Document Body Page Navigation Panel Document Outline

Capital District Physicians'

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4.Your costs for covered services
Section 5. BenefitsOVERVIEW
Section 6. General exclusionsthings we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for the Capital District Physicians Health Plan, Inc. 2003
2003 Rate Information for Capital District Physicians Health Plan

Pages 1--56

Page 1


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

Capital District Physicians' Health Plan
http:// www. cdphp. com 2003
A Health Maintenance Organization

Serving: Upstate, Hudson Valley, and Western New York.
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
Region I includes the Capital Area of New York.
SG1 Self Only SG2 Self and Family

Region II includes the Hudson Valley of New York.
QB1 Self Only QB2 Self and Family

Region III includes the North and Central New York area.
PW1 Self Only PW2 Self and Family

RI 73-549

For changes in benefits,
see page 7.

This Plan has Excellent accreditation from the NCQA.
See the 2003 Guide for more information on accreditation. 1.
1 Page 2 3
B Table of Contents 2003 CDPHP 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.

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

2003 CDPHP C Table of Contents 3.
3 Page 4 5
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.

2003 CDPHP D Introduction/ Plain Language 4.
4 Page 5 6

2003 CDPHP 1 Table of Contents 5.
5 Page 6 7

2003 CDPHP 2 Table of Contents 6.
6 Page 7 8

Introduction
This brochure describes the benefits of Capital District Physicians' Health Plan, Inc. under our contract (CS 2612) with
the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address
for CDPHP administrative offices is:

Capital District Physicians' Health Plan, Inc.
Patroon Creek Corporate Center
1223 Washington Avenue
Albany, NY 12206-1057

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 for 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 50. 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 Capital District Physician's Health Plan (CDPHP).

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

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW
Washington, DC 20415-3650.

2003 CDPHP 3 Introduction/ Plain Language 7.
7 Page 8 9
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 employers you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to
your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us
to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or
service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service,
or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-280-6885 and explain the situation.
If we do not resolve the issue:

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

2003 CDPHP 4 Stop Health Care Fraud

CALL THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10

Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible
for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

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

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

Who provides my health care?
The Capital District Physicians' Health Plan, Inc. (CDPHP) provides medical care through participating providers in their
private offices, area hospitals, and other health care facilities.

The first and most important decision each member must make is the selection of a primary care doctor. The decision is
important since it is through this doctor that all other health services, particularly those of specialists, are obtained. When
you enroll, you will be asked to let the Plan know which primary care doctor( s) you have selected for you and each of
your family members. In addition, female members may also select an obstetrician/ gynecologist. The Plan's provider
directory lists primary care doctors, (general practitioners, family practitioners, pediatricians, and internists), with their
locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a
regular basis and are available at the time of enrollment or by calling the Member Services Department at (518) 641-3700
or 1-800-777-2273. If you need help choosing a doctor, call the Plan. You may change your doctor selection by notifying
the Plan thirty (30) days in advance.

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

CDPHP is licensed in New York State.
CDPHP has been in existence for 18 years.
CDPHP is a not-for-profit health maintenance organization.

If you want more information about us, call 1-800-777-2273, or write to Member Services, CDPHP, Patroon Creek
Corporate Center, 1223 Washington Avenue, Albany, NY 12206. You may also contact us by fax at (518) 641-5005 or
visit our web site at www. cdphp. com.

2003 CDPHP 5 Section 1 9.
9 Page 10 11
Section 1. Facts about this HMO plan continued
Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our New York State
service area is:

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the area, you should consider enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans.
Contact your employing or retirement office.

2003 CDPHP 6 Section 1

Region I Code SG Region II Code QB Region III Code PW
Albany County Dutchess County Broome County
Columbia County Orange County Chenango County
Fulton County Ulster County Delaware County
Greene County Essex County
Montgomery County Hamilton County
Rensselaer County Herkimer County
Saratoga County Madison County
Schenectady County Oneida County
Schoharie County Otsego County
War ren County Tioga County
Washington County 10.
10 Page 11 12
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 15.7% for Self Only or 26.3% for Self and Family for
enrollment code PW.
Your share of the non-Postal premium will increase by 7.0% for Self or decrease by 4.1% for Self and Family for
enrollment code QB.
Your share of the non-Postal premium will increase by 9.2% for Self Only or 5.1% for Self and Family for enrollment
code SG.
Inpatient Copayment, you pay $100 per confinement limited to two per individual, four per family per calendar year.
Infertility services, you pay $10 per office visit or $100 per inpatient confinement limited to two per individual, four
per family per calendar year.

