OB-GYN health care providers you must choose from.

When You Want a Second Opinion
Your medical group is responsible for arranging second opinions and
specialty care with health care providers who are part of or who are
affiliated with your Blue Cross HMO medical group. Working with your
medical group supports and improves the coordination and quality of
your medical care.

If your primary care physician referred you to a specialist (called a
"group" specialist) and you want a second opinion, you have the right to
a second opinion by an appropriately qualified health care professional
who is part of the Blue Cross HMO provider network. If there is no
appropriately qualified health care professional in the network, we will
authorize a second opinion by another appropriately qualified health care
professional, taking into account your ability to travel.

Reasons for asking for a second opinion include, but are not limited to:
Questions about whether recommended surgical procedures are reasonable or necessary. 15.
15 Page 16 17
2003 Blue Cross-HMO Plan 12 Section 3
Questions about the diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or
substantial impairment, including but not limited to a serious chronic
condition.

The clinical indications are not clear or are complex and confusing.
A diagnosis is in doubt because of test results that do not agree.
The first doctor is unable to diagnose the condition.
The treatment plan in progress is not improving your medical condition within an appropriate period of time.

You have tried to follow the treatment plan or you have talked with the specialist about serious concerns you have about your diagnosis
or plan of care.
To ask for a second opinion about recommendations by your primary
care physician, call your primary care physician or your Blue Cross
HMO coordinator at your medical group.

To ask for a second opinion from a specialist outside your medical group,
please call us at 800/ 235-8631. The customer service representative will
verify your Blue Cross HMO membership, get preliminary information,
and give your request to an RN case manager.

A decision is made within five business days from when we get the
information necessary to make a decision. Decisions on urgent requests
are made within a time frame appropriate to your medical condition and
no later than the next business day.

When approved, your case manager helps you with selecting a Blue
Cross HMO specialist within a reasonable travel distance and makes
arrangements for your appointment at a time convenient for you and
appropriate to your medical condition. If your medical condition is
serious, your appointment will be scheduled within no more than
seventy-two (72) hours. Your case manager will work with you and your
medical group to make sure the specialist has your medical records
before your appointment. Except for your usual co-payment, we cover
the specialist's fee.

An approval letter is sent to you and the specialist. The letter includes
the services approved and the date of your scheduled appointment. It
also includes a toll free number to call your case manager if you have
questions or need additional help. Approval is for the second opinion
consultation only. It does not include any other services such as lab, x-ray,
or treatment by the specialist. You and your primary care physician
will get a copy of the specialist's report, which includes any
recommended diagnostic testing or procedures. When you get the report,
you and your primary care physician or group specialist should work
together to determine your treatment options and develop a treatment
plan. Your medical group must authorize all follow-up care.

Only our Medical Director may decide when we will not cover the fees
for a specialist you choose. This may happen when you choose a
specialist who is not part of the Blue Cross HMO network and the same
kind of specialist is available in the network. If your request is not
approved, the letter we send you will include the names of the specialists
that can be approved.

You may appeal a disapproval decision by following our complaint
process. Procedures for filing a complaint are described later in this
booklet under Section 8 and in your denial letter. 16.
16 Page 17 18
2003 Blue Cross-HMO Plan 13 Section 3
If you have questions or need more information about this program,
please contact your Blue Cross HMO coordinator at your medical group
or call us at 800/ 235-8631.

Here are other things you should know about specialty care:
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.

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 There may be a time when your primary care physician says you need to go to the hospital. If it is not an emergency, the medical group will look
into whether or not it is medically necessary. If the medical group
approves your hospital stay, you will need to go to a hospital that works
with your medical group. The same is true for admissions to a skilled
nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 235-8631. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

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

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the
necessary care. 17.
17 Page 18 19
2003 Blue Cross-HMO Plan 14 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.

Deductible This Plan does not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for infertility
services.

Your catastrophic protection
out-of-pocket maximum After your copayments total $1,000 for one family member or $3,000 for three or more family members in any calendar year, you do not have to

pay any more for covered services. However, copayments or
coinsurance for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue
to pay copayments or coinsurance for these services:

Prescription drug benefits
Infertility services
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 18.
18 Page 19 20
2003 Blue Cross-HMO Plan 15 Section 5
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 63 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 800/ 235-8631 or at our website at www. bluecrossca. com.

(a) Medical services and supplies provided by physicians and other health care professionals ......................... 16-24
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies and cardiac rehabilitation

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 Care
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals...................... 25-27
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .................................................. 28-31
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Hospice care
Ambulance

(d) Emergency services .................................................................................................................................. 32-33
Emergency inside or outside of our service area

(e) Mental health and substance abuse benefits............................................................................................... 34-37
(f) Prescription drug benefits ......................................................................................................................... 38-41
(g) Special Features ............................................................................................................................................ 42
(h) Dental benefits .............................................................................................................................................. 43
(i) Non-FEHB benefits available to Plan members.............................................................................................. 44

Summary of benefits ............................................................................................................................................ 63 19.
19 Page 20 21
2003 Blue Cross-HMO Plan 16 Section 5 (a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

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.

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

coverage, including with Medicare.

