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CareFirst BlueChoice, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1.
Section 2.
Section 3.
Section 4.
- Your costs for covered services
- Your catastrophic protection out-of-pocket maximum
Section 5.
- Benefits
- Overview
Section 6. General exclusions
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- Coverage information
- When you lose benefits.
Long term care insurance is still available
Index
Summary of benefits.
Rates

Pages 1--64

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
2003
Serving: The Maryland, Northern Virginia, and Washington, DC area
Enrollment in this Plan is limited. You must live or work in our
geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
2G1 Self Only
2G2 Self and Family

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

A Health Maintenance Organization
CareFirst BlueChoice, Inc. http:// www. carefirst. com

RI 73-718
For changes
in benefits
see page 8. 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 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). 3.
3 Page 4 5
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.

f 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
nformation 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 CareFirst BlueChoice, Inc. Table of Contents 2
Table of Contents
Introduction .............................................................................................................................................................................................. 4
Plain Language .......................................................................................................................................................................................... 4
Stop Health Care Fraud! ............................................................................................................................................................................ 4
Section 1. Facts about this HMO plan ...................................................................................................................................................... 6
How we pay providers ............................................................................................................................................................. 6
Who provides my health care?................................................................................................................................................. 6
Your Rights.............................................................................................................................................................................. 6
Service Area............................................................................................................................................................................. 7
Section 2. How we change for 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
Hospital care .................................................................................................................................................................... 10
Circumstances beyond our control......................................................................................................................................... 10
Services requiring our prior approval .................................................................................................................................... 11
Section 4. Your costs for covered services.................. 12
Copayments ..................................................................................................................................................................... 12
Deductible........................................................................................................................................................................ 12
Coinsurance ..................................................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum.......................................................................................................... 12
Section 5. Benefits .................................................................................................................................................................................. 13
Overview....................................................................................................................................................................Could not acquire words on page 6 ............ 13
(a) Medical services and supplies provided by physicians and other health care professionals ....................................... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals.................................... 25
(c) Services provided by a hospital or other facility, and ambulance services.................................................................. 29
(d) Emergency services/ accidents ..................................................................................................................................... 32
(e) Mental health and substance abuse benefits ................................................................................................................ 35
(f) Prescription drug benefits............................................................................................................................................ 37 5.
5 Page 6 7

6 Page 7 8
2003 CareFirst BlueChoice, Inc. 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of CareFirst BlueChoice, Inc. under our contract (CS 2797) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for CareFirst BlueChoice
administrative offices is

CareFirst BlueChoice, Inc.
550 12 th Street S. W.
Washington D. C. 20065

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

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plan language to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance "you" means the enrollee or family member; "we"
means CareFirst Blue Choice, 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 E Street, NW Washington, DC 20415-3650.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program
premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired. 7.
7 Page 8 9
2003 CareFirst BlueChoice, Inc. 5 Introduction/ Plain Language/ Advisory
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) 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 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 866/ 520-6099 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 202-428-3300
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 CareFirst BlueChoice, 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.

Who provides my health care?
Since we are an Individual Practice Association (IPA) model HMO, you receive care from a network of physicians who practice in
their private offices. In addition, our plan has designated facilities for diagnostic radiology and laboratory services. As a member,
you may choose your own primary care doctor from our provider directory.

If you think you need mental health and substance abuse treatment, you should first contact our vendor Magellan Behavioral Health
(or other vendor we determine) at 800/ 245-7013. If you need treatment, Magellan will refer you to one of their network providers.
Magellan, not your primary care doctor, must coordinate all your mental health and substance abuse services.

Your Rights
OPM requires that all FEHB Plans to 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.

We are in compliance with Federal and State licensing and certification requirements
We have been in existence since 1984
We are a for profit corporation
CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. . Registered trademark of
the Blue Cross and Blue Shield Association. . 'Registered trademark of CareFirst of Maryland, Inc.