2003 CDPHP 7 Section 2 11.
11 Page 12 13
Section 3. How you get care
Identification cards We will send you an identification (ID) card. You should carry your ID card with you at all times. You must show it whenever you receive services from
a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive
your ID card, use your copy of the Health Benefits Election Form, SF-2809,
your health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-777-2273
or (518) 641-3700.

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

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

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
Web site.

What you must do It depends on the type of care you need. First, you and each family member to get covered care must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care.
The Plan provider directory lists primary care doctors, with their locations
and phone numbers, and notes whether or not the doctor is accepting new
patients. If you need help choosing a doctor, call the Plan. You may change
your doctor selection by notifying the Plan thirty (30) days in advance.

Primary care Your primary care physician can be a family practitioner, internist, general practitioner, or pediatrician. Your primary care physician will provide most
of your health care, or give you a referral to see a specialist. Women may
also select an OB/ GYN in addition to their primary care physician.

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

Specialty care Your primary care physician will authorize you to visit a specialist for needed care. The primary care physician must provide or authorize all follow-up care.
Do not go to the specialist for return visits unless your primary care physician
gives you a referral. However, you may see your obstetrician/ gynecologist of
record, seek coverage for emergency care, or obtain a routine eye exam once
every 24 months without a referral.

2003 CDPHP 8 Section 3 12.
12 Page 13 14
Section 3. How you get care continued
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will work with the
specialist, the Plan, and the member or member's designee to develop a
treatment plan that allows you to see your specialist for a certain number
of visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand). The treatment plan must be
approved by CDPHP.

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

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

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

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

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our member service department immediately, or as soon as possible, at
(518) 641-3700 or 1-800-777-2273. If you are new to the FEHB Program,
we will arrange for you to receive care.

2003 CDPHP 9 Section 3 13.
13 Page 14 15
Section 3. How you get care continued
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 92nd day after you become a member of this Plan, whichever happens
first.

These provisions apply only to the hospital benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from us.
The approval is based on whether the service is covered, medically necessary,
and follows generally accepted medical practice.

We call this review and approval process prior approval. Your physician or
specialist must obtain prior approval for the following services: hospitalization
or skilled nursing facility care, home health care, inpatient rehabilitation unit
or facility services, prosthetic devices, some identified medications, durable
medical equipment, home dialysis, and hospice care. Prior approval is also
required for physical therapy, occupational therapy, speech therapy, mental
health/ substance abuse, GHT, and other services such as off-plan referrals.

Your primary care physician and/ or specialist contacts CDPHP's Resource
Coordination Management Department with a description of the medical
necessity of the request.

A nurse reviewer reviews the request. Clinical information is obtained to
support the medical necessity of the request. Clinical information is reviewed
against established criteria. Decisions are based on the appropriateness of care.
Ultimate determinations are made by the Plan's Medical Director. Upon approval
you and your provider are notified via telephone and mail. Services that do
not receive prior approval will not be covered by the Plan.

2003 CDPHP 10 Section 3 14.
14 Page 15 16
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment
of $10 per office visit and when you go in the hospital, you pay $100 per
admission limited to two per individual/ four per family per year.

Deductible We do 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 20% of our allowance for durable medical
equipment.

Your catastrophic protection We do not have an out-of-pocket maximum. out-of-pocket maximum

2003 CDPHP 11 Section 4 15.
15 Page 16 17

Section 5. Benefits OVERVIEW (See page 7 for how our benefits changed this year and page 50 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 (518) 641-3700
or 1-800-777-2273 or at our Web site at www. cdphp. com.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . 13 20
Diagnostic and treatment services Hearing services (testing, treatment, and supplies)
Lab, X-ray, and other diagnostic tests Vision services (testing, treatment, and supplies)
Preventive care, adult Foot care
Preventive care, children Orthopedic and prosthetic devices
Maternity care Durable medical equipment (DME)
Family planning Home health services
Infertility services Chiropractic
Allergy care Alternative treatments
Treatment therapies Educational classes and programs
Physical and occupational therapies
Speech therapy

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . 21 23
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 25
Inpatient hospital Extended care benefits/ skilled nursing care facility benefits
Outpatient hospital or ambulatory surgical center Hospice care
Ambulance

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 27
Medical emergency Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 29
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 31
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Non-emergency routine care for full-time Childbirth Education Reimbursement Program
students out-of-area Centers of Excellence for transplants, surgery, etc.
Services for deaf and hearing impaired

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

2003 CDPHP 12 Section 5 16.
16 Page 17 18
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Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.

