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OSF HealthPlans

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
- How we pay providers
- Who provides my health care?
- Your Rights
- Service Area
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
- Identification cards
- Where you get covered care
  - Plan providers
  - Plan facilities
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Copayments
- Deductible
- Coinsurance
- Your catastrophic protection
Section 5. Benefits -- OVERVIEW
- (a) Medical services and supplies
- (b). Surgical and anesthesia services
- (c). Services provided by a hospital
- (d). Emergency services/accidents
- (e). Mental health and substance abuse
- (f). Prescription drug benefits
- (g). Special Features
- (h). Dental benefits
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
- No pre-existing condition limitation
- Where you can get information FEHB Program
- Types of coverage available
  - Childrens Equity Act
- When benefits and
- When you retire
When you lose benefits
- When FEHB coverage ends
- Spouse equity coverage
- Temporary Continuation of Coverage
- Converting to individual coverage
- Getting a Certificate of Group Health Plan Coverage
Long Term Care Insurance Is Still Available!
Index
Summary of benefits
2003 Rate Information

Pages 1--60

Page 1


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

OSF HealthPlans http://www.osfhealthplans.com 2003
A Health Maintenance Organization

Serving: Central Illinois and Central-Northwestern Illinois
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:
9F1 Self Only 9F2 Self and Family

RI 73-762

This Plan has received an Excellent status from the National Committee for
Quality Assurance (NCQA). See the 2003 Guide for more information on
accreditation.

For changes in
benefits see pg. 8 1.
1 Page 2 3

2.
2 Page 3 4
Notice of the Office of Personnel Managements
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. 3.
3 Page 4 5

Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal
representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner
described above. Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www.opm.gov/insure on the web. You may also call 202-606-0191 and ask for OPMs FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P.O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by
mail within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

Index ................................................................................................................................................................52
Summary of benefits....................................................................................................................................................53
Rates..Back cover 6.
6 Page 7 8

2003 OSF HealthPlans 4 Introduction/Plain Language/Advisory
Introduction
This brochure describes the benefits of OSF HealthPlans under our contract (CS 2829) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for OSF HealthPlans
administrative offices is:
OSF HealthPlans 7915 N. Hale Ave., Suite D
Peoria, IL 61615-2047
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

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

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; we means OSF HealthPlans.
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 OPMs 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. 7.
7 Page 8 9
2003 OSF HealthPlans 5 Introduction/Plain Language/Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid. Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/OSF-5222 and explain the situation.
If we do not resolve the issue:

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

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

2003 OSF HealthPlans 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, and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plans benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.
Who provides my health care?
OSF HealthPlans, Inc. is a Mixed Model Prepayment (MMP) plan. The Plan contracts with hospitals, group physician practices, individual physician practices, and other health care providers that provide medical care to members in
central Illinois and central-northwestern Illinois.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPMs 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 were awarded an Excellent status for our commercial HMO/POS combined plans for all 28 Illinois service area counties by the National Committee for Quality Assurance (NCQA).
We have been in existence for 7 years We are a for profit entity
We scored above the 90 th percentile nationwide in the rating categories of Health Plan Overall, Health Care Overall and Personal Physician in our HEDIS 2002 Member Satisfaction Survey. We were also above the 90 th
percentile nationwide for Customer Service, Getting Care Quickly, How Well Doctors Communicate, Claims Processing and Courteous and Helpful Office Staff. We scored above the 75 th percentile nationwide for Getting
Needed Care.
If you want more information about us, call 800/OSF-5222, or write to OSF HealthPlans, 7915 N. Hale Ave., Peoria, IL, 61615-2047. You may also contact us by fax at 309/677-8259 or visit our website at www.osfhealthplans.com. 9.
9 Page 10 11
2003 OSF HealthPlans 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:

Central Illinois: Dewitt, Fulton, Knox, Livingston, Marshall, McLean, Peoria, Tazewell, and Woodford Counties.
Central-Northwestern Illinois: Boone, Bureau, DeKalb, Henderson, Henry, Kane, LaSalle, Lee, McDonough, McHenry, Mercer, Ogle, Putnam, Stark, Stephenson, Warren, Whiteside, and Winnebago Counties.