If you want more information about us, call 866/ 520-6099, 410/ 356-4602, or write to CareFirst Blue Choice, Inc., P. O. Box 644,
Owings Mills, MD 21117-9998. You may also contact us by fax at 410/ 998-5809 or visit our website at www. carefirst. com. 9.
9 Page 10 11
2003 CareFirst BlueChoice, Inc. 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice.
Our service area is: The District of Columbia, Maryland (entire State), and the Virginia counties of Arlington, Fairfax, Fauquier,
Lounden, Prince William, Spotsylvania, and Stafford, plus the cities of Alexandria, Falls Church and Fredericksburg.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you may be able to take advantage of our Guest Membership
Program. This program will allow you or your dependents, which reside out of the service area for an extended period of time, to
utilize the benefits of an affiliated Blue Cross Blue Shield HMO. Please contact us at 866/ 520-6099 or 410/ 356-4602 for more
information on the Guest Membership Program. If you or a family member move, you do not have to wait until Open Season to
change plans. Contact your employing or retirement office. 10.
10 Page 11 12
2003 CareFirst BlueChoice, Inc. 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

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

Changes to this Plan
Your share of the non-Postal premium will increase by 61% for Self Only or 56% for Self and Family We now charge a $20 copay for primary care office visits and a $30 copay for specialist office visits. (Section 5( a))
We now charge a $30 copay for emergency care visits at participating urgent care centers and $50 copay for emergency care visits at non-participating urgent care centers or an emergency room. (Section 5 (d))
We now charge a $30 copay for emergency care visits in a specialist office or an office setting outside our service area. (Section 5( d))
We now charge a $100 deductible per person per year for prescription drugs. (Section 5 (f)) 11.
11 Page 12 13
2003 CareFirst BlueChoice 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 866/ 520-6099 or 410/ 356-4602 or
write to us at CareFirst Blue Choice, Inc., P. O. Box 644, Owings Mills, MD 21117-9998.

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

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

We list Plan providers in the provider directory, which we update periodically. The list is
also on our website.

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

What you must do It depends on the type of care you need. First, you and each family member must choose to
get covered care a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. Each member may choose his or her

own primary care doctor from our provider directory.

Primary care Your primary care physician can be a family practitioner, general 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. When you
receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see your Plan
gynecologist for a routine visit without a referral.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will work with the Plan to develop a
treatment plan that allows you to see your specialist for a certain number of visits
without additional referrals. Your primary care physician will use our criteria when
creating your treatment plan (the physician may have to get an authorization or
approval beforehand).

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 12.
12 Page 13 14
2003 CareFirst BlueChoice Inc. 10 Section 3
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 866/ 520-6099 or 410/ 356-4602. If you are new to the
FEHB Program, we will arrange for you to receive care.

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

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

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care. 13.
13 Page 14 15
2003 CareFirst BlueChoice Inc. 11 Section 3
Services requiring Your primary care physician has authority to refer you for most services. For certain services,
our prior approval however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process pre-authorization. Your physician must obtain pre-
authorization for services such as, but not limited to the following:

Inpatient services
Outpatient services
Hospice care
Skilled nursing facility
Home health care
Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic therapy
Growth Hormone Therapy
Dialysis in a hospital setting

Your primary care physician will contact us for pre-authorization or an extension of a pre-
authorized service. Your services may be denied if pre-authorization is not obtained. 14.
14 Page 15 16
2003 CareFirst BlueChoice, Inc. 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy,
etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $20 per
office visit.

Deductible A deductible is a fixed expense you must incur for certain covered services and supplies
before we start paying benefits for them. Copayments do not count toward any
deductible.

We charge a $100 per person per year deductible for prescription drug purchases.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 25% of our allowance for durable medical equipment.

Your catastrophic protection After your copayments total $1,900 per person or $5,500 per family enrollment in any
out-of-pocket maximum for calendar year, you do not have to pay any more for covered services. However,
copayments copayment for the following services do not count toward you out-of-pocket maximum, and you must continue to pay copayments for these services:

Prescription drugs
Durable Medical Equipment (DME)
Be sure to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum. 15.
15 Page 16 17
2003 CareFirst BlueChoice, Inc. 13 Section 5
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 60 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 866/ 520-6099 or 410/ 356-4602 or at our
website at www. carefirst. com.