I M
P O
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T

Benefit Description You pay

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

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

Nothing
Nothing
Nothing

$10 per office visit
$10 per office visit

Professional services of physicians
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
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 20.
20 Page 21 22
2003 Blue Cross-HMO Plan 17 Section 5 (a)
Preventive care, adult You pay
Full physical exams and periodic check-ups ordered by your primary care physician.

Eye exams to determine the need for vision correction. Vision exams include a vision check by your primary care physician to see
if it is medically necessary for you to have a complete vision exam
by a vision specialist. If approved by your primary care physician,
this may include an exam with diagnosis, a treatment program and
refractions.

Ear exams to determine the need for hearing correction. Hearing exams include tests to diagnose and correct hearing

Health screenings as prescribed by your primary care physician, such as mammograms, Pap tests and any cervical cancer screening
tests approved by the U. S. Food and Drug Administration, prostate
cancer screenings, sigmoidoscopies, colonoscopies and all other
medically accepted cancer screening tests..

Immunizations prescribed by your primary care physician..

$10 per office visit
Nothing
Nothing

Nothing
Nothing

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

Preventive care, (all enrolled children regardless of age) You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care for routine examinations and care, such as:
--Full physical exams and periodic check-ups ordered by your
primary care physician

--Eye exams to determine the need for vision correction. Vision
exams include a vision check by your primary care physician to
see if it is medically necessary for you to have a complete vision
exam by a vision specialist. If approved by your primary care
physician, this may include an exam with diagnosis, a treatment
program and refractions

--Ear exams to determine the need for hearing correction. Hearing
exams include tests to diagnose and correct hearing

Nothing
Nothing
Nothing 21.
21 Page 22 23
2003 Blue Cross-HMO Plan 18 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.
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. Newborn
circumcision is covered under Surgery benefits (See 5b).

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

Surgery benefits (Section 5b).

$10 per office visit
Nothing
$10 per office visit

Family planning You pay
A broad range of voluntary family planning services, such as:
Voluntary sterilization for females (tubal ligation)..
Voluntary sterilization for males (vasectomy).
Family planning visits .
Shots and implants for birth control (such as Depo provera)

Intrauterine contraceptive devices (IUDs) and diaphragms, dispensed by a doctor...
Doctor's services to prescribe, fit and insert an IUD or diaphragm.
Genetic testing, when medically necessary..
NOTE: Oral contraceptives are covered under the prescription drug
benefit.

$150
$50
$10 per office visit

Nothing
Nothing

$10 per office visit
Nothing

Not covered: Reversal of voluntary surgical sterilization All charges 22.
22 Page 23 24
2003 Blue Cross-HMO Plan 19 Section 5 (a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
--intravaginal insemination (IVI)
--intracervical insemination (ICI)
--intrauterine insemination (IUI)
Note: We cover fertility drugs under the prescription drug benefit.

50% for all care

Not covered:
Infertility services after voluntary sterilization
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 serum
$10 per office visit
Nothing

Treatment therapies You pay
Chemotherapy and radiation therapy
Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy.

Growth hormone therapy when approved by your primary care physician..

Nothing
Nothing
Nothing

Nothing
Nothing 23.
23 Page 24 25
2003 Blue Cross-HMO Plan 20 Section 5 (a)
Physical and occupational therapies and cardiac rehabilitation You pay
Visits for rehabilitation, such as physical therapy and occupational therapy when prescribed by your physician for the services of each
of the following:
--qualified licensed physical therapists; and
--licensed occupational therapists.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 days.

Nothing

Nothing
Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges

Speech therapy You pay
Visits to a licensed speech therapist when prescribed by your physician. Nothing

Hearing services (testing, treatment, and supplies) You pay
Hearing testing which includes screenings to diagnose and correct hearing Nothing

Not covered:
Hearing aids or services for fitting or making a hearing aid All charges

Vision services (testing, treatment, and supplies) You pay
Vision screening includes a vision check by your primary care physician to see if it is medically necessary for you to have a

complete vision exam by a vision specialist. If approved by your
primary care physician, this may include an exam with diagnosis, a
treatment program and refractions.

Nothing

Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive laser surgeries

All charges

Foot care You pay
We cover medically necessary care for the diagnosis and treatment of
conditions of the foot, when prescribed by your physician.

See durable medical equipment for information on podiatric shoe
inserts.

$10 per office visit

Not covered:
Routine foot care All charges 24.
24 Page 25 26
2003 Blue Cross-HMO Plan 21 Section 5 (a)
Orthopedic and prosthetic devices You pay
Surgical implants.........................................................................................
Artificial limbs or eyes ................................................................................
The first pair of contact lenses or eye glasses when needed after a covered and

medically necessary eye surgery ..................................................................
Breast prostheses following a mastectomy ...................................................
Prosthetic devices to restore a method of speaking when required as a result

of a laryngectomy........................................................................................
Colostomy supplies .....................................................................................

Supplies needed to take care of these devices ...............................................

Nothing
Nothing

Nothing
Nothing

Nothing
Nothing
Nothing

Not covered:
Orthopedic shoes (except when joined to braces) or shoe inserts (except custom molded orthotics). This does not apply to shoes and

inserts designed to prevent or treat foot complications due to
diabetes.
Scalp hair prosthesis including wigs and any other form of hair replacement.

