John Deere Health Plan, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--60

Page 1


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

2
John Deere Health Plan, Inc. http:/ www. JohnDeereHealth. com
2003
A Health Maintenance Organization

Serving: West Central Illinois and Eastern Iowa
Enrollment in this Plan is limited. You must live in our Geographic
service area to enroll. See page 6 for requirements.

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

Enrollment codes for this Plan:
YH1 Self Only
YH2 Self and Family

For changes
in benefits
see page 8.

RI 73-661 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

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

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

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

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

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

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

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.

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 3.
3 Page 4 5
information that you authorized OPM to release, or that was given out for law enforcement purposes or to
pay for your health care or a disputed claim. ..
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address). ..
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be
able to agree to your request if the information is used to conduct operations in the manner described above. ..
Get a separate paper copy of this notice.

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

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

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

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

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

. Plan facilities......................................................................................................................................... 9

What you must do to get covered care......................................................................................................... 9
. Primary care .......................................................................................................................................... 9

. Specialty care ................................................................................................................................... 9-10
. Hospital care........................................................................................................................................ 10

Circumstances beyond our control ............................................................................................................ 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services................................................................................................................. 12
. Copayments......................................................................................................................................... 12

. Deductible ........................................................................................................................................... 12
. Coinsurance......................................................................................................................................... 12

Your out-of-pocket maximum................................................................................................................... 12
Section 5. Benefits......................................................... 13-36
Overview ................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ............. 14-21
(b) Surgical and anesthesia services provided by physicians and other health care professionals ......... 22-25
(c) Services provided by a hospital or other facility, and ambulance services ....................................... 26-27
(d) Emergency services/ accidents........................................................................................................... 28-29
(e) Mental health and substance abuse benefits...................................................................................... 30-31
(f) Prescription drug benefits ................................................................................................................. 32-33
(g) Special features ...................................................................................................................................... 34
(h) Dental benefits ....................................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members..................................................................................... 36 5.
5 Page 6 7
2003 John Deere Health Plan, Inc. Table of Contents 3
Section 6. General exclusions --things we don't cover ............................................................................................. 37
Section 7. Filing a claim for covered services ............................................................................................................ 38
Section 8. The disputed claims process ................................................................................................................ 39-40
Section 9. Coordinating benefits with other coverage ................................................................................................ 41
When you have
. Other health coverage........................................................................................................................... 41

. Original Medicare .......................................................................................................................... 41-43
. Medicare managed care plan.......................................................................................................... 43-44

TRICARE/ Workers' Compensation/ Medicaid........................................................................................... 44
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 ........................................................................................................................................ 46-48
Coverage information ........................................................................................................................ 46-47
. 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 ................................................................................................... 48
. Your medical and claims records are confidential........................................................................... 48
. When you retire .............................................................................................................................. 48

When you lose benefits ............................................................................................................................ 48
. When FEHB coverage ends............................................................................................................. 48

. Spouse equity coverage .................................................................................................................. 48
. Temporary Continuation of Coverage (TCC)................................................................................. 48
. Converting to individual coverage.................................................................................................. 49
. Getting a Certificate of Group Health Plan Coverage.. 48

Long term care insurance is coming later in 2003. 50

Index........................................................................................................................................................ 51
Notes............................................................................................................................................................ 52
Summary of benefits.............................................................................................................................................. 53-54
Rates.. Back cover 6.
6 Page 7 8
2003 John Deere Health Plan, Inc Introduction/ Plain Language/ Advisory 4
Introduction
This brochure describes the benefits of John Deere Health Plan, Inc. under our contract (CS 2746) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for John Deere
administrative offices is:

John Deere Health Plan, Inc.
1300 River Drive, Suite 200
Moline, IL 61265

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

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

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

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

.. Expect for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means John Deere Health Plan, Inc.

.. 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 # Street, NW Washington, DC
20415-3650. 7.
7 Page 8 9
2003 John Deere Health Plan, Inc Introduction/ Plain Language/ Advisory 5
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/ 747-1446 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 John Deere Health Plan, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

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

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

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

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

Participating providers are located throughout the service area. There are 462 primary care doctors, 1,823 specialists,
and 29 hospitals in the Illinois service area; and 460 primary care doctors, 2,702 specialists, and 45 hospitals in the
Iowa service area.

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

.. John Deere Health Plan, Inc. is a for profit organization
.. We have been in existence since 1985.
.. John Deere Health Plan, Inc. considers a drug, device, medical treatment or procedure to be experimental or

investigational if it has not bee approved for use by one of the following agencies: the Food and Drug
Administration, National Cancer Institute, or Department of Health and Human Services.

If you want more information about us, call 800/ 747-1446, or write to 1300 River Drive, Suite 200, Moline, IL
61265. You may also contact us by fax at 563/ 359-1665 or visit our website at www. johndeerehealth. com.