(a) Medical services and supplies provided by physicians and other health care professionals .......................................... 14-24
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and Occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ...................................... 25-28
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ..................................................................... 29-31

Inpatient hospital
Outpatient hospital or ambulatory surgical
center

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

(d) Emergency services/ accidents........................................................................................................................................... 32-34
Medical Emergency Ambulance

(e) Mental health and substance abuse benefits ..................................................................................................................... 35-36
(f) Prescription drug benefits................................................................................................................................................... 37-38
(g) Special features ....................................................................................................................................................................... 39
Flexible benefits option

24 hour nurse line
Care team program
Guest membership
(h) Dental benefits .......................................................................................................................................................................... 40
(i) Non-FEHB benefits available to Plan members....................................................................................................................... 41

Summary of benefits....................................................................................................................................................................... 60 16.
16 Page 17 18
2003 CareFirst BlueChoice, Inc. 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other
health care professionals

I
M
P
O
R
T
A
N
T

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

Plan physicians must provide or arrange your care.
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

$20 per primary care physician (PCP) visit

$30 per specialist visit

Professional services of physicians
Office medical consultation
Second surgical opinion
At home

$20 per PCP visit
$30 per specialist visit
In a plan urgent care center (see Emergency care 5( d)) $30 per visit
During a hospital stay
In a skilled nursing facility Nothing

Diagnostic and treatment services --continued on next page 17.
17 Page 18 19
2003 CareFirst BlueChoice, Inc. 15 Section 5( a)
Diagnostic and treatment services (continued) You pay
Not covered:
Test required for marriage; employment; foreign travel; or
government licensing
All charges

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, if these services are
rendered at an approved
radiological provider or approved
laboratory.

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol annually
Colorectal Cancer Screening, including

-Fecal occult blood test
-Sigmoidoscopy, screening every five years starting at age 50

Nothing, if these services are
rendered at an approved
laboratory.

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

Nothing, if these services are
rendered at an approved
laboratory.

Routine pap test
Note: The office visit is covered at a $20 PCP copay or a $30 specialist
copay if pap test is received on the same day

Nothing, if these services are
rendered at an approved
laboratory.

Preventive Care, Adult --continued on next page 18.
18 Page 19 20
2003 CareFirst BlueChoice, Inc. 16 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram covered for women age 35 and older, as
follows:

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

Nothing, if these services are
rendered at an approved radiology
provider.

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

All charges

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

immunizations)
Influenza vaccines, annually
Pneumococcal vaccine, age 65 and over

Nothing if you receive these
services through a well child visit
or a complete physical. Otherwise,
$20 per PCP visit and $30 per
specialist visit.

Not covered: Immunizations for the purpose of school, work, or travel All charges
Preventive care, children

Childhood immunizations recommended by the American Academy of Pediatrics $20 per PCP visit
$30 per specialist visit

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

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 (through age 22)

$20 per PCP visit
$30 per specialist visit

$10 per visit at participating vision
centers or $25 per visit at
participating opthalmologists with
a referral 19.
19 Page 20 21
2003 CareFirst BlueChoice, Inc. 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

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

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

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

Office visit copays for routine obstetrical care are waived after the first maternity care visit.

$20 per PCP visit
$30 per specialist visit

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

$20 per PCP visit
$30 per specialist visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges 20.
20 Page 21 22
2003 CareFirst BlueChoice, Inc. 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.

$20 per PCP visit
$30 per specialist visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:
-In vitro fertilization
-embryo transfer, gamete GIFT, and zygote ZIFT
-Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment
Allergy injection
$20 per PCP visit

$30 per specialist visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges 21.
21 Page 22 23
2003 CareFirst BlueChoice, Inc. 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 27.

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

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment.
Call Advance Secure at 800/ 294-5979 for preauthorization. We will
ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment; otherwise, we will only cover GHT services from the date
you submit the information. If you do not ask or if we determine GHT
is not medically necessary, we will not cover the GHT or related
services and supplies. See Services requiring our prior approval in
Section 3.