All charges

Durable medical equipment (DME) You pay
You can rent or buy up to $2,000 (a calendar year) of long-lasting medical equipment (called durable medical equipment) and supplies if

they are:
--Ordered by your Plan physician.
--Used only for the health problem.
--Used only by the person who needs the equipment or supplies.
--Made only for medical use. We cover items such as:
Hospital beds
Wheelchairs
Insulin pumps Surgical bras

Note: Covered medical supplies include therapeutic shoes and inserts designed to prevent foot complications due to diabetes.

Nothing

Durable Medical Equipment is Not covered if:
--It is needed only for your comfort or hygiene.
--It is for exercise.
--It is needed for making the room or home comfortable, such as air
conditioning or air filters.

All charges 25.
25 Page 26 27
2003 Blue Cross-HMO Plan 22 Section 5 (a)
Home health services You pay
You can get the following home health care, furnished by a home health
agency (HHA):
Care from a registered nurse
Physical therapy, occupational therapy, speech therapy, or respiratory therapy

Visits with a medical social service worker
Care from of a health aide who works under a registered nurse with the HHA.

Services include oxygen therapy, intravenous therapy and medications

Nothing

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

Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

All charge

Chiropractic Care You pay
Covered up to 20 visits in a year when you see
a chiropractor in the American Specialty Health Plans (ASHP) network.

Also up to $50 per calendar year in rental or purchase charges are
covered for medical equipment and supplies ordered by an ASHP
chiropractor, and approved as medically necessary by ASHP. Such
medical equipment includes: (1) elbow, back, thoracic, lumbar, rib or
wrist supports; (2) cervical collars or pillows; (3) ankle, knee, lumbar,
or wrist braces; (4) heel lifts; (5) hot or cold packs; (6) lumbar cushions;
(7) orthotics; and (8) home traction units for treatment of the cervical or
lumbar regions.

Note: The ASHP chiropractor is responsible for obtaining the necessary approval from the Plan.

$10 per office visit

Not covered:
Any services provided by ASHP that are not approved by us, except for the first visit;

The services of a non-ASHP chiropractor.

All charges

Alternative treatments You pay
Acupuncture Medically necessary acupuncture if referred by your primary care physician and approved by the medical group, for the

treatment of chronic pain.
$10 per office visit

Not covered:
Acupressure, or massage to help pain, treat illness or promote health by putting pressure to one or more areas of the body All charges 26.
26 Page 27 28
2003 Blue Cross-HMO Plan 23 Section 5 (a)
Educational classes and programs You pay
Coverage is limited to:

Diabetes self-management programs supervised by a doctor to teach you and your family members about the disease and how to
take care of it. This includes training, education and nutrition
therapy to enable you to use the equipment, supplies and medicines
needed to manage the disease.

Other health education programs given by your primary care physician or the medical group. Ask about our many programs to:

--Educate you about living a healthy life
--Get a health screening
--Learn about your health problem

Usually Nothing-Separate
copayments may apply to some
programs. Call us for more
information.

Cancer Clinical Trials You pay
Routine patient care costs, as defined below, for phase I, phase II, phase III and
phase IV cancer clinical trials

All of the following conditions must be met:
The treatment you get in a clinical trial must either:
Involve a drug that is exempt under federal regulations from a new drug application, or

Be approved by (i) one of the National Institutes of Health, (ii) the U. S. Food and Drug Administration in the form of an investigational
new drug application, (iii) the United States Department of Defense,
or (iv) the United States Veteran's Administration.

You must have cancer to be able to participate in these clinical trials.
Participation in these clinical trials must be recommended by your primary care physician after deciding it will help you.

For the purpose of this provision, a clinical trial must have a therapeutic intent. Clinical trials to just test toxicity are not included in this coverage.
Routine patient care costs are the costs associated with the services provided,
including drugs, items, devices and services which would otherwise be covered
under the Plan, including health care services which are:

Typically provided absent a clinical trial.
Required solely to provide the investigational drug, item, device or service.

Clinically appropriate monitoring of the investigational item or service.
Prevention of complications arising from the provision of the investigational drug, item, device, or service.

Reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including the diagnosis or
care of the complications.

$10 per office visit
Nothing for all other services 27.
27 Page 28 29
2003 Blue Cross-HMO Plan 24 Section 5 (a)
Not covered:
Drugs or devices not approved by the U. S. Food and Drug Administration that are part of the clinical trial.

Services other than health care services, such as travel, housing, companion expenses and other nonclinical expenses that you may need
because of the treatment you get for the purposes of the clinical trial.
Any item or service provided solely to satisfy data collection and analysis needs not used in the clinical management of the patient.

Health care services that, except for the fact they are provided in a clinical trial, are otherwise specifically excluded from the Plan.
Health care services usually provided by the research sponsors free of charge to members enrolled in the trial.

All charges 28.
28 Page 29 30
2003 Blue Cross-HMO Plan 25 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. Any costs associated with the facility charge (i. e. hospital, surgical center, etc.)

are covered in Section 5 (c).