Service Area
To enroll in this Plan, you must live in our Service Area. Our service area is:

Illinois: Bloomington, Moline, Peoria, and Rock Island areas. This includes the counties of Bureau, Carroll, DeWitt,
Henry, Jo Daviess, Knox, LaSalle, Lee, Livingston, McLean, Marshall, Mercer, Peoria, Rock Island, Stark, Tazewell,
Warren, Whiteside, and Woodford.

Iowa: Burlington, Cedar Rapids, Dubuque, Iowa City, Marshalltown, Ottumwa, Quad Cities areas. This includes the
counties of Appanoose, Benton, Cedar, Clayton, Clinton, Davis, Delaware, Des Moines, Dubuque, Henry, Iowa, 9.
9 Page 10 11
2003 John Deere Health Plan, Inc. 7 Section 1
Jackson, Jasper, Jefferson, Johnson, Jones, Keokuk, Lee, Linn, Louisa, Mahaska, Marshall, Monroe, Muscatine,
Poweshiek, Scott, Tama, Van Buren, Wapello, and Washington.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside of our service
area, we will pay only for emergency care. We will not pay for any other health care services outside of our service
area without a pre-approved referral.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live outside of the service area (for example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a
family member move, you do not have to wait until Open Season to change plans. Contact your employing office or
retirement office. 10.
10 Page 11 12
2003 John Deere Health Plan, Inc. Section 2 8
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 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 on the Non-Postal premium will decrease by 2. 1% for Self Only or 26. 4% for Self and Family. 11.
11 Page 12 13
2003 John Deere Health Plan, Inc. 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/ 247/ 9110.

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

. Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update
periodically.

. 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.

What you must do
to get covered 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.

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

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

. Specialty care Your primary care physician will refer you to a specialist for needed care.
However, you may see any specialist participating in our plan without a
referral. This would include a woman being able to see her Plan
gynecologist for her annual routine examination.

Here are other things you should know about specialty care:
. If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval
beforehand). 12.
12 Page 13 14
2003 John Deere Health Plan, Inc. 10 Section 3
. If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.

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

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

.. terminate our contract with your specialist for other than cause; or

.. drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or

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

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

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

. Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 747-1446. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

.. You are discharged, not merely moved to an alternative care center; or

.. The day your benefits from your former plan run out; or
.. The 92 nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the benefits of the hospitalized person. 13.
13 Page 14 15
2003 John Deere Health Plan, Inc. 11 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
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.

We call this review and approval process precertification. Your
physician must obtain precertification for the following services: services
outside the service area, services provided by non-Plan providers, and
experimental or investigational procedures or treatments; drugs for
Sexual Dysfunction. 14.
14 Page 15 16
2003 John Deere Health Plan, Inc. 12
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
. Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a
copayment of $15 per office visit and when you are admitted into a
hospital, you pay $100 per day.

. Deductible We do not have a deductible.

. Coinsurance We do not have coinsurance

Your out-of-pocket maximum
for copayments After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for

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

.. prescription drugs

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum.

Section 4 15.
15 Page 16 17
2003 John Deere Health Plan, Inc. Section 5 13
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and pages 52-53 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 800/ 747-1446 or at our website at www. johndeerehealth. com
(a) 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

. Speech therapy
.. Hearing services
.. Vision services
. Treatment therapies
.. Physical and occupational therapies
. Foot care
. Orthopedic and prosthetic devices
. Durable medical equipment (DME)
. Home health services
. Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals....................... 22-25
. Surgical procedures
. Reconstructive surgery
. Oral and maxillofacial surgery
. Organ/ tissue transplants
. Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services..................................................... 26-27
. Inpatient hospital
. Outpatient hospital or ambulatory

surgical center

. Extended care benefits/ skilled nursing care
facility benefits .
Hospice care .
Ambulance

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

(e) Mental health and substance abuse benefits ................................................................................................... 30-31
(f) Prescription drug benefits............................................................................................................................... 32-33
(g) Special features..................................................................................................................................................... 34

(h) Dental benefits...................................................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members ................................................................................................... 36

Summary of benefits.............................................................................................................................................. 52-53 16.
16 Page 17 18
2003 John Deere Health Plan, Inc. Section 5 14
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

.. 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
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services

Professional services of physicians
.. In physician's office $15 per office visit

Professional services of physicians
.. In an urgent care center

.. During a hospital stay
.. In a skilled nursing facility
.. Office medical consultations
.. Second surgical opinion

$15 per office visit
Nothing for hospital visits

At home $15 copay per house call
Lab, X-ray and other diagnostic tests
Tests, such as:
.. Blood tests
.. Urinalysis
.. Non-routine pap tests
.. Pathology
.. X-rays
.. Non-routine Mammograms
.. Cat Scans/ MRI
.. Ultrasound
.. Electrocardiogram and EEG

Nothing 17.
17 Page 18 19
2003 John Deere Health Plan, Inc. Section 5 15
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

.. Routine Prostate Specific Antigen (PSA) test one annually for men age
40 and older

.. Routine pap test

Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$15 per office visit

Routine mammogram covered for women age 35 and older, as
follows:

.. From age 35 through 39, one during this five year period

.. Age 40 and above, one every calendar year

$15 per office visit

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

.. Influenza vaccines, annually, age 65 and over

.. Pneumococcal vaccines, annually, age 65 and over

$15 per office visit

Preventive care, children
.. Childhood immunizations recommended by the American Academy
of Pediatrics
$15 per office visit

.. Examinations, such as:
.. Eye exams through age 17 to determine the need for vision
correction.

