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Blue Shield of California Access+

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
- How we pay providers
- Your Rights
- Service Area
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
- Other changes
Section 3. How you get care
- Identification cards
- Where you get covered care
  - Plan providers
  - Plan facilities
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Copayments
- Coinsurance
- Your catastrophic protection out-of-pocket maximum
Section 5. Benefits OVERVIEW
Section 5(a). Medical services and supplies provided by physicians and other health care professionals
- Diagnostic and treatment services
- Lab, x-ray and other diagnostic tests
- Preventive care, adult
- Preventive care, children
- Maternity care
- Family planning
- Infertility services
- Allergy care
- Treatment therapies
- Physical and occupational therapies
- Speech therapy
- Hearing services (testing, treatment, and supplies)
- Vision services (testing, treatment, and supplies)
- Foot care
- Orthopedic and prosthetic devices
- Durable medical equipment (DME)
- Home health services
- Chiropractic/Alternative treatments
- Educational classes and programs
- Clinical Trial for Cancer Services
Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals
- Surgical procedures
- Reconstructive surgery
- Oral and maxillofacial surgery
- Organ/tissue transplants
- Anesthesia
Section 5(c). Services provided by a hospital or other facility, and ambulance services
- Inpatient hospital
- Outpatient hospital or ambulatory surgical center
- Extended care benefits/skilled nursing care facility benefits
- Hospice care
- Ambulance
Section 5(d). Emergency services/accidents
- Emergency within our service area
- Emergency outside our service area
- Ambulance
Section 5(e). Mental health and substance abuse benefits
- Mental health and substance abuse benefits
- Out-of-Network Benefit
Section 5(f). Prescription drug benefits
- Covered medications and supplies
Section 5 (g). Special Features
- High risk pregnancies
- Self-referral to Specialty services
Section 5(h). Dental benefits
- Accidental injury benefit
- Dental benefits
Section 5(i). Non-FEHB benefits available to Plan members
- Blue Shield of California Dental Options - Now You Have Choices
- Receive Discounts from Vision One Eyecare Program on Frames and Lenses
- Receive Discounts through the mylifepath sm American Specialty Health Networks Discount Program - Acupuncture, Chiropractic and Massage Therapy
- Medical Care for Vacations, Business Travel and College Students
- Blue Shield 65 Plus, A Medicare+Choice Prepaid Plan
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- Primary Payer Chart
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 Access+ 2003
2003 Rate Information for Blue Shield of California Access+

Pages 1--58

Page 1 2
Blue Shield of California Access+ 2003
http:// www. mylifepath. com
A Health Maintenance Organization

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

This plan has been granted Commendable Accreditation for its commercial plans from the NCQA. See the 2003 Guide for more information on accreditation.
Enrollment codes for this plan:
SJ1 Self Only SJ2 Self and Family

RI 73-574

For
changes in benefits,

see page 8. 1.
1 Page 2 3
OFFICE OF THE DIRECTOR
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
WASHINGTON, DC 20415-0001

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 Cole James Director 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. 3.
3 Page 4 5
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

Privacy Complaints
Office of Personnel Management P. O. Box 707

Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 Access+ 3 Table of Contents
Section 8. The disputed claims process ........................................................................................................................................................... 39
Section 9. Coordinating benefits with other coverage................................................................................................................................. 41
When you have other health coverage
What is Medicare............................................................................................................................................................................ 41
Medicare managed care plan....................................................................................................................................................... 43
TRICARE AND CHAMPVA...................................................................................................................................................... 43
Workers' Compensation ............................................................................................................................................................... 43
Medicaid............................................................................................................................................................................................ 43
Other Government agencies ........................................................................................................................................................ 44
When others are responsible for injuries................................................................................................................................. 44
Section 10. Definitions of terms we use in this brochure .............................................................................................................................. 45
Section 11. FEHB facts........................................................................................................................................................................................... 46
Coverage information....................................................................................................................................................................... 46

No pre-existing condition limitation ........................................................................................................................................ 46
Where you get information about enrolling in the FEHB Program............................................................................... 46
Types of coverage available for you and your family......................................................................................................... 46
Children's Equity Act.................................................................................................................................................................. 47
When benefits and premiums start.......................................................................................................................................... 47
When you retire............................................................................................................................................................................. 48
When you lose benefits ..................................................................................................................................................................... 48
When FEHB coverage ends ....................................................................................................................................................... 48
Spouse equity coverage ............................................................................................................................................................... 48
Temporary Continuation of Coverage (TCC)...................................................................................................................... 48
Enrolling in TCC.......................................................................................................................................................................... 48
Converting to individual coverage........................................................................................................................................... 49
Getting a Certificate of Group Health Plan Coverage ....................................................................................................... 49
Long-term care insurance is still available ....................................................................................................................................................... 50
Index............................................................................................................................................................................................................................ 51
Summary of benefits ............................................................................................................................................................................................... 52
Rates ............................................................................................................................................................................................................ Back cover 6.
6 Page 7 8
2003 Access+ 4 Introduction
Introduction
This brochure describes the benefits of Blue Shield of California Access+ under our contract (CS2639) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for administrative offices is:

Blue Shield of California
Access+ HMO sm 50 Beale Street

San Francisco, CA 94105
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Blue Shield of California.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2003 Access+ 5 Stop Healthcare Fraud!
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you 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 800-880-8086 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self-support).

If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM
if you are retired.

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

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

1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10
2003 Access+ 6 Section 1
Section 1. Facts about this HMO plan
This plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to
treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from plan providers, you will not have to submit claim forms except for your annual eye exam. You only
pay the copayments and coinsurance described in this brochure. When you receive emergency services from non-plan providers, you may have to submit claim forms.

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

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

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about your health plan, its 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.

Corporate Form Blue Shield of California is a not-for-profit corporation that was founded in 1939.
Fiscal Solvency Blue Shield of California meets or exceeds California Department of Managed Health Care standards for
fiscal solvency, confidentiality of medical records and transfer of medical records.