I M
P O
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A N
T

Benefit Description You pay

Surgical procedures
A comprehensive range of services, such as:
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Any medically necessary eye surgery Endoscopy procedures

Biopsy procedures
Removal of tumors and cysts
Treatment of burns
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity as determined by your medical group, when the treatment is approved in advance

Insertion of internal prostethic devices. See 5( a) Orthopedic braces and prosthetic devices for device coverage information.
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits or
a pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing

Voluntary sterilization for female (tubal ligation).
Voluntary sterilization for male (vasectomy)
$150
$50

Not covered:
Reversal of voluntary sterilization;
Radial keratotomy and other refractive laser surgeries.

All charges 29.
29 Page 30 31
2003 Blue Cross-HMO Plan 26 Section 5( b)
Reconstructive surgery You pay
Reconstructive surgery performed to correct deformities caused by congenital or developmental

abnormalities, illness, or injury for the purpose of improving bodily
function, reducing symptoms or creating a normal appearance.

Nothing

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

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

up to 48 hours after the procedure.

Nothing

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form. This does not apply to surgery you
might need to:
--give you back the use of a body part
--have a breast reconstruction after a mastectomy
--Correct or repair a deformity caused by birth defects, abnormal
development, injury or illness in order to improve function,
symptomatology or create a normal appearance.
Cosmetic surgery does not become reconstructive because of
psychological or psychiatric reasons.

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;
Excision of cysts and incision of abscesses when done as independent procedures;

Splint therapy or surgical treatment for disorders of the joints linking the jawbones and the skull (the temporomandibular joints);
including the complex of muscles, nerves and other tissues related to
those joints; and
Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

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 30.
30 Page 31 32
2003 Blue Cross-HMO Plan 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Kidney
Liver
Lung: Single Double
Pancreas
Allogenic (donor) bone marrow transplants

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

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors, when approved by the Plan medical director

Autologous tandem transplants for testicular and other 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
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.

Nothing

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

Transplants not listed as covered

All charges

Anesthesia You pay
Professional services provided in
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Dental Care
General anesthesia and facility services when dental care must be provided
in a hospital or ambulatory surgery center when you are:
Less than seven years old;
Developmentally disabled; or
Your health is compromised and general anesthesia is medically necessary.

Note: No benefits are provided for the dental procedure itself or for the professional services of a dentist to do the dental procedure.

Nothing
Nothing 31.
31 Page 32 33
2003 Blue Cross-HMO Plan 28 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
Sections 5( a) or (b).

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

Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.

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

Nothing

Inpatient hospital continued on next page. 32.
32 Page 33 34
2003 Blue Cross-HMO Plan 29 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood transfusions. This includes the cost of blood, blood products or blood processing

Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services

Note: Inpatient hospital services are covered for dental care only when the stay is:
--Needed for dental care because of other medical problems you may
have;
--Ordered by a doctor (M. D.) or a dentist (D. D. S.); and
--Approved by the medical group.

Nothing

Not covered:
Custodial care
Non-covered facilities, such as nursing homes, convalescent care facilities, schools, etc.

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges

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

Dental Care
Facility services when dental care must be provided in a hospital or
ambulatory surgery center when you are:
Less than seven years old;
Developmentally disabled; or
Your health is compromised and general anesthesia is medically necessary.

Note: No benefits are provided for the dental procedure itself or for the
professional services of a dentist to do the dental procedure.

Nothing
Nothing 33.
33 Page 34 35
2003 Blue Cross-HMO Plan 30 Section 5( c)
Skilled nursing care facility benefits You pay
We cover the following care in a skilled nursing facility for up to 100 days in a
calendar year.
A room with two or more beds
Special treatment rooms
Regular nursing services
Laboratory tests Physical therapy, occupational therapy, speech therapy, or respiratory

therapy
Drugs and medicines given during your stay. This includes oxygen.
Blood transfusions
Needed medical supplies and appliances

Nothing

Not covered: custodial care All charges
Hospice care You pay
We cover the following hospice care if you have an illness that may lead to
death within one year. Your primary care physician will work with the hospice
and help develop your care plan. The hospice must send a written care plan to
your medical group every 30 days.

Interdisciplinary team care to develop and maintain a plan of care
Short-term inpatient hospital care in periods of crisis or as respite care. Respite care is provided on an occasional basis for up to five consecutive

days per admission
Physical therapy, occupational therapy, speech therapy and respiratory therapy

Social services and counseling services
Skilled nursing services given by or under the supervision of a registered nurse

Certified home health aide services and homemaker services given under the supervision of a registered nurse

Diet and nutrition advice; nutrition help such as intravenous feeding or hyperalimentation
Volunteer services given by trained hospice volunteers directed by a hospice staff member
Drugs and medicines prescribed by a doctor
Medical supplies, oxygen and respiratory therapy supplies
Care which controls pain and relieves symptoms
Bereavement services, including assessing the needs of the bereaved family and developing a care plan to meet those needs, both before and

after death. Bereavement services are available to covered members of the
immediate family (spouse, children, step-children, parents, brothers and
sisters) for up to one year after the employee's or covered family
member's death

Nothing

Not covered: Independent nursing, homemaker services All charges 34.
34 Page 35 36
2003 Blue Cross-HMO Plan 31 Section 5( c)
Ambulance You pay
You can get these services from a licensed ambulance in an emergency or
when ordered by your primary care physician. (We will provide benefits for
these services if you receive them as a result of a 9-1-1 emergency response
system call for help if you think you have an emergency.) Air ambulance is
also covered, but, only if ground ambulance service can't provide the service
needed. Air ambulance service, if medically necessary, is provided only to the
nearest hospital that can give you the care you need.