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

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

During a hospital stay Nothing
In a skilled nursing facility up to 90 days with prior approval

Off ice medical consultations $10 per visit
Second surgical opinion

At home $10 per visit
Not covered All charges
Surgery primarily for cosmetic purposes
Homemaker services
Storage of blood and blood derivatives, except in the case of autologous
blood donations required for a scheduled surgical procedure.
Already a General exclusion

2003 CDPHP 13 Section 5 (a) 17.
17 Page 18 19
Lab, X-ray and other diagnostic tests You pay
Tests, such as: Nothing if you receive these services
Blood tests at a preferred facility; otherwise,
Urinalysis
$10 per office visit

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

Non-routine pap tests $10 per office visit

Preventive care, adult
Routine screenings, such as: Nothing
Total blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test every 5 years starting at age 50
Sigmoidoscopy, screening every five years starting at age 50

Prostate Specific Antigen (PSA) test one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

Routine mammogram covered for women age 35 and older, as follows: Nothing
From age 35 through 39, one baseline during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Routine immunizations, limited to: Nothing
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over
(except as provided for under Childhood immunizations)

Influenza vaccines, annually
Pneumococcal vaccine, age 65 and over

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

2003 CDPHP 14 Section 5 (a) 18.
18 Page 19 20

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

Well-child care charges for routine examinations, immunizations and Nothing.
care through age 22. Well-child care for the following visits: 1 month,
2 months, 4 months, 6 months, 9 months, 12 months, 15 months, and
18 months, ages 2 22 an annual exam

Examinations, such as: $10 per office visit.
Eye exams through age 17 to determine the need for vision correction.
Limited to one every 24 months.

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)

Maternity care
Complete maternity (obstetrical) care, such as: $10 office visit for the initial
Prenatal care diagnosis. You pay nothing thereafter.

Delivery $100 per confinement limited to
Postnatal care two per individual, four per family
Note: Here are some things to keep in mind:
per calendar year.

You do not need to precertify your normal delivery; see page 10 for
other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.

We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.

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

Not covered: Elective sonograms to determine fetal sex All charges

2003 CDPHP 15 Section 5 (a) 19.
19 Page 20 21
Family planning You pay
A range of voluntary family planning services, limited to: $10 per office visit
Voluntary sterilization (See Surgical procedures Section 5 (b))

Surgically implanted contraceptives $5 for a covered generic,
Injectable contraceptive drugs (such as Depo provera) $20 for a covered brand name

Intrauterine devices (IUDs) $10 per office visit
Diaphragms
Genetic counseling when approved
NOTE: We cover oral contraceptives under the prescription drug benefit.

Not covered: reversal of voluntary surgical sterilization All charges

Infertility services
Diagnosis and treatment of infertility, such as: $10 per office visit
Artificial insemination: Nothing for covered inpatient
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover fertility drugs under the prescription drug benefit for up to
six cycles per lifetime.

Not covered: All charges
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm
Leuprolide Acetate when used for cessation of ovulation.
Items such as ovulation predictor kits and home pregnancy testing kits.
IVIG when utilized for infertility or pregnancy loss.

Allergy care
Testing and treatment $10 per office visit
Allergy injection Nothing
Allergy serum

Not covered: provocative food testing and sublingual allergy desensitization All charges

2003 CDPHP 16 Section 5 (a) 20.
20 Page 21 22

Treatment therapies You pay
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone marrow
transplants are limited to those transplants listed under Organ/ Tissue
Transplants on page 23.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy $10 per office visit if received as an
outpatient. Covered in full if part of
home health care.

Growth hormone therapy (GHT) $10 per office visit
Note: We will only cover GHT when we preauthorize the treatment.
Your physician will call for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. If you
do not ask or if we determine GHT is not medically necessary, we will
not cover the GHT or related services and supplies. See Services requiring
our prior approval in Section 3.