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 should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other states. 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 OSF HealthPlans 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 Managements Privacy Practices is included. A section on the Childrens 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 0.0% for Self Only or 0.9% for Self and Family. Your copay for a Primary Care Physician or Specialist is now $20 per visit. (Section 5a)
Your copay for inpatient hospital services is now $500 per admission. (Section 5c) Your copay for an emergency room visit is now $100 per visit. (Section 5d)
Your copay is now $10 for up to a 34-day supply of a preferred generic drug; $20 for a preferred drug; and $40 for a non-preferred drug. (Section 5f)
Your will now pay a $10 copay plus the price difference in the cost of the name brand drug and the generic drug when a generic is available. (Section 5f)
You will pay 2 copays for a 35-90 day-supply of drugs. (Section 5f) 11.
11 Page 12 13
2003 OSF HealthPlans 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800/OSF-
5222 or write to us at OSF HealthPlans, 7915 N. Hale Avenue, Suite D, Peoria, IL 61615.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments, and/or coinsurance, and you will not have to file claims.
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. To make sure we provide high value health care services and products, we do have guidelines and policies for providers that request to
participate in our network. In addition, the National Committee for Quality Assurance (NCQA) has developed standards and guidelines that
we also follow.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website. You may also call us at
800/OSF-5222 to receive information about our providers.
Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically.

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care. You should try to choose a primary care
physician that is familiar with your medical history. If you must choose a new physician, we encourage you to schedule an appointment as soon
as possible so he/she can become familiar with you and you can become familiar with him/her. If you need help choosing a primary care
physician, please call 800/OSF-5222 and we will assist you.

Primary care Your primary care physician can be a pediatrician, family practitioner or internist. 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.
You may change two (2) times a year with a thirty (30) day interval between changes. If you contact us by the fifteenth (15 th ) of the month,
your change will be effective the first of the following month. If you contact us after the fifteenth (15 th ), there will be a month between
changes. This allows enough time for offices to schedule appointments and to notify Primary Care Physicians of new patients. 12.
12 Page 13 14
2003 OSF HealthPlans 10 Section 3
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, female members may see network OB/GYNs 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 develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary
care physician and specialist will work together with you and the Plan when creating your treatment plan. 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 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. 13.
13 Page 14 15
2003 OSF HealthPlans 11 Section 3
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800/OSF-5222. 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.

Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from
us. 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 the referral process. Your physician must obtain a referral for the following services (this list is
intended as an example only): Inpatient hospitalization, outpatient surgery, certain outpatient diagnostic procedures, specialty physician
office visits, durable medical equipment, home health care, growth hormone therapy (GHT), physical therapy, occupational therapy, and
speech therapy. It is also your responsibility to notify us within 48 hours of any Emergency room visit. If you are unsure a service needs a
referral, call us at 800/OSF-5222.
Except in a medical emergency, you must contact your primary care physician for a referral before seeing any other doctor or obtaining
special services. Referral to a participating specialist is given at the primary care physicians discretion; if specialists or consultants are
required beyond those who are Plan doctors, the primary care physician will make arrangements for appropriate referrals.

On referrals, the primary care physician will give specific instructions to the consultant as to what services are authorized. Authorizations will be
for an adequate number of direct visits under an approved treatment plan. If additional services or visits are suggested by the consultant, over and
above the approved treatment plan, you must first check with your primary care physician. Do not go to the specialist unless your primary
care physician has arranged for, and the Plan has issued an authorization for, the referral. 14.
14 Page 15 16
2003 OSF HealthPlans 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 and when you go in the hospital, you
pay $500 per admission.
Deductible We do not have a deductible.
Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 20% of our allowance for durable medical equipment, prosthetic devices, and orthopedic devices.

Your catastrophic protection After your copayments and/or coinsurance total $1,500 per person or out-of-pocket maximum for $3,000 per family enrollment in any calendar year, you do not have to
coinsurance and copayments pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your out-of-
pocket maximum, and you must continue to pay copayments or coinsurance for these services:

Durable medical equipment; Prosthetic devices;
Orthopedic devices; and Prescription drugs

Be sure to keep accurate records of your copayments and/or coinsurance since you are responsible for informing us when you reach the maximum. 15.
15 Page 16 17

2003 OSF HealthPlans 13 Section 5
Section 5. Benefits --OVERVIEW (See page 8 for how our benefits changed this year and page 53 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 800/OSF-5222 or at our website at www.osfhealthplans.com.