.. Ear exams through age 17 to determine the need for hearing
correction

.. Examinations done on the day of immunizations (under age 22)

.. Well-child care charges for routine examinations, immunizations and
care (under age 22)

$15 per office visit 18.
18 Page 19 20
2003 John Deere Health Plan, Inc. Section 5 16
Maternity care You pay
Complete maternity (obstetrical) care, such as:
.. Prenatal care

.. Delivery
.. Postnatal care

Note: Here are some things to keep in mind:
.. You do not need to precertify your normal delivery; see page 23 for
other circumstances, such as extended stays for you or your baby.

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

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

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

Nothing

Family planning
A range of voluntary family planning services, limited to:
.. Voluntary sterilization (See surgical procedures Section 5 (b))

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

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

$15 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges. 19.
19 Page 20 21
2003 John Deere Health Plan, Inc. Section 5 17
Infertility services
Diagnosis and treatment of infertility, such as:
.. Artificial insemination:

.. intravaginal insemination (IVI)
.. intracervical insemination (ICI)
.. intrauterine insemination (IUI)
.. in vitro fertilization
.. embryo transfer and GIFT
.. Injectable fertility drugs

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

$15 per office visit
$100 copay per inpatient surgery
$100 per day copay for inpatient
hospital confinement up to a $500
maximum

Not covered:
.. Cost of donor sperm
All charges.

Allergy care You pay
Testing and treatment
Allergy injection
$15 per office visit

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

Treatment therapies
.. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/ Tissue Transplants on page 22.

.. Respiratory and inhalation therapy

.. Dialysis hemodialysis and peritoneal dialysis
.. Intravenous (IV)/ Infusion Therapy Home IV and antibiotic
therapy

.. Growth hormone therapy (GHT)

Note: We will only cover GHT when we preauthorize the treatment.
Your Plan provider will arrange for authorization if the treatment is
found to be medically necessary.

$15 per office visit 20.
20 Page 21 22
2003 John Deere Health Plan, Inc. Section 5 18
Physical and occupational therapies
.. 60 visits per condition for the services of each of the following:
.. qualified physical therapists;
.. occupational therapists; and
.. cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction

Note: We only cover therapy to restore bodily function when there
has been a total or partial loss of bodily function due to illness or
injury.

Nothing

Not covered:
.. long-term rehabilitative therapy

.. exercise programs

All charges.

Speech therapy You pay
.. 60 visits per condition Nothing

Hearing services (testing, treatment, and supplies) You pay
.. First hearing aid and testing only when necessitated by accidental
injury

.. Hearing testing for children through age 17 (see Preventive care,
children)

$15 per office visit

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

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

$15 per office visit

.. Eye exam to determine the need for vision correction for children
through age 17 (see preventive care)
$15 per office visit 21.
21 Page 22 23
2003 John Deere Health Plan, Inc. Section 5 19
Not covered:
.. Eyeglasses or contact lenses and, after age 17, examinations for
them

.. Eye exercises and orthoptics

.. Radial keratotomy and other refractive surgery

.. Refractions, including lens prescriptions

All charges.

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

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

$15 per office visit

Not covered:
.. Podiatric services

.. Cutting, trimming or removal of corns, calluses, or the free edge of
toenails, and similar routine treatment of conditions of the foot, except as stated above

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

All charges.

Orthopedic and prosthetic devices You pay
.. Artificial limbs and eyes; stump hose
.. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

.. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5 (c) for payment information. See
5( b) for coverage of the surgery to insert the device.

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

$15 per office visit 22.
22 Page 23 24
2003 John Deere Health Plan, Inc. Section 5 20
Not covered:
.. orthopedic and corrective shoes

.. arch supports
.. foot orthotics
.. heel pads and heel cups
.. lumbosacral supports
.. corsets, trusses, elastic stockings, support hose, and other supportive
devices

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

All charges.

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

.. hospital beds;
.. wheelchairs;
.. crutches;
.. walkers;
.. blood glucose monitors; and
.. insulin pumps.
Note: Call us at 800/ 747-1446 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care
provider to rent or sell you durable medical equipment at discounted
rates and will tell you more about this service when you call.

Nothing

Home health services You pay
.. Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.