Physical and occupational therapies
Up to 120 calendar days per condition for the services of each $10 per office visit
of the following: $10 per outpatient visit

qualified physical therapists and Nothing during covered inpatient
occupational therapists admission
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery,
or a myocardial infarction is provided for up to 36 sessions.

Not covered: All charges
Long-term rehabilitative therapy
Exercise programs
Continuous ECG Monitoring and Thallium stress tests.
Services for chronic or maintenance phase of cardiac rehabilitation.

Speech therapy
Up to 60 calendar days per condition. $10 per office visit
$10 per outpatient visit
Nothing during covered inpatient
admission

Not covered: All charges
Care beyond treatment period.

2003 CDPHP 17 Section 5 (a) 21.
21 Page 22 23
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury $10 per office visit
Hearing testing for children through age 17 (see Preventive care,
children)

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

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment $10 per office visit
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)

Eye exam to determine the need for vision correction for children $10 per office visit
through age 17 (see preventive care)

Eye refractions once every 24 months
Eye exercises and orthoptics when approved

Not covered: All charges
Eyeglasses or contact lenses
Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic or $10 per office visit
peripheral vascular disease, such as diabetes.

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

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

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

2003 CDPHP 18 Section 5 (a) 22.
22 Page 23 24
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes 20 percent of charges
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, Nothing
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices as hospital
benefits; see Section 5 (c) for payment information. See 5( b) for
coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of 20 percent of charges
temporomandibular joint (TMJ) pain dysfunction syndrome.

Approved lumbosacral supports
Hair prosthesis once per lifetime when hair loss is related to a
medical condition

Not covered: All charges
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Corsets, trusses, elastic stockings, support hose, and other
supportive devices

Prosthetic replacements provided less than 3 years after the last one
we covered unless medically indicated

Stump hose

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

hospital beds
wheelchairs
crutches
walkers

blood glucose monitors 20 percent of charges or
insulin pumps $10 per item, whichever is less
Note: Your provider will call our office for authorization. We will arrange
with a health care provider to rent or sell you durable medical equipment.

Not covered: All charges
Motorized wheel chairs

2003 CDPHP 19 Section 5 (a) 23.
23 Page 24 25
Home health services You pay
Home health care ordered by a Plan physician and provided by a Nothing
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide

Services include oxygen therapy, intravenous therapy and medically 20 percent of charges
necessary medications.

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

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

Rest cures

Chiropractic
Medically necessary care for spinal manipulation. $10 per office visit

Alternative treatments
No benefit All charges

Educational classes and programs
Coverage is limited to: Nothing
Smoking Cessation Up 12 weeks, including all related expenses such
as drugs, per member per lifetime. You must attend a smoking cessation
program that CDPHP provides at no cost to you.

Peak Asthma Performance Members receive invitation to free class and
a quarterly newsletter about asthma. Members who attend the class receive
a peak flow meter, a video on asthma, a daily diary, and medication spacer.

PressureWise An interactive program for members identified as
hypertensive. Members attending program receive a blood pressure
monitor and information on taking their blood pressure at home.

2003 CDPHP 20 Section 5 (a) 24.
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Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care.
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).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section
3 to be sure which services require precertification and identify which surgeries
require precertification.

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: $10 per office visit; nothing
Operative procedures for hospital visit
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity, a condition in which an individual's
body mass index is greater than 40 and there is documented failure of a
non-surgical attempt.

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

Voluntary sterilization (e. g; Tubal ligation, Vasectomy) $10 per office visit
Surgically implanted contraceptive and intrauterine devices (IUDs).
Note: Devices are covered under 5( a) Prescription drug coverage.

Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done.

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.

2003 CDPHP 21 Section 5 (b) 25.
25 Page 26 27
Reconstructive surgery You pay
Surgery to correct a functional defect $10 per office visit; nothing for
Surgery to correct a condition caused by injury or illness if: hospital visits
the condition produced a major effect on the member's appearance
and

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

All stages of breast reconstruction surgery following a mastectomy, $10 per office visit; nothing for
such as: hospital visit

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.