$20 per PCP visit
$30 per specialist visit 22.
22 Page 23 24
2003 CareFirst BlueChoice, Inc. 20 Section 5( a)
Physical and occupational therapies You pay
Up to two consecutive months per condition for the services of each of the following if significant improvement can be expected within
90 days:
-qualified physical therapists and
-occupational therapists

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

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

$30 per specialist visit
Nothing during covered inpatient
admission

Not covered:
Long-term rehabilitative therapy
Exercise program
Cardiac rehabilitation
Chiropractic services

All charges

Speech therapy
Benefits limited to:
Up to two consecutive months per condition
$30 per specialist visit

Nothing during covered inpatient
admission

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17 (see Preventive care, children)

Note: Adult hearing tests are covered only if referred by a PCP.
$20 per PCP visit
$30 per specialist visit

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

All charges 23.
23 Page 24 25
2003 CareFirst BlueChoice, Inc. 21 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses to correct an impairment directly related to intraocular surgery (such as for cataracts)

Note: This is a medical benefit not a vision benefit.
$20 per PCP visit
$30 per specialist visit
Nothing for the eyeglasses

Eye exam (exam by ophthalmologist requires a referral) to determine the need for vision correction for children and adults (see
preventive care)
$10 per visit at participating vision
centers or $25 per visit at participating
opthalmologists

Daily wear contact lens exam and fittings $48 per visit and three follow-up fittings

Disposable contact lens exam, fitting and one year follow-up $78 per visit (includes fitting and follow-up)
Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

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.

$20 per PCP visit
$30 per specialist visit

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

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

treatment is by open cutting surgery)

All charges 24.
24 Page 25 26
2003 CareFirst BlueChoice, Inc. 22 Section 5( a)
Orthopedic and prosthetic devices You pay
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

$20 per PCP visit
$30 per specialist visit
Nothing for the devices

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 devices, such as artificial limbs and lenses following cataract removal unless covered under the DME benefit (see DME
below)
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 equipment up to $7,500 per calendar year. Under this benefit,
we also cover:

Hospital beds;
Wheelchairs;
Crutches;
Walkers;
Canes;
Commodes;
Suction machines;
Medical supplies (i. e. ostomy and catheter supplies, dialysis supplies, medical foods for inherited metabolic diseases and inborn

deficiencies of amino acid metabolism)
Externally worn non-surgical durable devices which replace a body part or assists a patient in performing a bodily function

Externally worn braces which improve the function of a limb

25% coinsurance up to Plan
$7,500 benefit maximum is met
and all charges over that amount.

Durable medical equipment --continued on next page 25.
25 Page 26 27
2003 CareFirst BlueChoice, Inc. 23 Section 5( a)
Durable medical equipment (DME) (continued) You pay
Not covered:
Hearing aids, eye glasses, contact lenses, dental prosthetics
Environment control products
Medical equipment of an expendable nature (i. e. ace bandages, incontinent pads)

Replacement of DME equipment not due to normal wear and tear
Comfort and convenience items
Exercise equipment
Equipment that can be used for non-medical purposes

All charges

Home health services
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;

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

All charges

Chiropractic
Chiropractic services, limited to spinal manipulation, evaluation and treatment, up to a maximum of 20 visits per calendar year
when provided by a chiropractor who is a plan provider.
$30 per specialist visit

Not covered
Services other than for musculoskeletal conditions of the spine.
All charges 26.
26 Page 27 28
2003 CareFirst BlueChoice, Inc. 24 Section 5( a)
Alternative treatments You Pay
No benefit All charges

Educational classes and programs
Coverage is limited to:

Diabetes self-management (Sponsored by the Plan's Health Education Department)

Smoking cessation Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as
drugs.

Nothing 27.
27 Page 28 29
2003 CareFirst BlueChoice, Inc. 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

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

Medicare.
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.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SURGICAL PROCEDURES.
Please refer to the precertification information shown in Section 3 to be sure which services require
precertification and identify which surgeries require precertification.