.. Services include oxygen therapy, intravenous therapy and
medications.

Nothing

Not covered: .. nursing care requested by, or for the convenience of, the patient or
the patient's family; .. nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.

All charges. 23.
23 Page 24 25
2003 John Deere Health Plan, Inc. Section 5 21
Alternative treatments
Not covered: .. acupuncture
.. chiropractic services
.. naturopathic services
.. hypnotherapy
.. biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

.. Diabetes self-management
Nothing 24.
24 Page 25 26
2003 John Deere Health Plan, Inc. Section 5 22
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

I M
P O
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A N
T

.. 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 a physician or other health care
professional for your surgical care. Look in Section 5( c) for charges associated with the facility
(i. e. hospital, surgical center, etc.).

I M
P O
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A N
T

Benefit Description You pay
Surgical procedures

A comprehensive range of services, such as:
.. Operative procedures

.. Treatment of fractures, including casting
.. Normal pre-and post-operative care by the surgeon
.. Correction of amblyopia and strabismus
.. Endoscopy procedures
.. Biopsy procedures
.. Removal of tumors and cysts
.. Correction of congenital anomalies (see reconstructive surgery)
.. Surgical treatment of morbid obesity --a condition in which an

individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over ..
Insertion of internal prosthetic devices. See 5( a) Orthopedic
and prosthetic devices for device coverage information. ..
Voluntary sterilization ..
Surgically implanted contraceptive and intrauterine devices
(IUDs) Note: Devices are covered under 5( a). ..
Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per office visit;
Nothing for hospital visits
$100 copay per inpatient surgical
procedure

Not covered: .. Reversal of voluntary sterilization
.. Routine treatment of conditions of the foot; see Foot care.
All charges. 25.
25 Page 26 27
2003 John Deere Health Plan, Inc. Section 5 23
Reconstructive surgery You pay
Surgery to correct a functional defect
.. Surgery to correct a condition caused by injury or illness if:

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

.. All stages of breast reconstruction surgery following a mastectomy,
such as:
.. surgery to produce a symmetrical appearance on the other breast;

.. treatment of any physical complications, such as lymphedemas;
.. breast prostheses and surgical bras and replacements (see
Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

$15 per office visit;
Nothing for hospital visits
$100 copay per inpatient surgical
procedure

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

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to: ..
Reduction of fractures of the jaws or facial bones; ..
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; ..
Removal of stones from salivary ducts; ..
Excision of leukoplakia or malignancies; ..
Excision of cysts and incision of abscesses when done as independent
procedures; and ..
Other surgical procedures that do not involve the teeth or their
supporting structures.

$15 per office visit
Nothing for hospital visits
$100 copay per inpatient surgical
procedure

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 John Deere Health Plan, Inc. Section 5 24
Organ/ tissue transplants You pay
Limited to:
.. Cornea

.. Heart
.. Heart/ lung
.. Kidney
.. Kidney/ Pancreas
.. Liver
.. Lung: Single Double
.. Pancreas
.. Allogeneic (donor) bone marrow transplants

.. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

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

.. National Transplant Program We participate with Centers of
Excellence across the nation

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

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

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

All charges

Anesthesia You pay
Professional services provided in
.. Hospital (inpatient)

Nothing 27.
27 Page 28 29
2003 John Deere Health Plan, Inc. Section 5 25
Professional services provided in
.. Hospital outpatient department
.. Skilled nursing facility
.. Ambulatory surgical center
.. Office

Nothing 28.
28 Page 29 30
2003 John Deere Health Plan, Inc. Section 5 26
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

I M
P O
R T
A N
T

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

.. Plan physicians must provide or arrange your care and you must be hospitalized
in a Plan facility.
.. Be sure to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

.. The amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

I M
P O
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A N
T

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

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

Other hospital services and supplies, such as: ..
Operating, recovery, maternity, and other treatment rooms ..
Prescribed drugs and medicines ..
Diagnostic laboratory tests and X-rays ..
Administration of blood and blood products ..
Blood or blood plasma, if not donated or replaced ..
Dressings, splints, casts, and sterile tray services ..
Medical supplies and equipment, including oxygen ..
Anesthetics, including nurse anesthetist services ..
Take-home items ..
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

$100 per day copay for an
inpatient confinement in the
hospital up to a $500
maximum

Not covered: .. Custodial care
.. Non-covered facilities, such as nursing homes, schools
.. Personal comfort items, such as telephone, television, barber

services, guest meals and beds .. Private nursing care

All charges. 29.
29 Page 30 31
2003 John Deere Health Plan, Inc. Section 5 27
Outpatient hospital or ambulatory surgical center You pay
.. Operating, recovery, and other treatment rooms
.. Prescribed drugs and medicines
.. Diagnostic laboratory tests, X-rays, and pathology services
.. Administration of blood, blood plasma, and other biologicals
.. Blood and blood plasma, if not donated or replaced
.. Pre-surgical testing
.. Dressings, casts, and sterile tray services
.. Medical supplies, including oxygen
.. Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