Not covered: All charges
Cosmetic surgery any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, limited to: $10 per office visit; nothing for
Reduction of fractures of the jaws or facial bones; hospital visit
Surgical correction of cleft lip, cleft palate, or severe functional
malocclusion;

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

Other surgical procedures that do not involve the teeth or their
supporting structures.

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

Dental work related to TMJ.

2003 CDPHP 22 Section 5 (b) 26.
26 Page 27 28
Organ/ tissue transplants You pay
Limited to: $10 per office visit; nothing at
Cornea hospital visit.
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal, and ovarian germ cell tumors

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

National Transplant Program (NTP) CDPHP facilitates organ
transplants at a CDPHP approved transplant center.

Limited Benefits Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's Medical Director in accordance with the Plan's protocols.

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

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

Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in Nothing
Hospital (inpatient)
Skilled nursing facility
Ambulatory surgical center

Off ice $10 per office visit

2003 CDPHP 23 Section 5 (b) 27.
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Section 5 (c). Services provided by a hospital or other facility, and ambulance services
Here are some important things to remember about these benefits: Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in
a Plan facility.
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).

Benefit Description You pay
Inpatient hospital
Room and board, such as $100 per confinement, limited to
ward, semiprivate, or intensive care accommodations; two per individual, four per family
general nursing care; and
per calendar year.

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

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home.

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

Private nursing care

2003 CDPHP 24 Section 5 (c) 28.
28 Page 29 30
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms $10 per day
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 20 percent of charges
Anesthetics and anesthesia service $10 per day
Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment. We do not cover
the dental procedures.

Not covered: Blood and blood derivatives not replaced by the member All charges

Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility up to 90 days in lieu of hospitalization. Nothing
Not covered: Custodial and rest care All charges

Hospice care
Up to 210 days combined inpatient and outpatient Nothing
Not covered: Independent nursing, homemaker services All charges

Ambulance
Local professional ambulance service when medically appropriate Nothing
Not covered: Transportation for convenience. All charges

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Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.

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

What to do in case of emergency: You should go directly to the emergency room, call 911 or the appropriate emergency response number, or call an
ambulance if the situation is a medical emergency as defined above.
Emergencies within our service area: If you are unsure whether your condition is an emergency, contact your primary care physician for assistance and guidance. However, if you believe you need immediate medical attention,

follow the emergency procedures.
Emergencies outside our service area: If you have an emergency outside of CDPHP's service area, simply go to the nearest hospital emergency room. If you are required to pay for services at the time of treatment, please request an

itemized bill. Send the bill along with your name and member ID number to CDPHP's Member Services Department,
Patroon Creek Corporate Center, 1223 Washington Avenue, Albany, NY 12206.

If you are not admitted to the hospital for further services or care, you will be responsible for a $50 copayment. If you are
admitted immediately, the emergency room copayment is waived and the hospital services will cost $100 per confinement,
limited to two per individual, four per family per calendar year.

After receiving emergency medical care, be sure your primary care physician is notified within forty-eight (48) hours,
unless it is not reasonably possible to do so. He or she will need to know what services were provided before scheduling
any of your follow-up care. All follow-up care must be provided or directed by your primary care physician. Examples of
follow-up care are removal of stitches, cast removal, and X-rays.

Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including $50 per visit. Copayment is waived
doctors' services if admitted. $100 per confinement
limited to two per individual, four
per family per calendar year.

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

2003 CDPHP 26 Section 5 (d) 30.
30 Page 31 32
Emergency outside our service area You pay
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $25 per visit

Emergency care as an outpatient or inpatient at a hospital, including $50 per visit. Copayment is waived
doctors' services if admitted. $100 per confinement
limited to two per individual, four
per family per calendar year.

Not covered: All charges
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area

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

Ambulance
Professional ambulance service when medically appropriate. Nothing
Air ambulance if medically appropriate.
See 5( c) for non-emergency service.

Not covered: Non-emergency or routine transport. All charges

2003 CDPHP 27 Section 5 (d) 31.
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Section 5 (e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be
no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits: All benefits are subject to the definitions, limitations, and exclusions in this brochure

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

Benefit Description You pay
Mental health and substance abuse benefits
Diagnostic and treatment services recommended by a Plan provider and Your cost sharing responsibilities
contained in a treatment plan that we approve. The treatment plan may are no greater than for other illness
include services, drugs, and supplies described elsewhere in this brochure. or conditions.