"Gag Clauses" A "gag clause" is when a physician does not disclose all treatment options based on cost considerations. You have the right to have a clear understanding of the medical condition and any proposed appropriate
necessary treatment alternatives, including available success/ outcomes information, regardless of cost or benefit coverage, so you can make an informed decision before receiving treatment.

Medical Records Access+ members have the right, both under state law and Blue Shield of California policy, to review,
summarize and copy their own medical records. Members can request and will receive amendments to their medical records as they are made.

State Licensing Access+ has been licensed by the State of California since 1978.
If you want more information about us, call us at 800-880-8086, or write to Blue Shield of California Access+, P. O. Box 7168, San Francisco, CA 94120-7168. You may also contact us by fax at 916-350-8780 or visit our website at http:// www. mylifepath. com. 9.
9 Page 10 11
2003 Access+ 7 Section 1
Service Area
To enroll in this plan, you must live in or work in our service area. This is where our providers practice. Our service area is:
County Name Excluded ZIP Codes
Alameda None Butte None

Contra Costa None
El Dorado 95613, 95619, 95623, 95633, 95636, 95643, 95651, 95656, 95667, 95684, 95709, 95720, 95721, 95726, 95735, and 96150 to 96158

Fresno None
Kern 93501, 93502, 93504, 93505, 93516, 93519, 93523, 93527, 93528, 93554 to 93556, 93560 and 93596 Kings None

Los Angeles 90704
Madera None Marin None

Merced None
Nevada 95724, 95728, 96111 and 96160 to 96162 Orange None

Placer 95701, 95714, 95715, 95717, 96140 to 96143, 96145, 96146 and 96148
Riverside 92225-26 Sacramento None

San Bernardino 92242, 92280, 92319, 92338 and 92363
San Diego 91905, 91906, 91934, 91948, 91963, 91980, 91987, 91990 to 91995, 92004 and 92086 San Francisco None

San Joaquin None
San Mateo None Santa Barbara None

Santa Clara None
Santa Cruz None Solano None

Sonoma None
Stanislaus None Tulare None

Ventura None
Yolo None

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will normally pay only for emergency or urgent care. We will not pay for any other health care service, except those that are specifically listed on

page 36 under the heading "Medical Care for Vacations, Business Travel and College Students."
If you or a covered family member move outside the service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO like ours that has agreements with affiliates in other states. See page 36 for details about our HMO medical care available for

vacations, business travel and college students coverage. If you or a family member move, you do not have to wait until Open Season
to change plans. Contact your employing or retirement office. 10.
10 Page 11 12
2003 Access+ 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5, Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.

A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB
Program enrollment.

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

Changes to this Plan
Your share of the non-Postal premium will increase by 16.8% for Self Only or 16.8% for Self and Family.

Audiometry examinations will be covered when performed by a physician or by an audiologist at the request of the physician. You pay $10.00 per office visit.

Treatment of damage to natural teeth caused solely by accidental injury is limited to medically necessary services until the
services result in initial palliative stabilization of the member.

The hospice care benefit has been changed. Care in the home is no longer limited to 100 visits per calendar year. Care in a hospice facility is no longer limited to 100 days of service and does not apply against the Extended Care day limits. Terminal

illness is considered to be a medical condition resulting in a prognosis of life of one year or less, if the disease follows its natural course. Covered hospice services will be provided at no charge.

Benefits will be provided for routine patient care for a member who has been accepted into an approved clinical trial for cancer and whose personal physician has obtained prior authorization from the plan. Certain conditions must be met. See page
21 for information concerning coverage including limitations and exclusions.

Other changes
We have changed our member services telephone number to 800-880-8086.

We have discontinued publishing the Health Resource Directory and have replaced it with the Mayo Clinic Guide to Self-Care
for new members.

We have clarified that drugs prescribed for the treatment of dental conditions are not covered by this plan.
We have clarified that routine circumcisions unrelated to illness or injury are covered when performed within 31 days of birth. Copay depends on setting where the procedure was performed.

We have clarified that for preventive care adult screening in addition to routine Pap tests other FDA (Food and Drug Administration) approved cervical cancer screening tests are covered.
We have clarified that in addition to covering surgically implanted breast implants following mastectomy we cover externally
worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy at no charge.

. 11.
11 Page 12 13
2003 Access+ 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a plan
provider, or fill a prescription at a plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits

enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-880-8086.

Where you get covered care You get care from "plan providers" and "plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims, except for your annual eye
examination.
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. All plan providers are

credentialed, according to national standards.
We list plan providers in the provider directory, which we update periodically. The list is
also on our website, http:// www. mylifepath. com.

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

we update periodically. The list is also on our website, http:// www. mylifepath. com.
What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. You must complete a Primary Care Physician Selection Form.

Primary care Your primary care physician can be a general practitioner, family practitioner, internist, pediatrician, or an OB/ GYN. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the plan, call us at 800-880-8086. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals.

The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral.
The exceptions to this are:
1. for true medical emergencies; 2. when another physician is on call for your physician;

3. when you self-refer to an Access+ participating specialist (not applicable to
infertility, emergency and urgent care and allergy services; mental health and substance abuse Access+ specialist care must be provided by a U. S. Behavioral

Health Plan (USBHPC) provider. See page 34 for details.); and
4. OB/ GYN services provided by an obstetrician/ gynecologist or family practitioner within the same IPA/ Medical Group as your primary care physician.

In all other instances, referral to a specialist is done at the primary care physician's direction; if non-plan specialists or consultants are required, the primary care physician
will arrange appropriate referrals. 12.
12 Page 13 14
2003 Access+ 10 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex or serious medical condition, your primary care physician will develop a treatment plan with you
that allows an adequate number of direct access visits with that specialist. Your primary care physician will use our criteria when creating your treatment plan.