$100 copay per admission

Extended care benefits/ skilled nursing care facility benefits
Extended care is provided when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate

Nothing

Not covered: custodial care All charges
Hospice care
Hospice care All charges

Not covered: Independent nursing, homemaker services All charges
Ambulance
.. Local professional ambulance service when medically appropriate Nothing 30.
30 Page 31 32
2003 John Deere Health Plan, Inc. Section 5 28
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

If you need to be hospitalized, the Emergency Room copay will be waived. If you need to be hospitalized
at a non-Plan facility, we must be notified as soon as reasonably possible. If your doctor believes care can
be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance
charges covered. Follow-up care by a non-Plan provider is not covered.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of an injury or sudden illness.

Benefit Description You pay
Emergency within our service area
.. Emergency care at a doctor's office

.. Emergency care at an urgent care center
$15 copay per visit

.. Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
$35 copay per visit

($ 35 copay waived, if
admitted) 31.
31 Page 32 33
2003 John Deere Health Plan, Inc. Section 5 29
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

.. Emergency care at a doctor's office
.. Emergency care at an urgent care center
$15 copay per visit

.. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$35 copay per visit

($ 35 copay waived, if
admitted)

Not covered:
.. Elective care or non-emergency care

.. Emergency care provided outside the service area if the need for
care could have been foreseen before leaving the service area .. Medical and hospital costs resulting from a normal full-term

delivery of a baby outside the service area

All charges.

Ambulance
Professional ambulance service, including air when medically
appropriate.

See 5( c) for non-emergency service.

Nothing 32.
32 Page 33 34
2003 John Deere Health Plan, Inc. Section 5 30
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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A N
T

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

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

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

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

I M
P O
R T
A N
T

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

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

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

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

.. Medication management

$15 copay per office visit

Mental health and substance abuse benefits (continued) You Pay
.. Diagnostic tests $15 copay per office visit

.. Services provided by a hospital or other facility
.. Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment.

$100 per day copay per
confinement up to a $500
maximum 33.
33 Page 34 35
2003 John Deere Health Plan, Inc. Section 5 31
Mental health and substance abuse benefits (continued) You Pay
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

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

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
We offer convenient and confidential access to mental health and
substance abuse services. By calling 800/ 867-6758, an experienced mental
health care professional will assess your needs and refer you to the
appropriate qualified provider. This process is called authorization it
helps you get the care you need quickly and conveniently.

Please note that all inpatient and outpatient services need to be authorized
prior to treatment. 34.
34 Page 35 36
2003 John Deere Health Plan, Inc. Section 5 32
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T

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

.. All benefits are subject to the definitions, limitations and exclusions in this brochure and
are payable only when we determine they are medically necessary.

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

I
M
P
O
R
T
A
N
T

There are important features you should be aware of. These include:
.. Who can write your prescription. A licensed physician must write the prescription

.. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication.

.. We use a formulary. The formulary is a list of preferred drugs in each therapeutic drug category.
A member may select a drug not listed on this formulary, but the member will be expected to pay the higher copay amount based on their selection.

.. These are the dispensing limitations. You are limited to a 30 day supply of drug medications per
visit at the retail pharmacy and a 90 day supply of maintenance medications obtained via mail order. Two copays will be applied to the 90 day mail order supply based on the drug tier level of the drugs

prescribed or selected.
.. Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to
more expensive brand-name drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original brand name-product. The U. S. Food and Drug
Administration set quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand-name drugs.

Generics cost less that the equivalent brand-name product. However, you and your physician have
the option to request a name-brand drug if a generic option is not available. Using the most cost-effective
medication saves money.

.. When you have to file a claim. You should send a copy of your paid receipt with you name address
and Social Security number clearly written at the top. Receipts may be mailed to: Attn: Claims
Department, 3800 -23 rd Avenue, Moline IL 61265

.. A generic equivalent will be dispensed if it is available, unless your physician specifically requires
a name brand. If you receive a name brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as Written for the name brand drug, you
have to pay the difference in cost between the name brand drug and the generic.