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

Professional services, including individual or group therapy by providers $10 per visit
such as psychiatrists, psychologists, or clinical social workers

Medication management

Diagnostic tests $10 per visit
Services provided by a hospital or other facility $10 outpatient, $100 per confinement
Services in approved alternative care settings such as: partial limited to two per individual, four
hospitalization, full-day hospitalization, facility based intensive per family per calendar year.
outpatient treatment

Not covered in the network: Services we have not approved All charges.

Mental health and substance abuse benefits Continued on next page

2003 CDPHP 28 Section 5 (e) 32.
32 Page 33 34
Mental Health and substance abuse benefits (Continued)
Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits, you must follow your treatment plan and all of our network
authorization processes. These include:
Mental Health Care You have direct access to mental health care without the need for a referral
from your primary care physician, except in the case of psychiatric (M. D.)
care where a referral still will be needed from your primary care physician.

A direct access toll-free telephone number, 1-800-700-4824, to the Capital
District Behavioral Alliance will connect you to a qualified mental health
clinician who will assist and arrange for treatment. For your convenience,
the telephone number for mental health services is also included on your
CDPHP ID card.

Alcohol/ Substance Abuse Benefits You have access to alcohol and substance abuse care with a referral from
your primary care physician. These benefits are coordinated by St. Peter's
Addiction Recovery Center (SPARC). CDPHP members can also contact
SPARC directly at 1-800-427-9025.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits: We cover prescribed drugs and medications, as described in the chart beginning on
the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure
and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician must write the prescription.
Where you can obtain them.
You must fill the prescription at a Plan pharmacy, or by mail for a maintenance medication.
Approved maintenance prescriptions can be filled through the mail at two copayments for a 90-day supply.
We use a formulary. A formulary is a list of prescription drugs covered by CDPHP based on their efficacy and cost in providing effective patient care. We cover non-formulary drugs prescribed by a Plan doctor. Coverage is available

for all formulary drugs.
You may have a medical necessity for an excluded drug. You will receive a non-covered prescription under the following conditions:

1. Documented allergic/ adverse reaction to a formulary drug;
2. Documented failure on a formulary drug; or
3. Documented patient stability/ control issues for a patient where a formulary drug is contraindicated or a change in
therapy is not advisable.

Your provider who is prescribing the medication must supply appropriate information and complete a medical exception
request. A determination regarding the medical exception request will be forwarded to you and your physician.

These are the dispensing limitations. Prescriptions filled at a participating pharmacy are limited to a 30-day supply. Maintenance prescriptions are filled up to a 90-day supply by mail order. Only certain maintenance prescriptions are

available via mail order to insure quality, proper dosage, and medical appropriateness. Prescription refills received prior
to the next scheduled refill date will not be filled.

There are different copayments for generic and brand name prescriptions. If there is no generic equivalent available,
you will still be responsible for the brand name copayment.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than name-brand drugs.

When you have to file a claim. You do not have to submit claims.
Prescription drug benefits begin on the next page.

2003 CDPHP 30 Section 5 (f) 34.
34 Page 35 36
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician $5 per generic
and obtained from a Plan pharmacy or through our mail order program: $20 per brand name

Self-administered injectable drugs. 90-day mail order supply available for
Implanted time-release medications. There will be no refund of any $10 per generic, $40 per brand name.
portion of the copay if the medication is removed before the end of
its expected life. Note: If there is no generic equivalent available, you will still have to pay

the brand name copay.

Durable medical equipment for insulin-dependent persons with $10 or 20 percent, whichever is less
pre-authorization.

Nutritional supplements for the therapeutic treatment of $5 per generic
phenylketonuria (PKU). $20 per brand name

Infertility drugs. 90-day mail order supply available for
Intravenous fluids and medication for home use. $10 per generic, $40 per brand name.
Prescription drugs for certain inherited disease of amino acid and Note: If there is no generic equivalent
organic acid metabolism shall include modified solid food products available, you will still have to pay
that are low protein or which contain modified protein which are the brand name copay.
medically necessary for up to 12 months. Benefit limit of $2,500.

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

Disposable needles and syringes for the administration of covered 20 percent
medications (non-diabetic)

Insulin, oral agents to control blood sugar, needles, test strips, lancets, $10 or 20 percent, whichever is less.
and visual reading and urine test strips.