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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 prostethic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

$20 per PCP office or outpatient
visit

$30 per specialist office or
outpatient visit

Nothing for inpatient visits

Surgical procedures --continued on next page 28.
28 Page 29 30
2003 CareFirst BlueChoice, Inc. 26 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns

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

$20 per PCP office or outpatient
visit

$30 per specialist office or
outpatient visit

Nothing for inpatient visits

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

All charges

Reconstructive surgery
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.

$20 per PCP office or outpatient
visit

$30 per specialist office or
outpatient visit

Nothing for inpatient visits

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.

See above.

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

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges 29.
29 Page 30 31
2003 CareFirst BlueChoice, Inc. 27 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

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

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

$20 per PCP office or outpatient visit
$30 per specialist office or outpatient
visit

Nothing for inpatient visits

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

Organ/ tissue transplants
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
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 pre & post recipient related medical and hospital
expenses of the donor when we cover the recipient.

$20 per PCP office or outpatient visit
$30 per specialist office or outpatient
visit

Nothing for inpatient visits 30.
30 Page 31 32
2003 CareFirst BlueChoice, Inc. 28 Section 5( b)
Organ/ tissue transplants (continued) You pay
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
Professional services provided in

Hospital (inpatient)
Nothing

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

Nothing 31.
31 Page 32 33
2003 CareFirst BlueChoice, Inc. 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

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

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

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

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

YOUR PYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL
STAYS. Please refer to Section 3 to be sure which services require precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.

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

Nothing

Inpatient hospital --continued on next page. 32.
32 Page 33 34
2003 CareFirst BlueChoice, Inc. 30 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
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

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent 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

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medications
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.

$20 per PCP visit
$30 per specialist visit

Not covered: blood and blood derivatives not replaced by the member All charges 33.
33 Page 34 35
2003 CareFirst BlueChoice, Inc. 31 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You Pay
If a Plan doctor determines that you need full-time skilled nursing care or need
to stay in a skilled nursing facility, and we approve that decision, we will give
you the comprehensive range of benefits with no dollar or day limit.

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

doctor.

Nothing

Not covered: custodial care All charges
Hospice care

If terminally ill, you are covered for supportive and palliative care in
your home or at a hospice. This includes inpatient and outpatient care
and family counseling. A Plan doctor, who certifies that you are in the
terminal stages of illness, with a life expectancy of approximately six
months or less, will direct these services.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 34.
34 Page 35 36
2003 CareFirst BlueChoice, Inc. 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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.

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

What to do in case of emergency:
Emergencies within our service area: For emergencies, please call your primary care physician. If your PCP is unavailable, call FirstHelp at 800/ 535-9700
and a registered nurse will give you health care advice. In extreme emergencies, where your life or limbs are in
jeopardy, and you cannot reach your doctor, contact the local emergency system (911, for example) or go to the nearest
hospital emergency room. Be sure to tell the workers in the emergency room that you are a Plan member so they can
notify the Plan

If you need to stay in a facility our plan does not designate (a non-Plan facility), you must notify the Plan at 800/ 367-
1799 or 202/ 646-0090 within 48 hours or on the first working day after the day they admitted you, unless you cannot
reasonably do so. If you stay in a non-Plan facility and a Plan doctor believes that a Plan hospital can give you better
care, then the facility will transfer you when medically feasible and we will fully cover any ambulance charges.

You can receive benefits for care from non-Plan providers if you did not reach a Plan provider in time and the delay
would result in death, disability or significantly jeopardize your condition.

For this Plan to cover you, only Plan-providers can give you follow-up care that the non-Plan providers recommend.

Emergency Services --continued on next page 35.
35 Page 36 37
2003 CareFirst BlueChoice, Inc. 33 Section 5( d)
Emergencies outside our service area:
You can receive benefits for any medically necessary health service that you require immediately because of injury or
unforeseen illness.

For emergencies, please contact FirstHelp at 800/ 535-9700 and a registered nurse will give you health care advice. In
extreme emergencies, where your life or limbs are in jeopardy, contact the local emergency system (911, for example) or
go to the nearest hospital emergency room.