.. We have an open formulary. If your physician believes a name brand product is necessary or there
is no generic drug available, your physician may prescribe a name brand drug from a formulary list.
This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a
lower cost. To order a prescription drug brochure, call 800/ 747-1446. 35.
35 Page 36 37
2003 John Deere Health Plan, Inc. Section 5 33
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

.. Fertility drugs
.. Drugs and medicines that by Federal law of the United States

require a physician's prescription for their purchase, except as those
listed as Not covered. ..
Insulin ..
Disposable needles and syringes for the administration of covered
medications ..
Drugs for sexual dysfunction (see prior authorization pg. 11) ..
Contraceptive drugs and devices

$10 copay for generic drugs for a
30 day supply

$20 copay for formulary brand
name drugs for a 30 day supply

$35 copay for non-formulary
brand name drugs for a 30 day
supply

Mail Order
$20 copay for generic drugs for a
90 day supply

$40 copay for formulary brand
name drugs for a 90 day supply

$70 copay for non-formulary
brand name drugs for a 90 day
supply

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

Not covered:
.. Drugs and supplies for cosmetic purposes

.. Drugs to enhance athletic performance
.. Smoking cessation drugs and medications
.. Drugs prescribed for weight loss/ appetite suppressants and dietary
supplements

.. Drugs for which there is a nonprescription equivalent available

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

.. Nonprescription medicines

.. Drugs obtained at a non-Plan pharmacy, except of out-of-area
emergencies

All Charges 36.
36 Page 37 38
2003 John Deere Health Plan, Inc. Section 5 34
Section 5 (g). Special Features
Feature Description

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call the number that appears on the reverse of your membership
card and talk with a registered nurse who will discuss treatment
options and answer your health questions.

Services for deaf and
hearing impaired

TDD Phone available: 800/ 884-4327

High risk pregnancies Members may enroll in our prenatal program, "New Generations" by simply calling our customer service representatives as 800/ 747-1446
Centers of excellence We participate with Centers of Excellence across the nation. Contact customer services at 800/ 747-1446 for details
Travel benefit/ services
overseas

You are eligible for worldwide emergency coverage. If you are
planning a trip, contact our customer service department at 800/ 747-
1446 for details 37.
37 Page 38 39
2003 John Deere Health Plan, Inc. Section 5 35
Section 5 (h). Dental benefits
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.
.. This Plan has no dental coverage except for dental services rendered as a result of an
accidental injury.
.. We cover hospitalization for dental procedures only when a nondental 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 O
R T
A N
T

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

Nothing

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

Dental Care
A nationwide network of dentist have agreed to limit their charges to a specific reduced fee schedule for John Deere
Health Plan, Inc. members. To locate current dentist in your area, call 888/ 596-5300. You can also nominate dentist
by asking your dentist to call for an information package at 800/ 949-5449.

This non-FEHB benefit is not an insurance plan. Refer to your dental fee schedule to find the maximum charge
payable by you. If you chose a participating dentist, show your John Deere Health ID card to the dentist's office
before you receive services. You pay only up to the maximum charge and the dentist should not bill you for the
balance.

Vision Care
A nationwide network of ophthalmologists and optometrists have agreed to offer John Deere Health Plan, Inc.
members discounts on frames and lenses, coatings and option, contact lenses and disposable contacts through any
participating provider locations. This network currently contracts with approximately 10,000 providers in fifty states.

To locate a participating provider in your area, call 800/ 999-5431. When you purchase eyewear, show the provider
your John Deere Health ID card before you receive services. 39.
39 Page 40 41
2003 John Deere Health Plan, Inc. 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition.

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

.. Services, drugs, or supplies you receive while you are not enrolled in this Plan;

.. Services, drugs, or supplies that are not medically necessary;
.. Services, drugs, or supplies not required according to accepted standards of medical, dental, or
psychiatric practice;

.. Experimental or investigational procedures, treatments, drugs or devices;

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

.. Services, drugs, or supplies related to sex transformations; or

.. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 40.
40 Page 41 42
2003 John Deere Health Plan, Inc. 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

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

Medical, Hospital, Drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 800/ 747-1446.

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

.. Covered member's name and ID number;

.. Name and address of the physician or facility that provided the
service or supply;

.. Dates you received the services or supplies;

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

.. Receipts, if you paid for your services.

Submit your claims to: John Deere Health Plan 3800 -23 rd Avenue,
Moline, IL 61265

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 John Deere Health Plan, Inc. 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: John Deere Health Plan 3800 23 rd Ave. Moline, Ill 61265
(c) Include a statement about why you believe our initial decision was wrong, based on specific
benefit provisions in this brochure; and

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

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C. 20415-3630. 42.
42 Page 43 44
2003 John Deere Health Plan, Inc. 40 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
.. A statement about why you believe our decision was wrong, based on specific benefit provisions in
this brochure;
.. Copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms;
.. Copies of all letters you sent to us about the claim;

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply
to which claim.

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

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

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

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file
the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which your 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/ 747-1446 and we will expedite our review; or

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

.. You may call OPM's Health Benefits Contracts Division III at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time. 43.
43 Page 44 45
2003 John Deere Health Plan, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

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

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

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

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

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

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

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

When you are enrolled Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. 44.
44 Page 45 46
2003 John Deere Health Plan, Inc. 42 Section 9
We will not waive any of our copayments, coinsurance, and deductibles. The following chart illustrates whether
the Original Medicare Plan or this Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

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

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

2) Are an annuitant, .