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. We will not pay for you to see a specialist who does not participate

with our plan, unless your primary care physician refers you to a non-plan specialist for a
second opinion.

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; 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 or when clinically
appropriate 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. Contact us to
coordinate care for these types of cases.

Second Opinions If there is a question about your diagnosis or if additional information concerning your condition would be helpful in determining the most appropriate plan of treatment, your
primary care physician will, upon request, refer you to another physician for a second medical opinion. If you are requesting a second opinion about care you received from
your primary care physician, a physician within the same Medical Group\ IPA as your primary care physician will provide the second opinion. If you are requesting a second
opinion about care received from a specialist, any plan specialist of the same equivalent
specialty may provide the second opinion. We must authorize all second opinion consultations. 13.
13 Page 14 15
2003 Access+ 11 Section 3
Hospital care Your plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our plan begins, call our member service department immediately at 800-880-8086. If you are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,

we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

Your primary care physician must obtain a preauthorization from us for; (1) selected drugs and drug dosages which require prior authorization for medical necessity, (2)
growth hormone therapy (GHT) (3) organ transplants (4) bone marrow transplants and
(5) cancer clinical trials.

See page 24 in Section 5( b) for the preauthorization process for organ and bone marrow
transplants. 14.
14 Page 15 16
2003 Access+ 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.

Coinsurance Coinsurance is the percentage of our allowable fee that you must pay for your care.
Example: In our plan, you pay 50% of our allowance for infertility services or durable medical equipment.

Your catastrophic protection out-of-pocket maximum for
coinsurance and copayments

After your copayments and your percentage of allowable charges for medical and surgical services total $1,000 per person or $2,000 per family enrollment in any calendar
year, you do not have to pay any more for covered services. However, the following services do not count toward your catastrophic protection out-of-pocket maximum, and
you must continue to pay copayments for these services:
1. your prescription drugs 2. infertility services
3. the Access+ self-referral specialty visit copayments.
For mental health and substance abuse benefits you pay $1,000 in copayments or
coinsurance for a Self Only enrollment or $2,000 for a Self and Family enrollment. After that you do not have to make any further payments the rest of the year for authorized

treatment or services. However, you must continue to pay copayments for prescription
drugs.

Be sure to keep accurate records of your copayments and coinsurances since you are
responsible for informing us when you reach the maximum. 15.
15 Page 16 17
2003 Access+ 13 Section 5
Section 5. Benefits OVERVIEW (See page 8 for how our benefits changed this year and page 52 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms for annual eye exams, or more information about our benefits, contact us at 800-880-8086 or at our website at http:// www. mylifepath. com.

Medical services and supplies provided by physicians and other health care professionals ................................................................... 14-21
Diagnostic and treatment services
Lab, x-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

Speech therapy
Hearing services (screening)
Vision services (screening)
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
Clinical trial for cancer services

Surgical and anesthesia services provided by physicians and other health care professionals ............................................................... 22-24
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

Services provided by a hospital or other facility, and ambulance services................................................................................................. 25-27
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care

Hospice care
Ambulance

Emergency services/ accidents ............................................................................................................................................................................ 28-29
Medical emergency Ambulance

Mental health and substance abuse benefits .................................................................................................................................................... 30-31
Prescription drug benefits.................................................................................................................................................................................... 32-33
Special features ........................................................................................................................................................................................................... 34

High risk pregnancies Self referral to specialty services

Dental benefits............................................................................................................................................................................................................. 35
Non-FEHB benefits available to Plan members .................................................................................................................................................... 36
Summary of benefits .................................................................................................................................................................................................. 52 16.
16 Page 17 18
2003 Access+ 14 Section 5 (a)
Section 5( a). Medical services and supplies provided by physicians and other health care professionals
I
M P

O
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A
N T

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

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

I
M P

O
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A
N T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
During a hospital stay
In a skilled nursing facility
Vaccines for pediatric and adult immunizations
Inpatient non-dental treatment of temporomandibular joint (TMJ) syndrome

Nothing

Office visits, including routine newborn circumcision performed within 31 days of birth unrelated to illness or injury
Office medical consultations
Second opinions

$10 per office visit

Home visit by physician $25 per visit
Self-referral to a plan specialist under Access+ option $30 per office visit
In an urgent care center $50 per visit
Home visit by nurse or health aide $5 per visit
Lab, x-ray and other diagnostic tests

Tests, such as:
Blood tests
Urinalysis
Pathology
X-rays
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Non-routine Pap tests
Non-routine mammograms $10 per test 17.
17 Page 18 19
2003 Access+ 15 Section 5 (a)
Preventive care, adult You Pay
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening every five years starting at age 50
-Colonoscopy once every 10 years at age 50

Nothing

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older Nothing
Routine Pap tests or other FDA (Food and Drug Administration) approved cervical cancer screening tests every year Nothing

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 49, one every one or two years
From age 50 through 64, one every year
At age 65 and older, one every two years

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges
Routine immunizations as recommended by the United States Public Health Service
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccines, annually, age 50 and older
Pneumococcal vaccine for adults 65 and older
Recommended travel immunizations
Hepatitis A, hepatitis B and lyme disease immunization for individuals at high risk

Nothing

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

Well-child care charges for routine examinations, immunizations and care (through age 17)

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

Nothing 18.
18 Page 19 20
2003 Access+ 16 Section 5 (a)
Maternity care You Pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Nothing

Note: Here are some things to keep in mind:
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 5( b)).

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, such as:
Physician office visit for fitting a diaphragm.
Nothing

Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo Provera)
Intrauterine devices (IUDs)
Diaphragms

NOTE: We cover oral contraceptives under the prescription drug benefit.