If you need to stay in a medical facility, you must notify the Plan at 800/ 367-1799 or 202/ 646-0090 within 48 hours or
on the first working day after the date they admit you, unless not reasonably possible to do so. If a Plan doctor believes a
Plan hospital can give you better care, then the facility will transfer you when medically feasible, and we will fully cover
any ambulance charges.

For this Plan to cover you, Plan providers must provide any of the follow-up care that non-Plan providers may
recommend to you. 36.
36 Page 37 38
2003 CareFirst BlueChoice, Inc. 34 Section 5( d)
Benefit Description You pay
Emergency within our service area

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

$20 per PCP office visit; $30
per specialist office visit

$50 per non-participating
urgent care center visit;
$30 per participating
urgent care center visit;

$50 per hospital emergency
room visit.

Note: Emergency room copay
waived if admitted into the
hospital

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
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$30 per office visit
$50 per hospital emergency
room or urgent care center
visit.

Note: Emergency room copay
waived if admitted into the
hospital

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 when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance All charges 37.
37 Page 38 39
2003 CareFirst BlueChoice, Inc. 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.

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

We have no calendar year deductible.

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

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Benefit Description You pay
Mental health and substance abuse
benefits

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

$30 per specialist visit

Mental health and substance abuse benefits --continued on next page 38.
38 Page 39 40
2003 CareFirst BlueChoice, Inc. 36 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing

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

Nothing for inpatient care;
otherwise $30 per specialist
visit

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 obtain a treatment plan and follow all of the following authorization processes:
We administer mental health and substance abuse benefits under a contract
with Magellan Behavioral Health (or another vendor we determine). If you
think you need mental health or substance abuse services you must first call
Magellan at 800/ 245-7013. If you need treatment, Magellan will refer you
to one of their network providers. Magellan must coordinate all mental
health and substance services, not your primary care doctor.

Limitation We may limit your benefits if you do not obtain a treatment plan. 39.
39 Page 40 41
2003 CareFirst BlueChoice, Inc. 37 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically
necessary.
We have a $100 per person per 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.

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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. You may contact AdvancePCS at 800/ 241-3371 to get more information

on the mail order service.
We use a formulary. A formulary is a preferred list of drugs that we selected to meet patient needs at a lower cost The formulary includes both generic and brand name drugs. You will be responsible

for higher charges if your doctors prescribes a drug not on our formulary list. However, non-formulary
drugs will be covered when prescribed by a Plan doctor.

We have an open formulary. If your physician believes a name brand product is necessary or there
is no generic available, your physician may prescribe a name brand drug from a formulary list. This
list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower
cost. To order a prescription drug brochure, call AdvancePCS at 1-800-241-3371.

These are the dispensing limitations. You can receive up to 34 days worth of medication for each fill of non-maintenance prescriptions at a local Plan pharmacy. In addition, you can receive up to 90 days
of medications through our mail order pharmacy program. Your copay will be $10, $20, or $35 for a
34-day supply or less at the retail pharmacy and twice that amount for 35-day supply or greater up to 90
days by mail. The same prescriptions can be purchased through the mail order service as your
community pharmacy. In most cases, you can get a refill once you have taken 75% of the medication.
Your prescription will not be refilled prior to the 75% usage guidelines. A generic equivalent will be
dispensed if it is available, unless your physician specifically requires a name brand. Certain drugs
require clinical prior authorization. Contact the Plan for a listing of which drugs are subject to the prior
authorization policy. Prior authorization may be initiated by the Prescriber or the pharmacy by calling
Advance Secure at 800/ 294-5979 (or other vendor as determined by the Plan).

Why use generic drugs? A generic drug is the chemical equivalent of a corresponding brand name
drug dispensed at a lower cost. You can reduce your out-of-pocket expenses by choosing a generic
drug over a brand name drug.

When you have to file a claim. Call our preferred drug vendor, AdvancePCS, at 800/ 241-3371 to order prescription drug claim forms. You will send the prescription drug claim form to:
AdvancePCS, PO Box 853901, Richardson TX 75085-3901.