Drugs for sexual dysfunction with applicable limits. $5 per generic
Contraceptive drugs and devices $20 per brand name
Smoking Cessation prescriptions up to a 12-week supply. 90-day mail order supply available for
Note: Members must complete a smoking cessation class. $10 per generic, $40 per brand name.
Classes are provided free to members. Note: If there is no generic equivalent
available, you will still have to pay
the brand name copay.

Not covered: All charges
Drugs and supplies for cosmetic purposes
Vitamins, nutrients, and food supplements that can be purchased
without a prescription

Nonprescription medicines
Weight loss prescriptions
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy, except for out-of-area
emergencies

2003 CDPHP 31 Section 5 (f) 35.
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Section 5 (g). Special Features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

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

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

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

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

Non-emergency routine care If you are away at school and need medical care (non-preventive) for an for full-time students illness or injury, coverage is available. When a medical situation develops,

out-of-the area call 1-800-274-2332 prior to seeking care and CDPHP will arrange for medical services and payment with a practitioner in the area.

Childbirth Education CDPHP will reimburse expectant mothers 50 percent of the cost, up to $30 Reimbursement Program per year, for participating in and completing childbirth education classes.
Once you complete the class, send the receipt and certificate of completion
to CDPHP, Patroon Creek Corporate Center, 1223 Washington Avenue,
Albany, NY 12206, for reimbursement.

Services for deaf and The telephone system also includes a TDD system. Members may call hearing impaired 1-877-261-1164 for services.

Centers of excellence for CDPHP facilitates care at approved transplant centers for medically necessary, transplants/ heart surgery/ etc. non-experimental treatment.

2003 CDPHP 32 Section 5 (g) 36.
36 Page 37 38
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Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan dentists must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair $10 per visit
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury

Dental benefits
We have no other dental benefits.

2003 CDPHP 33 Section 5 (h) 37.
37 Page 38 39

Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

2003 CDPHP 34 Section 5 (i)
"The Road to Good Health" Wellness Workshops Through a series of wellness workshops, you will learn
how the combined power of good nutrition, regular exercise
and stress management can help you move toward
optimal health and well-being. A schedule of wellness
programs appears on our web site, www. cdphp. com and
in SmartMoves, CDPHP's quarterly member newsletter.
All wellness programs are free to members.

Wellness Discount Program The Wellness Discount Program allows you to receive
discounts at a variety of health and wellness facilities.

Disease Management Programs Smoking Cessation Up 12 weeks, including all
related expenses such as drugs, per member per
lifetime. You must attend a smoking cessation
program that CDPHP provides at no cost to you.

Peak Asthma Performance Members receive invitation
to free class and a quarterly newsletter about asthma.
Members who attend the class receive a peak flow meter,
a video on asthma, a daily diary and medication spacer.

PressureWise An interactive program for members
identified as hypertensive. Members attending program
receive a blood pressure monitor and information on
taking their blood pressure at home. 38.
38 Page 39 40

Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover
it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition and we agree, as discussed under What Services Require Our Prior Approval on page 10.

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies required for obtaining or continuing employment or insurance, attending schools or camp,
or travel; or.

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

2003 CDPHP 35 Section 6 39.
39 Page 40 41
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

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

Medical, hospital and drug In most cases, providers and facilities file claims for you. benefits Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance,
call us at 1-800-777-2273 or (518) 641-3700.

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

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

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

Receipts, if you paid for your services.
Submit your claims to: Capital District Physicians' Health Plan, Inc., Member Services Department
Patroon Creek Corporate Center
1223 Washington Avenue
Albany, NY 12206.

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

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

2003 CDPHP 36 Section 7 40.
40 Page 41 42
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

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

(b) Send your request to us at: Capital District Physicians' Health Plan, Inc., Patroon Creek Corporate Center,
1223 Washington Avenue, Albany, NY 12206; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

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

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

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

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

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

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C. 20415-3630.

2003 CDPHP 37 Section 8 41.
41 Page 42 43
Section 8. The disputed claims process continued
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

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

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.

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

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

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
1-800-777-2273 or (518) 641-3700 and we will expedite our review; or

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

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

2003 CDPHP 38 Section 8 42.
42 Page 43 44
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you are covered or a family member is covered under health coverage another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according
to the National Association of Insurance Commissioners' guidelines.