Base charge and mileage
Disposable supplies
Monitoring, EKG's or ECG's, cardiac defibrillation, CPR, oxygen, and IV Solutions

IN SOME AREAS, THERE IS A 9-1-1 EMERGENCY RESPONSE
SYSTEM. THIS SYSTEM IS TO BE USED ONLY WHEN THERE IS AN
EMERGENCY.

Nothing 35.
35 Page 36 37
2003 Blue Cross-HMO Plan 32 Section 5( d)
Section 5 (d). Emergency services
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically

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

coverage, including with Medicare.

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What is a medical emergency?

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

What is urgent care?
We provide coverage for medically necessary care by non-Plan providers to prevent serious deterioration of
your health resulting from an unforeseen illness or injury when you are more than 20 miles from your medical
group (or your medical group's enrollment area hospital if you are enrolled in an independent practice
association), and seeking health services cannot wait until you return.

If you need urgent care you should seek medical attention immediately. If you are admitted to a hospital for
urgently needed care, you should contact your primary care physician or Medical Group within 48 hours,
unless extraordinary circumstances prevent such notification. Follow-up care will be covered when the care
required continues to meet our definition of "Urgent Care". Urgent care is defined as services received for a
sudden, serious, or unexpected illness, injury or condition, which is not an emergency, but which requires
immediate care for the relief of pain or diagnosis and treatment of such condition.

What to do in case of emergency:
If you need emergency services, get the medical care you need right away. In some areas, there is a 9-1-1
emergency response system that you may call for emergency services (this system is to be used only when there is
an emergency that requires an emergency response).

Once you are stabilized, your primary care physician must approve any care you need after that.
Ask the hospital or emergency room doctor to call your primary care physician.
Your primary care physician will approve any other medically necessary care or will take over your care. You may need to pay a copayment for emergency room services. We cover the rest.

If You Are In-Area. You are in-area if you are 20 miles or less from your medical group (or 20 miles or less from your medical group's hospital, if your medical group is an independent practice association).
If you need emergency services, get the medical care you need right away. If you want, you may also call your
primary care physician and follow his or her instructions.

Your primary care physician or medical group may:
Ask you to come into their office;
Give you the name of a hospital or emergency room and tell you to go there;
Order an ambulance for you;
Give you the name of another doctor or medical group and tell you to go there; or
Tell you to call the 9-1-1 emergency response system. 36.
36 Page 37 38
2003 Blue Cross-HMO Plan 33 Section 5( d)
If You're Out of Area. You can still get emergency services if you are more than 20 miles away from your medical group.
If you need emergency services, get the medical care you need right away (follow the instructions above for What
to do in case of emergency). In some areas, there is a 9-1-1 emergency response system that you may call for
emergency services (this system is to be used only when there is an emergency that requires an emergency
response). You must call us within 48 hours if you are admitted to a hospital.

Remember:
We won't cover services that do not fit the description of medical emergency on page 32.
Your primary care physician must approve care you get once you are stabilized, unless Blue Cross HMO approves it.

Once your medical group or Blue Cross HMO gives an approval for emergency services, they cannot withdraw it.

Benefit Description You pay
Emergency inside or outside of our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care on an outpatient basis at a hospital (if care results in admission to a hospital, the copayment will not apply)

Emergency care at a hospital on an inpatient basis

$10 per office visit
$25 per visit

$25 per visit
Nothing

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 37.
37 Page 38 39
2003 Blue Cross-HMO Plan 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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Cost-sharing and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.

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

necessary.
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 can get care for outpatient professional treatment of mental health and substance abuse conditions by a Plan provider without getting prior

approval from your medical group. In order for care to be covered, you must go to a Plan provider. You can get a directory of Plan providers from
us by calling 800/ 235-8631. You must get prior approval for all inpatient facility based care and any visits to a non-Plan provider. Please see Medical
Management Programs on page 35 for more information.

I M
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Benefit Description You pay
Mental health and substance abuse benefits

We will cover services for the treatment of mental health
and substance abuse conditions provided by a Plan provider.
We will also cover services of a non-Plan provider if an
authorized referral is obtained.

Cost sharing and limitations for benefits that we
cover (for example, visit/ day limits, coinsurance,
copayments, and catastrophic protection out-of-pocket
maximums) for mental health and substance
abuse are based on the cost sharing and limits for
similar benefits under our network medical,
hospital, prescription drug, diagnostic testing, and
surgical benefits.

Professional services, including individual or group therapy by providers such as psychiatrists,

psychologists, or clinical social workers...
Medication management...

Diagnostic laboratory or x-ray tests.
Facility-based care (care provided in a hospital, psychiatric health facility, or residential treatment

center).
Note: If facility based care is not approved by us
before you get care, we will not provide benefits.
Please see Medical Management Programs on page
35 for more information.

$10 per office visit
$10 per office visit
Nothing

Nothing

Not covered:
Services we have not approved.

Note: OPM's review of disputes about network
treatment plans will be based on the treatment plan's
clinical appropriateness. OPM will generally not
order one clinically appropriate treatment plan in
favor of another.