Prescription drug benefits begin on the next page. 40.
40 Page 41 42
2003 CareFirst BlueChoice, Inc. 38 Section 5( f)
Benefit Description You pay
After the calendar year
deductible

Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

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

Drugs for sexual dysfunction (Subject to dosage limitations. Contact the Plan for these limitations)
Contraceptive drugs and devices
Smoking deterrents
Diabetic supplies, including insulin syringes, needles, glucose test strips, lancets and alcohol swabs

Allergy serum
Note: Intravenous fluids and medications for home use, implantable drugs
(such as Norplant), some injectable drugs (such as Depo Provera), and IUDs
are covered under the Medical and Surgical Benefits.

Note: Injectable coverage will be limited to those medications that are usually
self-injected.

$ 10 per unit or refill for generic
prescriptions

$ 20 per unit or refill for
prescriptions on the Plan's
formulary brand name list

$ 35 per unit or refill for all other
prescripitons

Note: You may use the Plan's mail
Service and receive a 90-day supply
For two copayments.

Nothing

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs for weight loss

All Charges 41.
41 Page 42 43
2003 CareFirst BlueChoice, Inc. 39 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits
options

Under the flexible benefits option, we determine the most effective way to
provide services.

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

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

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

24 hour nurse line If you have any health concerns, call FirstHelp at 1-800-535-9700, 24 hours a day, 7 days a week and talk with a registered nurse who will discuss
treatment options and answer your health questions.

Care Team Program We provide programs for members diagnosed with coronary artery disease, congestive heart failure, diabetes, cancer, and asthma. These programs are
designed to help you better understand and manage your condition. Our Care
Team Program benefits may include:

Educational materials, such as self-monitoring charts, resource listings, self-care tips, and a quarterly newsletter

A health assessment and nurse consultation
Access to a 24-hour Nurse Advisor help line
Please call us at 866/ 520-6099 or 410/ 356-4602 for more information about
our Care Team Program

Guest membership If you or one of your covered family member move outside of our service area for an extended period of time (for example, if your child goes to college
in another state), you may be able to take advantage of our Guest
Membership Program. This program would allow you or your dependents
the option to utilize the benefits of an affiliated BlueCross BlueShield HMO.
Please contact us at 866/ 520-6099 or 410/ 356-4602 for more information on
the Guest Membership Program 42.
42 Page 43 44
2003 CareFirst BlueChoice, Inc. 40 Section 5( h)
Section 5 (h). Dental benefits
I
M
P
O
R
T
A
N
T

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

medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health

of the patient. See Section 5( c) for inpatient hospital benefits. We do not cover
the dental procedure unless it is described below.

I
M
P
O
R
T
A
N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
sound natural teeth. The need for these services must result from an
accidental injury.

$20 per PCP visit
$30 per specialist visit

Dental benefits
We have no other dental benefits. 43.
43 Page 44 45
2003 CareFirst BlueChoice, Inc. 41 Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them . Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Dental care
What is covered
The following preventive and diagnostic services are covered when provided by Plan dentists; you pay a $ 14 adult copay
or a $ 10 child copay per visit:

Oral examinations
Prophylaxis, or cleaning ( every 6 months)
Fluoride treatment
Pulp Vitality tests
Diagnostic casts
Oral Hygiene instruction

You pay 50% of your participating dentist' s usual and customary fees for:
X-rays
Fillings
Sealants

For all other non-accidental services under this program, you pay 75% of the participating dentist' s usual and customary
fees, including:

Restorations
Crown and bridge services
Endodontic services
Periodontics
Prosthodontics, removables
Oral surgery services
Broken appointment fee
Orthodontic services
TMJ treatment
Cosmetic and anesthetic services

Please note: Availability of dental providers is limited to the Metro Washington DC area.

Expanded vision care
As a CareFirst BlueChoice member, you are entitled to receive a 25% discount on contact lenses, frames, and eyeglass
lenses. This savings is available only at participating Block Vision ( formally MEC HealthCare) providers ( see the
BlueChoice provider directory) .