$10 per item

Voluntary Sterilization
Vasectomy
Tubal ligation
$75 $100

Not covered: Reversal of voluntary surgical sterilization All charges
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)

Covered injectable fertility drugs

50% of allowable charges

Oral fertility drugs (See Prescription Drug Benefits) Regular cost sharing
Infertility service continued on next page 19.
19 Page 20 21
2003 Access+ 17 Section 5 (a)
Infertility services (continued) You pay
Not covered:
Infertility services after voluntary sterilization
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, eggs and frozen embryos and their collection and storage

All charges

Allergy care
Allergy serum Nothing

Testing and treatment
Allergy injection $10 per office visit
Customized antigens 50% of allowable charges

Not covered: Provocative food testing and sublingual allergy desensitization All charges
Treatment therapies
Growth hormone therapy (GHT)

Note: We will only cover GHT for medically necessary conditions when we have preauthorized the treatment. Such authorization must be obtained through your primary

care physician.
Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/ Tissue Transplants on page 24.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy and antibiotic therapy

$10 per office visit

Physical and occupational therapies
These are covered benefits when determined by us to be medically necessary and it is demonstrated that the member's condition will significantly improve as a result of the

services.
-qualified physical therapists; and
-occupational therapists.

Note: Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living.

$10 per visit

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial
infarction, is provided at a plan facility, if medically necessary with the appropriate treatment plan.
$10 per visit

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges 20.
20 Page 21 22
2003 Access+ 18 Section 5 (a)
Speech therapy You Pay
Speech therapy by a qualified speech therapist is covered when it is determined by us to be medically necessary and it is demonstrated that the member's condition will

significantly improve as a result of the services.
$10 per visit

Hearing services (testing, treatment, and supplies)
Hearing screening for children through age 17 (see Preventive care, children) Nothing

Audiometry examinations when performed by a physician or by an audiologist at the request of the physician $10 per office visit

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

All charges

Vision services (testing, treatment, and supplies)
Contact lenses, if medically necessary to treat eye conditions such as keratoconus and keratitis sicca or when required as a result of cataract surgery when no intraocular lens
has been implanted, are covered.
$10 per office visit

Annual eye refraction; in addition to the medical and surgical benefits provided for diagnosis and treatment of disease of the eye, an annual eye refraction (to provide a
written lens prescription) may be obtained from Medical Eye Services (MES) providers.
MES directories can be ordered by calling 800-880-8086.

Note: See Preventive care, children for eye screenings for children.

$10 per office visit

Not covered:
Eyeglasses or contact lenses (See page 36 for details about eyewear discounts)
Eye exercises and orthoptics
Radial keratotomy, refractive keratoplasty and other refractive surgery

All charges

Foot care
Not covered: Routine foot care All charges
Orthopedic and prosthetic devices
Surgically implanted breast implant following mastectomy
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
Nothing

Surgically implanted prosthetic devices, such as artificial joints, pacemakers:
Inpatient Hospital
Outpatient Hospital
Nothing
$50 per surgery

Orthopedic devices (and their repair) such as braces and functional foot orthoses
Prosthetic devices (and their repair) such as artificial limbs, Blom-Singer prostheses and contact lenses necessary to treat certain medical eye conditions. Contact us for details. 50% of allowable charges

Orthopedic and prosthetic devices continued on next page 21.
21 Page 22 23
2003 Access+ 19 Section 5 (a)
Orthopedic and prosthetic devices (continued) You Pay
Not covered:
Orthopedic and corrective shoes
Arch supports
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices
Penile prostheses

All charges

Durable medical equipment (DME)
Purchase or rental up to the purchase price, including repair and adjustment, of durable
medical equipment prescribed by your plan physician. Under this benefit, we cover:

Colostomy/ ostomy supplies
Hospital beds
Wheelchairs
Crutches
Walkers
Canes
Traction equipment
Peak flow monitor for self-management of asthma
Glucose monitor for self-management of diabetes
Apnea monitor for management of newborns

Note: Call us at 800-880-8086 as soon as your plan physician prescribes this equipment. We have contracted with health care providers to rent or sell you durable medical

equipment at discounted rates and we will tell you more about this service when you call.

50% of allowable charges

Not covered:
Exercise equipment
Disposable medical supplies for home use
Speech/ language assistance devices except as listed under prosthetic devices
Self-monitoring equipment and home testing devices, except as listed in the covered
section

Wigs

All charges

Home health services
Home health care ordered by a plan physician and provided by a registered nurse (R. N.), Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST),
Respiratory Therapist (RT), licensed vocational nurse (L. V. N.), or home health aide
Services include oxygen therapy, intravenous therapy and medications

$5 per visit

Home visit by physician $25 per visit
Home Health Services continued on next page 22.
22 Page 23 24
2003 Access+ 20 Section 5 (a)
Home health services (continued) You pay
Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient's family
Services primarily for hygiene, feeding, exercising, moving the patient, homemaking,
companionship or giving oral medication

All charges

Chiropractic/ Alternative treatments
Chiropractic services (up to 20 medically necessary visits per year) members may self-refer
to American Specialty Health Plans (ASHP) Providers by calling 800-678-9133 or visiting our website for participating practitioners
$10 per office visit

Each member is allowed a pre-authorized appliance benefit of up to $50 per year.
Appliance benefits that are pre-authorized such as:
Elbow supports
Back supports (Thoracic)
Cervical collars

All charges above $50 per year

Not covered:
All charges after the 20 visit annual maximum
Naturopathic services
Hypnotherapy
Services for or related to acupuncture (see page 36 for Non-FEHB discount information.)
Note: See page 36 Non-FEHB benefits available to plan members. Significant discounts
through the mylifepath sm Alternative Health Services Discount Program -acupuncture and massage therapy.

All charges

Educational classes and programs
Coverage is limited to:

Health education newsletter
Mayo Clinic Guide to Self-Care for new members
First Steps sm prenatal education program
Preventive health reminders and educational publications

Nothing 23.
23 Page 24 25
2003 Access+ 21 Section 5 (a)
Clinical Trial for Cancer Services
Benefits are provided for routine patient care for a member whose personal physician has
obtained prior authorization from the plan and who has been accepted into an approved clinical trial for cancer provided that:

1. the clinical trial has a therapeutic intent and the member's treating physician determines that participation in the clinical trial has a meaningful potential to benefit
the member with a therapeutic intent; and
2. the member's treating physician recommends participation in the clinical trial; and
3. the hospital and/ or physician conducting the clinical trial is a plan provider, unless the protocol for the trial is not available through a plan provider.