All charges 38.
38 Page 39 40
2003 Blue Cross-HMO Plan 35 Section 5( e)
Mental health and substance abuse benefits CONTINUED
Medical Management Programs for Mental Health and Substance Abuse Conditions
Medical Management Programs apply only to the treatment of mental health and substance abuse conditions for the
following services:

facility based care (facility based care is care provided in a hospital, psychiatric health facility, or residential treatment center) and

authorized referrals to non-Plan providers.
The medical management programs are set up to work together with you and your physician to be sure that you get
appropriate medical care and avoid costs you weren't expecting.

You don't have to get a referral from your primary care physician when you go to a Plan provider for professional
services, such as counseling, for the treatment of mental health and substance abuse conditions. You can get a directory
of Plan providers who specialize in the treatment of mental health and substance abuse conditions from us by calling
800/ 235-8631.

Your primary care physician must provide or coordinate all other care and your medical group must approve it.
We have two medical management programs for treatment of mental health and substance abuse conditions:
The Utilization Review Program applies to facility-based care for the treatment of mental health and substance abuse conditions.

The Authorization Program applies to referrals to non-Plan providers.
We will pay benefits only if you are covered at the time you get services, and our payment will follow the terms and requirements of this Plan.

Utilization Review Program
The utilization review program looks at whether care is medically necessary and appropriate, and the setting in which
care is provided. We will let you and your physician know if we have determined that services can be safely provided
in an outpatient setting, or if we recommend an inpatient stay. We certify and monitor services so that you know when
it is no longer medically necessary and appropriate to continue those services.

You need to make sure that your physician contacts us before scheduling you for any service that requires utilization review. If you get any such service without following the directions under "How to Get Utilization

Reviews," no benefits will be provided for that service.
Utilization review has three parts:
Pre-service review. We look at non-emergency facility-based care for the treatment of mental health and substance abuse conditions and decide if the proposed facility-based care is medically necessary and appropriate.

Concurrent review. We look at and decide whether services are medically necessary and appropriate when pre-service review is not required or we are notified while service is being provided, such as with an emergency
admission to a hospital.
Retrospective review. We look at services that have already been provided:
When a pre-authorization, pre-service or concurrent review was not completed; or
To examine and audit medical information after services were provided.
Retrospective review may also be done for services that continued longer than originally certified. 39.
39 Page 40 41
2003 Blue Cross-HMO Plan 36 Section 5( e)
Mental health and substance abuse benefits CONTINUED
Effect on Benefits
When you don't get the required pre-service review before you get facility-based care for the treatment of mental health and substance abuse conditions, we will not provide benefits for those services.

Facility-based care for the treatment of mental health and substance abuse conditions will be provided only when the type and level of care requested is medically necessary and appropriate for your condition. If you go ahead
with any services that have been determined to be not medically necessary and appropriate at any stage of the
utilization review process, we will not provide benefits for those services.

When services are not reviewed before or during the time you receive the services, we will review those services when we receive the bill for benefit payment. If that review determines that part or all of the services were not

medically necessary and appropriate, we will not provide benefits for those services.
How to Get Utilization Reviews
Remember, you must make sure that the review has been done.
Pre-Service Reviews
No benefits will be provided if you do not get pre-service review before receiving scheduled (non-emergency) services,
as follows:

You must tell your physician that this Plan requires pre-service review. Physicians who are Plan providers will ask for the review for you. The toll-free number to call for pre-service review is 800/ 274-7767.

For all scheduled services that require utilization review, you or your physician must ask for the pre-service review at least three working days before you are to get services.
We will certify services that are medically necessary and appropriate. For facility-based care for the treatment of mental health and substance abuse conditions we will, if appropriate, certify the type and level of services, as well
as a specific length of stay. You, your physician and the provider of the service will get a written notice showing
this information.

If you do not get the certified service within 60 days of the certification, or if the type of the service changes, you must get a new pre-service review.

Concurrent Reviews
If pre-service review was not done, you, your physician or the provider of the service must contact us for concurrent review. If you have an emergency admission or procedure, you need to let us know within one working

day of the admission or procedure, unless your condition prevented you from telling us or a member of your family
was not available to tell us for you within that time period.

When you tell Plan providers that you must have utilization review, they will call us for you. You may ask a non-Plan provider to call the toll free number on your Member ID card or you may call directly.

When we decide that the service is medically necessary and appropriate, we will, depending upon the type of treatment or procedure, certify the service for a period of time that is medically appropriate. We will also decide on
the medically appropriate setting.
If we decide that the service is not medically necessary and appropriate, we will tell your physician by telephone no later than 24 hours after the decision. You and your physician will receive written notice no later than one business

day after the decision. 40.
40 Page 41 42
2003 Blue Cross-HMO Plan 37 Section 5( e)
Mental health and substance abuse benefits CONTINUED
Retrospective Reviews
We will do a retrospective review:

If we were not told of the service you received, and were not able to do the appropriate review before your discharge from the hospital or residential treatment center.

If pre-service or concurrent review was done, but services continued longer than originally certified.
For the evaluation and audit of medical documentation after you got the services, whether or not pre-service or concurrent review was performed.