Options
As a member of a CareFirst BlueCross BlueShield HMO, you can receive discounts on alternative therapies including
acupuncture, massage therapy and chiropractic care. Discounts are also available on laser vision correction and hearing
aids. Please visit our website at CareFirst. com for more information 44.
44 Page 45 46
2003 CareFirst BlueChoice, Inc. 42 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness disease, injury or
condition.

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service. 45.
45 Page 46 47
2003 CareFirst BlueChoice, Inc. 43 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.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 866/ 520-6099 or 410/ 356-4602.
When you must file a claim --such as for services you receive outside 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 any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to:
CareFirst BlueChoice, Inc, 550 12 th Street SW, Washington DC 20065

Prescription drugs Submit your claims to:
AdvancePCS, PO Box 853901, Richardson TX 75085-3901

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. 46.
46 Page 47 48
2003 CareFirst BlueChoice, Inc. 44 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: CareFirst BlueChoice Inc, P. O. Box 644, Owings Mills, MD 21117-
9998 and
(c) Include a statement about why you believe our initial decision was wrong, based on specific
benefit provisions in this brochure; and

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

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

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

We will write to you with our decision.

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 2,
1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply
to which claim. 47.
47 Page 48 49
2003 CareFirst BlueChoice, Inc. 45 Section 8
The Disputed Claims process (continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.

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

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

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

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

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 866/ 520-6099 or
410/ 356-4602 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 2 at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 48.
48 Page 49 50
2003 CareFirst BlueChoice, Inc. 46 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

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

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

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

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

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

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

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or precertified as required. 49.
49 Page 50 51
2003 CareFirst BlueChoice, Inc. 47 Section 9
Claims process when you have the Original Medicare Plan --You probably will never
have to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will then provide
secondary benefits for covered charges. You will not need to do anything. To find
out if you need to do something to file your claims, call us at 866/ 520-6099.

We do not waive any costs if the Original Medicare is your primary payer.

(Primary payer chart begins on next page.) 50.
50 Page 51 52
2003 CareFirst BlueChoice, Inc. 48 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

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

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

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

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

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

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

(except for claims
related to Workers'
Compensation.)

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

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

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

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

C. When you or a covered family member have FEHB and

1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee, or

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.
You will be responsible for amounts not covered by Medicare, Plan copays and amounts over the Plan allowance. 51.
51 Page 52 53
2003 CareFirst BlueChoice, Inc. 49 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

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

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

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

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

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. 52.
52 Page 53 54
2003 CareFirst BlueChoice, Inc. 50 Section 9
Once OWCP or similar agency pays its maximum benefits for your treatment, we will
cover your care. You must use our providers.

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

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

When other Government agencies We do not cover services and supplies when a local, State,
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 medical or hospital care for injuries or
for injuries 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. 53.
53 Page 54 55
2003 CareFirst BlueChoice, Inc. 51 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Treatment or services that could be rendered safely or reasonably by a person not medically skilled to provide such services. Such care that lasts 90 days or more is
sometimes known as Long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 12.
Experimental or
Investigational services

We consider services experimental or investigational if they do not meet
the following criteria:

Services legally used in testing or other studies on human patients Services recognized as safe and effective for the treatment of a
specific condition.
Services approved by any governmental authority whose approval is required.

Services approved for human use by the Federal Food and Drug Administration in the case a drug, therapeutic regimen, or device is
used.

Group health coverage Health coverage made available through employment or membership with a particular organization or group .

Medical necessity Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition;
are provided for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good practice in the medical community of your local area;
and,
are not mainly for the convenience for you or your doctor.

Us/ We Us and we refer to CareFirst BlueChoice, Inc.
You You refers to the enrollee and each covered family member. 54.
54 Page 55 56
2003 CareFirst BlueChoice, Inc. 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your spouse;
for you and your family 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) 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: 55.
55 Page 56 57
2003 CareFirst BlueChoice, Inc. 53 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan s Basic
Option;
if you have a Self Only enrollment in a fee-for-service plan or 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 Blue