Charges for routine patient care will be paid on the same basis and at the same benefit levels as any other similar covered service or supply.
Routine patient care consists of those services that would otherwise be covered by the plan if those services were not provided in connection with an approved clinical trial, but does
not include:
1. Drugs or devices that have not been approved by the federal Food and Drug Administration (FDA);

2. Services other than health care services, such as travel, housing, companion expenses and other non-clinical expenses;
3. Any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the clinical management of the patient;
4. Services that, except for the fact that they are being provided in a clinical trial, are specifically excluded under the plan;
5. Services customarily provided by the research sponsor free of charge for any enrollee in the trial.
An approved clinical trial is limited to a trial that is:
1. Approved by one of the following:
a. one of the National Institutes of Health;
b. the U. S. Food and Drug Administration, in the form of an investigational new drug application;

c. the United States Department of Defense;
d. the United States Veterans' Administration;
or
Involves a drug that is exempt under federal regulations from a new drug application.

Covered as any other similar service or supply 24.
24 Page 25 26
2003 Access+ 22 Section 5 (b)
Section 5( b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5 (c) for charges associated with the facility charge (i. e.
hospital, surgical center, etc.).

I M
P
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T
A N

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus, when medically necessary
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity for members who meet Blue Shield Medical Policy and clinical criteria for defined procedures and services that have been approved

by their Primary care physicians
Treatment of burns
Circumcisions performed during newborn's post delivery stay in hospital

Nothing in hospital

Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and prosthetic devices for device coverage information. $10 per procedure
Outpatient hospital surgery and supplies including routine newborn cirumcision
performed within 31 days of birth unrelated to illness or injury
$50 per surgery

Voluntary Sterilization
Vasectomy
Tubal ligation
$75
$100

Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot

All charges 25.
25 Page 26 27
2003 Access+ 23 Section 5 (b)
Reconstructive surgery You pay
Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenial anomalies are: protruding ear

deformities, cleft lip, cleft palate, birth marks, webbed fingers, and webbed toes

Nothing as an inpatient

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast
-treatment of any physical complications, such as lymphedemas

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.

See above

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

Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures
Surgical and anthroscopic treatment of TMJ is covered if prior history shows conservative medical treatment has failed. Splint therapy and physical therapy is covered,
see Section 5( a)
Other surgical procedures that do not involve the teeth or their supporting structures

Nothing as an inpatient

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

All charges 26.
26 Page 27 28
2003 Access+ 24 Section 5 (b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Skin
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Intestinal transplants (small intestine) and the small intestine with the liver or small
intestine with multiple organs such as the liver, stomach, and pancreas

Limited Benefits Allogenic (donor) bone marrow transplant; autologous bone marrow transplants ( autologous stem cell and peripheral stem cell support) for the following

conditions when authorized in writing by the Blue Shield Medical Director and performed at approved facilities: acute lymphocytic or non-lymphocytic leukemia,
advanced Hodgkin's lymphoma, advanced non-Hodgkin's lymphoma, advanced
neuroblastoma, and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Breast cancer, multiple myeloma, epithelial ovarian cancer and autologus tandem

transplants for testicular and other germ cell tumors are covered only when approved by
our Medical Director. Related medical and hospital expenses of the donor are covered when the recipient is covered by this plan.

Nothing

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

Implants of artificial organs
Transplants not listed as covered
Pancreas only transplants
Travel expenses unless authorized by us

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)
Skilled Nursing Facility

Nothing

Professional services provided in:
Hospital outpatient department
Ambulatory surgical center
Office

$50 outpatient copayment per treatment or surgery including
necessary supplies 27.
27 Page 28 29
2003 Access+ 25 Section 5 ( c)
Section 5( c). Services provided by a hospital or other facility, and ambulance services
I
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A
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a plan facility.
We have no calendar year deductible.
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).

I
M P

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A
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Benefit Description You pay
Inpatient hospital
Room and board, such as:
semiprivate or intensive care accommodations
general nursing care
meals and special diets when medically necessary
special duty nursing when medically necessary
private rooms when medically necessary

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

Nothing

Other hospital services and supplies, such as:
Operating, recovery, delivery room, newborn nursery, 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

Radiation therapy, chemotherapy, and renal dialysis

Nothing

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

Private nursing care

All charges 28.
28 Page 29 30
2003 Access+ 26 Section 5 ( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests, x-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental procedures when
necessitated by a non-dental physical impairment. We do not cover dental procedures for non-accidental injury to natural teeth. See page 35.

$50 per treatment or surgery including necessary supplies

Not covered: Blood and blood derivatives if replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
We provide benefits up to 100 days each calendar year when full time skilled nursing
care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by your plan physician and approved by us. Admissions to a sub-acute care

setting require prior approval and are limited to 100 days each calendar year. All
necessary services are covered, including:

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

Nothing

Not covered: Custodial care, rest cures, domiciliary or convalescent care and comfort items such as a telephone and television. All charges after the 100 day annual maximum. All charges 29.
29 Page 30 31
2003 Access+ 27 Section 5 ( c)
Hospice care
We cover the following services through a participating hospice agency when the member has a terminal illness with a prognosis of life of one year or less as determined by the member's

plan provider's certification. Admission to the hospice program must be prior approved by Blue Shield and the delegated IPA/ MG. If the member lives longer than one year, hospice
coverage can continue for a period of care if the plan provider recertifies that the member still
needs and remains eligible for hospice care. Upon recertification a member can receive care for two 90-day periods followed by an unlimited number of 60-day periods.