If such services are determined to not have been medically necessary and appropriate, we will deny certification.
Authorization Program
The authorization program provides prior approval for medical care or service by a non-Plan provider. The service you
receive must be a covered benefit of this Plan.

You must get approval before you get any non-emergency or non-urgent service from a non-Plan provider for the treatment of mental health and substance abuse conditions. The toll-free number to call for prior approval is

on your member ID card.
If you get any such service, and do not follow the procedures set forth in this section, no benefits will be provided for that service.

Authorized Referrals. In order for the benefits of this Plan to be provided, you must get approval before you get services from non-Plan providers. When you get proper approvals, these services are called authorized referral services.
Effect on Benefits. If you receive authorized referral services from a non-Plan provider, the Plan provider copayment
will apply. When you do not get a referral, no benefits are provided for services received from a non-Plan provider.

How to Get an Authorized Referral. You or your physician must call the toll-free telephone number on your member ID card before scheduling an admission to, or before you get the services of, a non-Plan provider.

When an Authorized Referral Will be Provided. Referrals to non-Plan providers will be approved only when all of the following conditions are met:
There is no Plan provider who practices the specialty you need, provides the required services or has the necessary facilities within 50-miles of your home; AND
You are referred to the non-Plan provider by a physician who is a Plan provider; AND
The services are authorized as medically necessary before you get the services.

Disagreements with Medical Management Program Decisions
If you or your physician don't agree with a Medical Management Program decision, or question how it was reached, either of you may ask for a review of the decision. To request a review, call the number or write to the
address included on your written notice of determination. If you send a written request it must include medical
information to support that services are medically necessary.

If you, your representative, or your physician acting for you, are still not satisfied with the reviewed decision, a written appeal may be sent to us.

If you are not satisfied with the appeal decision, you may follow the procedures under Section 8: The disputed claims process. 41.
41 Page 42 43
2003 Blue Cross-HMO Plan 38 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described on page 40.
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
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T
There are important features you should be aware of. These include:
Who can write your prescription. Drugs must be prescribed by a health care provider licensed to prescribe such medication, and must be given to you within one year of being prescribed.

Where you can obtain them. You may fill the prescription at any licensed retail pharmacy or by our mail service program.
Using Participating Pharmacies. To get medicine your physician has prescribed: --Go to a participating pharmacy.
--For help finding a participating pharmacy, call us at 1-800-700-2541.
--Show your Member ID card.
--Pay your copayment when you get the medicine. You must also pay for any medicine or supplies
that are not covered under the Plan.
--When your prescription is for a brand name drug, the pharmacist will substitute it with a generic drug
unless your physician writes "dispense as written".

Using Non-Participating Pharmacies. It will cost you more if you go to a non-participating Pharmacy:

--Take a claim form with you to the non-participating pharmacy. If you need a claim form or if you
have questions, call 1-800-700-2541.
--Have the pharmacist fill out the form and sign it.
--Then send the claim form (within 90 days) to:

Prescription Drug Program
P. O. Box 4165
Woodland Hills, CA 91365-4165

When we first get your claim, we take out:
--Costs for medicine or supplies not covered under the Plan,
--Then any cost more than the limited fee schedule we use for non-participating pharmacies, and
--Then your copayment.
The rest of the cost is covered.

If you are out of state, and you need medicine, --Call 1-800-700-2541 to find out where there is a participating pharmacy.

--If there is no participating pharmacy, pay for the drug and send us a claim form. 42.
42 Page 43 44
2003 Blue Cross-HMO Plan 39 Section 5( f)
Prescription drug benefits CONTINUED Getting your medicine through the mail. When you order medicines through the mail, here's what to
do:
--Get your prescription from your health care provider. He or she should be sure to sign it. It must have the drug name, how much and how often to take it, how to use it, the provider's name and address and

telephone number along with your name and address.
--Fill out the order form. The first time you use the mail service program, you must also send a filled out Patient Profile questionnaire about yourself. Call 1-866-274-6825for order forms and the Patient Profile

questionnaire.
--Be sure to send the copayment along with the prescription and the order form and the Patient Profile.
You can pay by check, money order, or credit card.
--Send your order to:
Blue Cross Prescription Drug Program -Mail Service
P. O. Box 961025
Fort Worth, TX 76161-9863
1-866-274-6825

--There may be some medicines you cannot order through this program. Call 1-866-274-6825 to
find out if you can order your medicine through the mail service program.

We use a formulary. A preferred drug list, sometimes called a formulary, is used to help your physician make prescribing decisions. This list of drugs is updated quarterly by a committee of doctors and

pharmacists so that the list includes drugs that are safe and effective in the treatment of disease. If you
are prescribed a non-preferred drug without "dispense as written", you will have to pay the higher
copayment listed on the next page.

You can get drugs not listed as preferred drugs for the lower copayment if the physician writes "do not
substitute" or "dispense as written" on the prescription. Some drugs need to be approved -the physician or
pharmacy will know which drugs they are.

If you have questions about whether a drug is on the preferred drug list or needs to be approved, please
call us at 1-800-700-2541.

If we don't approve a request for a drug that is not part of our preferred drug list, you or your
physician can appeal the decision by calling us at 1-800-700-2541. If you are not satisfied with the
result, please see Section 8: The disputed claims process.