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

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

What is Medicare? Medicare is a Health Insurance Program for: People 65 years of age and older.

Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you
or your spouse worked for at least 10 years in Medicare-covered employment,
you should be able to qualify for premium-free Part A insurance. (Someone
who was a Federal employee on January 1, 1983 or since automatically
qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or
your retirement check.

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

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in (Part A or Part B) the United States. It is the way everyone used to get Medicare benefits and is

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

When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be authorized by your Plan PCP or precertified as required.

Claims process when you have the Original Medicare Plan You probably will never have to file a claim when you have both our Plan and the

Original Medicare Plan.
When we are the primary payer, we will process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases your claim will be coordinated automatically

and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file
your claim, call us at 1-800-777-2273.
We will not waive any costs if the Original Medicare Plan is your primary payer.

(Primary payer chart begins on next page.)
2003 CDPHP 39 Section 9 43.
43 Page 44 45
Section 9. Coordinating benefits with other coverage continued
The following chart illustrates whether the Original Medicare or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.

Typically, your participating Plan provider will submit claims on your behalf. If your physician does not participate in
Medicare, you will have to file a claim with Medicare.

2003 CDPHP 40 Section 9

Primary Payer Chart
A. When either you or your covered spouse are age 65 or over and Then the primary payer is
Original Medicare This Plan
1) Are an active employee with the Federal government (including when you
or a family member are eligible for Medicare solely because of a disability),

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

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

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

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

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

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

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

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

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

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

b) Are an active employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c) Are a former spouse of an annuitant, or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d) Are a former spouse of an active employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.
44 Page 45 46

Section 9. Coordinating benefits with other coverage continued
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed
care plans, you can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans cover all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

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

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan.

In this case, we do not waive any of our copayments or coinsurance for your
FEHB coverage.

This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in

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

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage

to enroll in a Medicare managed care plan, eliminating your FEHB premium
(OPM does not contribute to your Medicare managed care plan premium). For
information on suspending your FEHB enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB Program, generally you may
do so only at the next Open Season unless you involuntarily lose coverage or
move out of the Medicare managed care plan's service area.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare Part B

and, if you can't get premium-free Part A, we will not ask you to enroll in it.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program.
CHAMPVA provides health coverage to disabled Veterans and their eligible
dependents. If both TRICARE and CHAMPVA and this Plan cover you, we
pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you
have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to

enroll in one of these programs, eliminating your FEHB premium. (OPM
does not contribute to any applicable plan premiums.) For information on
suspending your FEHB enrollment, contact your retirement office. If you later
want to re-enroll in the FEHB Program, generally you may do so only at the
next Open Season unless you involuntarily lose coverage under the program.

2003 CDPHP 41 Section 9 45.
45 Page 46 47
Section 9. Coordinating benefits with other coverage continued
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of
Workers' Compensation Programs (OWCP) or a similar Federal or State
agency determines they must provide; or

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

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former

spouse, you can suspend your FEHB coverage to enroll in one of these State
programs, eliminating your FEHB premium. For information on suspending
your FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next Open
Season unless you involuntarily lose coverage under the State program.

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

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

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

2003 CDPHP 42 Section 9 46.
46 Page 47 48

Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care that does not have a direct medical benefit such as house cleaning, preparing meals, personal hygiene. Custodial care that lasts
90 days or is sometimes known as long term care.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. We do not have deductibles. See page 11.
Experimental or A procedure that is not approved by the Federal Food and Drug Administration investigational services and/ or the National Institute of Health Technology Assessment.

Group health coverage Medical benefits such as hospital, surgical, and preventive that are purchased on an employer sponsored basis.
Medical necessity A service or treatment which is appropriate and consistent with the diagnosis and accepted standards in the medical community.
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in
different ways. We determine our allowance by the average community
charges. Our providers accept the allowances as payment in full.

Us/ We Us and we refer to Capital District Physicians' Health Plan, Inc.
Yo u You refers to the enrollee and each covered family member.

2003 CDPHP 43 Section 10 47.
47 Page 48 49

Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before limitation you enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office can about enrolling in the answer your questions, and give you a Guide to Federal Employees Health
FEHB Program Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave
without pay, enter military service, or retire;

When your enroll