Members can continue to receive covered services that are not related to the palliation and
management of the terminal illness from the appropriate plan provider. Subject to appropriate plan copays for the type of covered services.

Hospice coverage includes:
Interdisciplinary team care to develop and maintain an appropriate plan of care.
Nursing care services are covered on a continuous basis for as much as 24 hours a day during periods of crisis as necessary to maintain a member at home. Hospitalization is
covered when the interdisciplinary team makes the determination that skilled nursing care is required at a level that can't be provided in the home.

Skilled nursing services, certified health aide services and homemaker services under the
supervision of a qualified registered nurse.

Drugs and medicine, medical equipment and supplies that are reasonable and necessary for the palliation and management of terminal illness and related conditions.

Physical therapy, occupational therapy, and speech-language pathology services for
purposes of symptom control, or to enable the enrollee to maintain activities of daily living and basic functional skills.

Social services/ counseling services with medical social services provided by a qualified
social worker. Dietary counseling, by a qualified provider, will also be provided when needed.

Short-term inpatient care necessary to relieve family members or other persons caring for
the member. Such respite care is limited to an occasional basis and to no more than five consecutive days at a time.

Volunteer services.
Bereavement services.

Nothing in a hospice facility
Nothing for home physician
visit

Nothing for visit of other health care providers

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when ordered or authorized by a plan physician. Nothing 30.
30 Page 31 32
2003 Access+ 28 Section 5 (d)
Section 5( d). Emergency services/ accidents
I M
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T
A N

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

I M
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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are

emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area
If you are in an emergency situation, please call your primary care physician. In extreme emergencies, if you are unable to contact your physician, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital

emergency room. Be sure to tell the emergency room personnel that you are a plan member so they can notify us. You or a
family member should notify us. It is your responsibility to ensure that we have been notified.

If you need to be hospitalized, we must be notified immediately following your admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in non-plan facilities and a plan physician believes care can be
better provided in a plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-plan providers in a medical emergency only if delay in reaching a plan provider would result in death, disability or significant jeopardy to your condition. Any follow-up care recommended by non-plan providers
must be approved by us or provided by plan providers.
We pay reasonable charges for emergency services to the extent the services would have been covered if received from plan providers. If the emergency results in admission to a hospital, any applicable copayment is waived.

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
Emergency care as an outpatient or inpatient at a hospital, including doctors' services
Note: If the emergency results in admission to a hospital, the copayment is waived.

$50 per visit

Not covered: Elective care or non-emergency care All charges 31.
31 Page 32 33
2003 Access+ 29 Section 5 (d)
Emergency outside our service area You pay
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, we must be notified immediately following your admissions, unless it was not reasonably possible to notify us within that time. If you are
hospitalized in non-plan facilities and a plan physician believes care can be better
provided in a plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Reasonable charges for emergency care services to the extent the services would have
been covered if received from plan providers.

Note: If the emergency results in admission to a hospital, the copayment is waived.

Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services
$50 per visit

Not covered: Elective care or non-emergency care All charges
Ambulance
Professional ambulance service when medically appropriate. See 5( c) for non-emergency service. Nothing

Not covered: Taxi, wheelchair van, other non-ambulance assisted transportation All charges 32.
32 Page 33 34
2003 Access+ 30 Section 5 (e)
Section 5( e). Mental health and substance abuse benefits
Network Benefit

I M
P O
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T A

N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and
limitations for plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

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

We have no calendar year deductible.
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 Medicare.

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

I M
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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by plan providers and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and

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

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

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

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

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one
clinically appropriate treatment plan in favor of another.

All charges 33.
33 Page 34 35
2003 Access+ 31 Section 5 (e)
Mental health and substance abuse benefits (continued)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:

To obtain an authorization, call 877-263-8827. You should continue to identify yourself as a Blue Shield member and use your Blue Shield identification card and identification
numbers when contacting USBHPC or its participating providers.

Your health care provider should contact USBHPC at 877-263-9870 to obtain information about joining the USBHPC network, obtaining an authorization for your
treatment, or to speak with a member of USBHPC's clinical staff about issues related to
this benefit or your care.

If you would like a copy of a provider directory, you can contact the Blue Shield Member Services Department at 800-880-8086.

Out-of-Network Benefit
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.

See page 30 for In-Network benefits.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with Medicare.

Benefit Description You pay
Out-of-Network mental health and substance abuse benefits
Not covered out-of-network All charges 34.
34 Page 35 36
2003 Access+ 32 Section 5 (f)
Section 5( f). Prescription drug benefits
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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.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost
sharing works.

I M
P O
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T A

N
T

There are important features you should know about your prescription drug benefit. These include:
Who can write your prescription? A licensed physician, or other covered provider acting within the scope of their license.
Where can you obtain your prescriptions? You must fill the prescription at a retail plan pharmacy, or plan mail service pharmacy for a maintenance medication.

Mail Service Drug Program. Prescriptions are available by mail for up to a 90-day supply for maintenance drugs.
Maintenance drugs are a drug commonly prescribed for six months or longer to treat a chronic condition and are administered continuously rather than intermittently.

Generic drugs will be dispensed in lieu of brand name drugs when substitution is permissible by the physician. Call Member
Services at 800-880-8086 to receive a packet for ordering prescriptions through the mail.

We use a formulary. Prescription drug coverage is based on the use of the prescription drug formulary, a copy of which is available to you. Non-formulary drugs are always covered at the non-formulary copayment, unless excluded from the
prescription drug benefit. Selected drugs and drug dosages, require prior authorization for medical necessity. You should not become directly involved with us for this pre-authorization process. Your physician is responsible for obtaining prior
authorization and documenting medical necessity. If all necessary documentation is available from your physician, prior
authorization approval or denial will be provided to your physician within two working days of the request.