These are the dispensing limitations. You can get a 30-day or 100 unit supply, whichever is less, if you get the drug at a retail pharmacy. You can get a 60-day supply of drugs at a retail pharmacy for
treating attention deficit disorder if they:
--Are FDA approved for treating attention deficit disorder;
--Are federally classified as Schedule II drugs; and
--Require a triplicate prescription form.
If the physician prescribes a 60-day supply for the treatment of attention deficit disorders, you have
to pay double the amount of copay for retail pharmacy. If you get the drugs through our mail service
program, the copay will be the same as for any other drug.

You can get a 90-day supply if you get the drug from our mail service program.

Drugs for the treatment of impotence and/ or sexual dysfunction are:
--Limited to six tablets (or treatments) for a 30-day period; and
--Available at retail pharmacies only. You must give us proof that a medical condition has caused the problem.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original brand-name product. Generics cost less than the
equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for
generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name
drugs.
You can save money by using generic drugs. However, you and your physician have the option to
request a name-brand if a generic option is available. Using the most cost-effective medication saves
money. Prescription drug benefits begin on the next page. 43.
43 Page 44 45
2003 Blue Cross-HMO Plan 40 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 retail pharmacy or through our mail
order program:
Outpatient Drugs and medicines which require a prescription by law. Formulas prescribed by a physician for the treatment of

phenylketonuria. These formulas are subject to the brand name
copayment.
Oral and injectable contraceptive drugs
Prescribed contraceptive drugs and devices which are approved by the U. S. Food and Drug Administration.

Insulin, with a copayment charge applied to each vial
Diabetic supplies including insulin syringes, needles, glucose test tablets and test tape. Benedict's solution or equivalent and acetone

test tablets.
Disposable needles and syringes needed for injecting covered prescribed medication

Drugs used primarily for the purpose of treating infertility Smoking cessation drugs and medications, only if a prescription is
required by law
Drugs that have FDA labeling to be injected under the skin by you or a family member

Drugs for sexual dysfunction (see limits on page 39)
Here are some things to keep in mind about our prescription drug
program:

At participating pharmacies, a generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand
name drug.
If you receive brand name drugs when there is no generic equivalent, you will still have to pay the brand name drug
copayment.

For Blue Cross Participating Pharmacies:
Preferred generic drugs:
$5 copay per prescription or refill

Brand name drugs and generic,
non-preferred drugs if the
physician writes "dispense as
written":
$10 copay per prescription or refill

All non-preferred drugs if the
physician DOES NOT write
"dispense as written":
50% of the cost of the prescription or refill

For Non-participating Pharmacies:
Generic drugs:
$5 plus 50% of the drug limited fee schedule

Brand name drugs:
$10 plus 50% of the drug limited fee schedule

For drugs through the Mail Service Program:
Preferred generic drugs:
$5 copay per prescription or refill

Brand name drugs and generic,
non-preferred drugs if the
physician writes "dispense as
written":
$20 copay per prescription or refill

All non-preferred drugs if the
physician DOES NOT write
"dispense as written":
50% of the cost of the prescription or refill 44.
44 Page 45 46
2003 Blue Cross-HMO Plan 41 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Immunizing agents, biological sera, blood, blood products or blood plasma.

Drugs and medicines you can get without a physician's prescription, except insulin or niacin for cholesterol lowering.
Drugs labeled "Caution, Limited by Federal Law to Investigational Use," experimental drugs. Drugs and medicines prescribed for
experimental indications.
Any cost for a drug or medicine that is higher than what we cover.
Cosmetics, health and beauty aids.
Drugs used mainly for cosmetic purposes. Drugs for losing weight, except when needed to treat morbid obesity

(for example, diet pills and appetite suppressants).
Drugs you get outside the United States.
Infusion drugs, except drugs you inject under the skin yourself.
Herbal, nutritional and diet supplements.
Drugs to enhance athletic performance.

All charges 45.
45 Page 46 47
2003 Blue Cross-HMO Plan 42 Section 5( g)
Section 5 (g). Special features
Feature Description
MedCall (24-hour nurse assessment service) Your Plan includes MedCall, a 24-hour nurse assessment service to help you make decisions about your medical care. When you call MedCall toll free at
800-977-0037, be prepared to provide your name, the patient's name (if you're not calling for yourself), the employee's social security number, and

the patient's phone number.
The nurse will ask you some questions to help determine your health care
needs. Based on the information you provide, the advice may be:

Home self-care. A follow-up phone call may be made to determine how well home self-care is working.

Schedule a routine appointment within the next two weeks, or an appointment at the earliest time available (within 64 hours), with your
primary care physician.
Call your primary care physician for further discussion and assessment.
To go to an urgent care center used by your primary care physician.
To go to an emergency room used by your primary care physician.
Instructions to immediately call 911.
In addition to providing a nurse to help you make decisions about your health
care, MedCall gives you free unlimited access to its Audio Health Library
featuring recorded information on more than 100 health care topics. To
access the Audio Health Library, call toll free 800-977-0037 and follow the
instructions given.

We have made arrangements with an independent company to make MedCall
available to you as a special service. It may be discontinued without notice.

Note: MedCall is an optional service. Remember, the best place to go for medical care is your primary care physician. 46.
4