.
3) Are a reemployed annuitant with the Federal government when

a) The position is excluded from FEHB, or

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

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

5) Are enrolled in Part B only, regardless of your employment status, . (for Part B services) . (for other services)
6) Are a former Federal employee receiving Workers' Compensation and
the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

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

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

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

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

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

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

b) Are an active employee, or .
c) Are a former spouse of an annuitant, or .
d) Are a former spouse of an active employee . 45.
45 Page 46 47
2003 John Deere Health Plan, Inc. 43 Section 9
Claims process when you have the Original Medicare Plan--You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.

.. When we are the primary payer, we process the claim first.

.. When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something
about filing your claims, call us at 800/ 747-1446 or send us an e-mail
at www. johndeerehealth. com.

We do not waive some costs when you have the Original Medicare
Plan--When Original Medicare is the primary payer, we do not waive
some out-of-pocket costs.

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

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

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

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

Suspended FEHB coverage to enroll in a Medicare managed care
plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area. 46.
46 Page 47 48
2003 John Deere Health Plan, Inc. 44 Section 9
. If you do not enroll in If you do not have one or both Parts of Medicare, you can still be
Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can't get a premium-free Part A, we will not
ask you to enroll in it.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

Workers' Compensation We do not cover services that:
. you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

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

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

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 47.
47 Page 48 49
2003 John Deere Health Plan, Inc. 45 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided to a patient for the purpose of meeting personal needs rather than being able to cure a medical condition. This care includes
such things as changing dressings, assisting walking and dressing, and
applying medications.

Experimental or A drug, device, treatment or procedure that has not been approved for use
investigational services by a major governmental agency.

Us/ We Us and we refer to John Deere Health Plan, Inc.
You You refers to the enrollee and each covered family member. 48.
48 Page 49 50
2003 John Deere Health Plan, Inc. 46 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These

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

. When your enrollment ends; and

. When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or

retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

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

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

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for self and
family coverage in the Federal Employees Health Benefits (FEHB) 49.
49 Page 50 51
2003 John Deere Health Plan, Inc. 47 Section 11
Program, if you are an employee subject to a court or administrative
order requiring you to provide health benefits for your child( ren).

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

.. If you have no FEHB coverage, your employing office will enroll
you for self and family coverage in the option of the Blue Cross and
Blue Shield Service Benefit Plan that provides the lower level of
coverage; ..
If you have a self only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing
office will change your enrollment to self and family in the same
option of the same plan; or ..
If you are enrolled in an HMO that does not serve the area where the
children live, your employing office will change your enrollment to
self and family in the lower option of the Blue Cross and Blue Shield
Service Benefit Plan.

As long as the court/ administrative order is in effect, and you have at
least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to self only, or
change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the
children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage,
you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact you employing office
for further information. 50.
50 Page 51 52
2003 John Deere Health Plan, Inc. 48 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan
premiums start during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. Annuitants' coverage and premiums begin on

January 1. If you joined at any other time during the year, your employing office
will tell you the effective date of coverage.

Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

. OPM, this Plan, and subcontractors when they administer this contract;
. This Plan and appropriate third parties, such as other insurance plans
and the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;

. Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;

. OPM and the General Accounting Office when conducting audits;

. Individuals involved in bona fide medical research or education that
does not disclose your identity; or

. OPM, when reviewing a disputed claim or defending litigation about a claim.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for
other forms of coverage, such as temporary continuation of coverage (TCC).

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

.. Your enrollment ends, unless you cancel your enrollment, or

.. You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

. Spouse equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's enrollment This is
the case even when the court has ordered your former spouse to supply
health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download

the guide from OPM's website, www. opm. gov/ insure.

. Temporary Continuation of Coverage
(TCC)
If you leave Federal service, or if you lose coverage because you no
longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if 51.
51 Page 52 53
2003 John Deere Health Plan, Inc. 49 Section 11
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

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

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure.

It explains what you have to do to enroll.

. Converting to You may convert to a non-FEHB individual policy if:
individual coverage .. Your coverage under TCC or the spouse equity law ends. ( If you
canceled your coverage or did not pay your premium, you cannot
convert);

.. You decided not to receive coverage under TCC or the spouse equity
law; or

.. You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no
longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we will not impose a waiting period or limit your coverage due to pre-existing
conditions.

Getting a Certificate of
Group Health Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for

health coverage availability and continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a Certificate
of Group Health Plan Coverage that indicates how long you have been enrolled
with us. You can use this certificate when getting health insurance or other health
care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in
the certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. Se also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked question. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 52.
52 Page 53 54
2003 John Deere Health Plan, Inc. 50 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2003!
.. Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG! ..
How are YOU planning to pay for the future custodial or chronic care you may need? ..
You should consider buying long term care insurance.