Medications are selected for inclusion in Blue Shield's Outpatient Prescription Drug Formulary based on safety, efficacy, and FDA bio-equivalency data. The Blue Shield Pharmacy and Therapeutics Committee reviews new drugs and clinical data four
times a year.
Members may call Blue Shield Member Services at 800-880-8086 to find out if a specific drug is included in the Formulary. New members receive a printed copy of the formulary with their welcome kits. Formulary information is also available on Blue
Shield's website at http:// www. mylifepath. com.
In lieu of brand name drugs, generic drugs will be dispensed when substitution is permissible by the physician. If you request a brand name drug when a generic drug is available, you pay the difference between the cost of the brand name drug and its
equivalent generic drug, plus the appropriate copayment.
Prescription Days Supply Covered: Present your Access+ ID card at the participating pharmacy. A retail plan pharmacy may dispense up to a 30-day supply for the appropriate copayment. You will pay the appropriate copayment per prescription for
out-of-state emergencies. Maintenance drugs are available for up to a 90-day supply at the appropriate copayment per prescription through the plan mail service pharmacy.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic
name of a drug is its chemical name; the brand name is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and effectiveness.

A generic prescription costs you --and us --less than a brand name prescription. 35.
35 Page 36 37
2003 Access+ 33 Section 5 (f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a plan physician and
obtained from a retail plan pharmacy or through our mail service pharmacy:

Diabetic supplies limited to disposable insulin syringes, needles, pen delivery systems for the administration of insulin as determined by Blue Shield to be medically necessary and

glucose testing tablets and strips
Smoking cessation medication requiring a prescription (limited to one 12-week course of treatment per calendar year)

Formulary and non-formulary drugs for sexual dysfunction or sexual inadequacies will
be covered when the dysfunction is caused by medically documented organic disease. Prior plan approval is required and the maximum dosage dispensed will be limited by the

protocols established by us. Certain drugs for these conditions are not available through
the Mail Service option.

Formulary and non-formulary drugs and medicines that by federal law of the United States require a physician's prescription for their purchase, except as excluded below.

Insulin
Disposable needles and syringes for the administration of covered medications
Formulary and non-formulary oral contraceptive drugs and diaphragms.

$5 per generic formulary retail
plan pharmacy prescription

$10 per brand name formulary retail plan pharmacy
prescription
$25 per non-formulary retail plan pharmacy prescription

$10 per generic formulary mail service prescription
$20 per brand name formulary
mail service prescription

$50 per non-formulary mail service prescription

Here are some things to keep in mind about our prescription drug program:
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name. If your receive a brand name drug when a federally-approved
generic drug is available and your physician has not specified "Dispense as Written" for the brand name drug, you will pay the difference in the cost between the
brand name drug and the generic plus the copayment.

Appropriate copayment plus the difference in price of brand
name and generic drugs

Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non-plan pharmacy except for out-of-area emergencies
Compounded medication with formulary alternatives or those with no FDA approved indications

Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs for weight loss
Smoking cessation drugs without a prescription or for which there is a nonprescription equivalent available

Vitamins and nutritional substances that can be purchased without a prescription
Drugs prescribed for the treatment of dental conditions
Intravenous fluids and medications for home use and some injectable drugs, such as Depo Provera, are covered under Sections 5( a) or 5( b) Medical or Surgical services, not

the Prescription Drug Benefit.
Note: IUDs and implanted contraceptives dispensed by your physician are covered under Section 5( a), not the Prescription Drug Benefit.

All Charges 36.
36 Page 37 38
2003 Access+ 34 Section 5 (g)
Section 5 (g). Special Features
Feature Description
High risk pregnancies We cover the prenatal diagnosis of genetic disorders of the fetus in high-risk pregnancy cases.

Self-referral to Specialty services Access+ allows you to arrange office visits with plan specialists in the same Medical Group or IPA as your primary care physician without a referral. A few physicians are
not Access+ providers. You are advised to refer to the Access+ 2003 Provider Directory for Federal Employees to determine if your physician participates in the

Access+ self-referral option. Members who use this convenient feature are subject to a $30 copayment per specialty office visit. If the medical condition requires follow-up
care to the same specialist, you are encouraged to request that the specialist receive
prior authorization from your primary care physicians for additional visits at the regular office copayment of $10 per visit.

The Access+ specialist includes:
Examinations and consultations;
Conventional x-rays of the chest and abdomen;
X-rays of bones to diagnose suspected fractures;
Laboratory services;
Diagnostic or treatment procedures that would normally be provided with a referral; and
Vaccines and antibiotics.

The Access+ specialist visit does not include:
Diagnostic imaging such as CAT Scans, MRI or bone density measurements;
Services that are not covered benefits or that are not medically necessary;
Services of a provider not in the Access+ or USBHPC network (see section 5( e));
Allergy testing;
Endoscopic procedures;
Injectables, chemotherapy or other infusion drugs (not listed above);
Infertility services;
Emergency services;
Urgent care services;
Inpatient services or facility charges;
Services for which the Medical Group or IPA routinely allows the Member to self-refer without authorization from the Personal Physician;

OB/ GYN services by an obstetrician/ gynecologist or family practice Physician within
the same Medical Group/ IPA as the Personal Physician; and

Internet based consultations. 37.
37 Page 38 39
2003 Access+ 35 Section 5 (h)
Section 5( h). Dental benefits
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Plan providers must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is described below.

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

I
M P

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A
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Accidental injury benefit
The treatment of damage to natural teeth caused solely by an accidental injury is limited to medically necessary services until the services result in initial, palliative stabilization of the member as determined by the plan.

Note: Dental services provided after initial stabilization, prosthodontics, orthodontia and cosmetic services are not covered.
The benefit does not include damage to the natural teeth that is not accidental, e. g. resulting from chewing or biting.

Dental benefits
We have no other FEHB dental benefits. Please refer to page 36 for details about a comprehensive, non-FEHB optional Blue
Shield Dental Plan. 38.
38 Page 39 40
2003 Access+ 36 Section 5 (i)
Section 5( i). Non-FEHB benefits available to Plan members
The benefits described on this page are neither offered nor guaranteed under the contract with FEHB, but are made available to all enrollees and family members who are members of this plan. The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out-of-pocket maximums. These
benefits are not subject to the FEHB disputed claims procedure.

Blue Shield of California Dental Options -Now You Have Choices
Blue Shield has responded to your request of offering an optional dental plan with out of network benefits. New for this year is a PPO dental plan. We will continue to offer our dental HMO plan for those members who prefer this type of delivery. You

must enroll in Access+ or Blue Cross Blue Shield Service Benefit Plan to join our dental plans.
When you select the Blue Shield Dental PPO, you can see any dentist whenever you need covered dental services. To access care at the lowest out of pocket expense under this plan you should use a participating dentist.

When you select the Blue Shield Dental HMO and have a dental center provide and coordinate all of your family's dental care, you get the advantages of no deductibles, virtually no claim forms, no waiting periods and no plan maximums.
Monthly or Quarterly Dental Coverage Rates:
Dental PPO Dental HMO Monthly Quarterly Monthly Quarterly

Individual (Adult) $34 $102 $18.50 $55.50
Two-Party $65 $195 $35.50 $106.50 Family $101 $303 $52 $156

Call 888-271-4929 for a list of dentists, summary of benefits and an enrollment form.
Receive Discounts from Vision One Eyecare Program on Frames and Lenses Federal employees with Access+ coverage can enjoy savings of up to 60% on frames and lenses through our Vision One

Eyecare Program at Cole Vision California locations. Cole Vision services are available in the optical departments of many Sears, Target, JCPenney stores, Pearle Vision locations and at offices of participating private practice doctors. There is no
added premium for this money-saving feature. Simply present your Access+ identification card when you pay for your
eyewear and the discounts are automatic. For a location near you visit www. colemanagedvision. com or call 800-424-1155.

For coverage of eye refractions see page 18.
Receive Discounts through the mylifepath sm American Specialty Health Networks Discount Program -Acupuncture, Chiropractic and Massage Therapy

Access+ offers you participation in the mylifepath discount program, which entitles you to discounts up to 25% off certain health and wellness services. When you see a participating practitioner in the mylifepath American Specialty Health Networks
discount program, you'll experience savings on acupuncture, chiropractic and massage therapy. You will be responsible for all charges remaining after the discounts are applied. For more details on all features, please call 888-999-9452 or visit our
website at http:// www. mylifepath. com for health information and news about value-added features.
Medical Care for Vacations, Business Travel and College Students
You, and your eligible family members are covered for urgent and emergency care in all 50 states while you are on vacation
or business travel. There are no additional premiums for this coverage. "Guest membership" is also available on a temporary basis for members and dependents who will be living away from home and who need a local primary care provider. You pay

office copayments, which vary from state to state ($ 5 to $25) for guest visits and $50 for urgent care visits. For additional
information on these coverages, call 800-334-5487.

Blue Shield 65 Plus, A Medicare+ Choice Prepaid Plan
This Plan offers Medicare recipients the opportunity to enroll in the plan through Medicare. As indicated on page 41, annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in

a Medicare prepaid plan if one is available in their area. They may then later reenroll in the FEHB Program. Most federal
annuitants have Medicare Part A. Those without Medicare Part A may join this Medicare prepaid plan but will have to pay for hospital coverage in certain instances in addition to the Part B premium. Before you join the plan, ask whether the plan

covers hospital benefits and, if so, what you will have to pay. Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 888-713-0000 for information on the Medicare prepaid plan and the cost of that enrollment. Blue Shield 65 Plus is now available in Los Angeles and Orange counties and

portions of Riverside and San Bernardino counties.

Benefits on this page are not part of the FEHB Contract 39.
39 Page 40 41
2003 Access+ 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your plan physician determines it is medically necessary to prevent, diagnose, or treat your illness, disease,
injury or condition.
We do not cover the following:

Care by non-plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or mental health practice;
Experimental or investigational services except for services for members who have been accepted into an approved clinical trial for cancer as provided under covered services (Section 5( a)).

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

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies related to sexual dysfunction or sexual inadequacies (including penile prostheses) except as
provided for medically documented treatment of organically based conditions; or

Services performed by a close relative (the spouse, child, brother, sister, or parent of a member) or a person who ordinarily resides in the member's home.

Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2003 Access+ 38 Section 7
Section 7. Filing a claim for covered services
When you see plan physicians, receive services at plan hospitals and facilities, or obtain your prescription drugs at plan pharmacies, you will not have to file claims except for your annual eye examination. Just present your identification card and
pay your copayment or coinsurance.

You will also 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 benefits In most cases, providers and facilities file claims for you. Physicians must file on the form CMS-1500, Health Insurance Claim Form. Facilities will file on the UB-92
form. For claims questions and assistance, call us at 800-880-8086.

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

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to:
Blue Shield of California
Access+ Member Services P. O. Box 272550

Chico, CA 95927

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 41.
41 Page 42 43
2003 Access+ 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:
Step Description
1 You may appeal by either calling or writing the Member Services Department requesting Blue Shield of California to reconsider our initial decision. You must:

a) Write or call us within 6 months from the date of our decision; b) Send your written request to us at: Blue Shield of California, Member Services Department, P. O. Box 272550,
Chico, CA 95927. You may call our member service department at 800-880-8086 and request a Grievance Form.
We will mail or fax the form to you. 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.

Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

2 We have 30 days from the date we receive your request to: a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
b) Write to you and maintain our denial --go to step 4; or c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request go
to step 3.
3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 2, 1900 E Street, NW, Washington, DC 20415-3620

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.

(continued on next page) 42.
42 Page 43 44
2003 Access+ 40 Section 8
Note:
If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

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.
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 800-880-8086 and we will expedite our review; or

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

You may call OPM's Health Benefits Contracts Divisio