The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2003.
As part of its educational effort, OPM asks you to consider these questions:

What is long term care . It's insurance to help pay for long term care services you may
(LTC) insurance? need if you can't take care of yourself because of an extended illness or injury,
or an age-related disease, such as Alzheimer's. .
LTC insurance can provide broad, flexible benefits for nursing home care, care
in an assisted living facility, care in your home, adult day care, hospice care, and
more. LTC can supplement care provided by family members, reducing the
burden you place on them.
I'm healthy. I won't need . Welcome to the club!
long term care. Or will I? . 76% of Americans believe they will never need long term care, but the facts are
that about half of them will. And it's not just the old folks. About 40% of the
people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc. .
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their financial and retirement planning.

Is long term care expensive? . Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before inflation. .
Long term care can easily exhaust your savings. Long term care insurance can
protect your savings.

But won't my FEHB plan, . Not FEHB. Look at the "Not covered" blocks in sections 5( a)
Medicare or Medicaid cover and 5( c) of your FEHB brochure. Health plans don't cover
my long term care? custodial care or a stay in an assisted living facility or a continuing need for a
home health aide to help you get in and out bed and with other activities of daily
living. Limited stays in skilled nursing facilities can be covered in some
circumstances. .
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit. .
Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and preserve
your independence.

When will I get more information . Employees will get more information from their agencies
on how to apply for this new during the LTC open enrollment period in the late summer /
insurance coverage? early fall of 2003. .
Retirees will receive more information at home.

How can I find out more about the . Our toll-free teleservice center will begin in mid-2003. In the
Program NOW? meantime, you can learn more about the program on our web
site at www. opm. gov/ insure/ ltc. 53.
53 Page 54 55
2003 John Deere Health Plan, Inc. 51 Long Term Care Insurance
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 17, 21,32 Alternative treatment 19
Allogenic (donor) bone marrow
transplant 22

Ambulance 12, 23, 24, 25
Anesthesia 22
Autologous bone marrow
transplant 22
Biopsies 20 Blood and blood plasma 23

Breast cancer 22
Casts 20, 23, 24 Catastrophic protection 51

Changes for 2003 8
Chemotherapy 16
Cholesterol tests 14
Claims 35
Coinsurance 11
Colorectal cancer screening 14
Congenital anomalies 20, 21
Contraceptive devices and drugs 15,
20, 30
Coordination of benefits 38-41
Covered charges 11
Covered providers 8, 9
Crutches 18
Deductible 11 Definitions 42

Dental care 32
Diagnostic services 13, 24, 27
Disputed claims review 36, 37
Donor expenses (transplants) 22
Dressings 23, 24
Durable medical equipment
(DME) 18
Educational classes and programs 19 Effective date of enrollment 44

Emergency 25, 26
Experimental or investigational 5,
10, 34, 42

Eyeglasses 17
Family planning 15 Fecal occult blood test 14

General Exclusions 34 Hearing services 17
Home health services 19
Hospice care 24
Hospital 23, 24
Immunizations 14 Infertility 15

Inhospital physician care 20-22
Inpatient Hospital Benefits 23
Insulin 18, 30
Laboratory and pathological services 23, 24

Magnetic Resonance Imagings (MRIs) 13
Mail Order Prescription Drugs 29,
30
Mammograms 13, 14
Maternity Benefits 15, 23
Medicaid 41
Medically necessary 10
Medicare 40
Mental Conditions/ Substance
Abuse Benefits 27, 28
Newborn care 13, 15 Non-FEHB Benefits 33

Nurse
Nurse Anesthetist 23
Registered Nurse 23, 31
Nursery charges 15
Obstetrical care 15 Occupational therapy 16

Ocular injury 17
Office visits 13-20
Oral and maxillofacial surgery 21
Orthopedic devices 18, 20
Out-of-pocket maximum 11
Outpatient facility care 24
Oxygen 18, 19, 23, 24

Pap test 13, 14 Physical therapy 16
Physician 8
Precertification 10
Preventive care, adult 14
Preventive care, children 14
Prescription drugs 29, 30
Prior approval 10
Prostate cancer screening 14
Prosthetic devices 17, 18, 20
Psychologist 27
Radiation therapy 16 Renal dialysis 16, 18

Room and board 23
Second surgical opinion 13 Skilled nursing facility care 13,

22, 24
Smoking cessation 19, 30
Speech therapy 16
Splints 23
Sterilization procedures 15,
20
Subrogation 41
Substance abuse 27, 28
Surgery 20-24 ..
Anesthesia 22 ..
Oral 21 ..
Outpatient 22, 24, 26 ..
Reconstructive 20, 21
Syringes 30
Temporary continuation of coverage 44, 47

Transplants 22
Treatment therapies 16
Vision services 14, 17, 33 Wheelchairs 18

Workers' compensation 41
X-rays 13, 23, 24 54.
54 Page 55 56
2003 John Deere Health Plan, Inc. 52 Notes
Notes 55.
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