(a) Medical services and supplies provided by physicians and other health care professionals.....................................14-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
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........................22-24
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services......................................................25-26
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/accidents.........................................................................................................................27-28
Medical emergency Ambulance
(e) Mental health and substance abuse benefits....................................................................................................29-30
(f) Prescription drug benefits................................................................................................................................31-34
(g) Special features.....................................................................................................................................................35

Services for deaf and hearing impaired Centers of excellence for transplants

(h) Dental benefits......................................................................................................................................................36
Summary of benefits....................................................................................................................................................53 16.
16 Page 17 18
2003 OSF HealthPlans 15 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 physicians office
In an urgent care center
Office medical consultations
Second surgical opinion

$20 per office visit to your primary care physician or a specialist

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Nothing

At home $20 per visit by your primary care physician
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

14 17.
17 Page 18 19
2003 OSF HealthPlans 15 Section 5(a)
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every three years starting at age 50
Routine laboratory testing or screening
Blood pressure checks
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older

Routine pap test

$20 per office visit

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

Nothing

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

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over
Out of country travel immunizations

$20 per office visit

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $20 per office visit

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

$20 per office visit 18.
18 Page 19 20
2003 OSF HealthPlans 15 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 11 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 mothers 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).

$100 per delivery
Note: $500 per admission copay is applicable.

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
Limited to:
Voluntary sterilization (See Surgical procedures Section 5(b)) $20 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, and all contraceptive drugs and devices. All charges.

16 19.
19 Page 20 21
2003 OSF HealthPlans 15 Section 5(a)
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
In vitro fertilization

Embryo transfers
Uterine embryo lavage
Gamete intrafallopian tube transfer (GIFT)
Zygote intrafallopian tube transfer (ZIFT)
Low tubal ovum transfer
Fertility drugs (covered under Prescription drug benefits)

$20 per office visit

Not covered:
Payment for medical services to a surrogate for purposes of child birth

Non-medical costs of an egg or sperm donor
Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment

Allergy injection
$20 per office visit

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

17 20.
20 Page 21 22
2003 OSF HealthPlans 15 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 24.
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. Have your doctor call 800/OSF-5222 for preauthorization. We will ask

your doctor to submit information that establishes that the GHT is medically necessary. Your doctor must ask us to authorize GHT before
you begin treatment; otherwise, we will only cover GHT services from the date your doctor submits the information. If your doctor does not ask
for preauthorization 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 office visit

Physical and occupational therapies
50 visits per condition per calendar year for the services of each of the following:

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.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction.

$20 per visit

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
$2,000 maximum benefit per person per calendar year for the services of the following:

-----qualified speech therapists
$20 per visit

18 21.
21 Page 22 23
2003 OSF HealthPlans 15 Section 5(a)
Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 (see Preventive care, children) $20 per office visit

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

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses following cataract surgery. Nothing

Eye exam to determine the need for vision correction for children through age 17 (See Preventive care, children)
An eye refraction every twenty-four (24) months
A retinal exam for diabetic members every twelve (12) months.

$20 per office visit

Not covered:
Eyeglasses or contact lenses (except as above) and, after age 17, examinations for them

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 office 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.

19 22.
22 Page 23 24
2003 OSF HealthPlans 15 Section 5(a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: 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.
Braces
Trusses
Corrective shoes or foot orthotics which are an integral part of a lower body brace

20% of eligible charges

Not covered:
Orthopedic and corrective shoes(except as above)
arch supports or lifts
foot orthotics (except as above)
heel pads and heel cups
lumbosacral supports
corsets, elastic stockings, support hose, and other supportive devices

the cost of a penile implanted device

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs (non-motorized);
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Call us at 800/OSF-5222 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider

to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of eligible charges

lancets and test strips for diabetic members Nothing
Not covered: Motorized wheelchairs All charges.

20 23.
23 Page 24 25

2003 OSF HealthPlans 15 Section 5(a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed

vocational nurse (L.V.N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered: nursing care requested by, or for the convenience of, the patient or
the patients family; home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Chiropractic
No benefit. All charges.

Alternative treatments
No benefit. All charges.

Not covered: acupuncture
naturopathic services hypnotherapy
biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

Diabetes self-management
Notes to Mom A program for women planning to become pregnant or already pregnant. Call 877/615-2447 to sign up.

Your Choice A program available to members who smoke that is a self-help mail program that consists of letters, educational information
and motivational workbooks. Our goal is to increase your desire to quit smoking. If you would like to register, please call 877/761-8618 or e-
mail yourchoice@osfhealthcare.org.

Nothing

21 24.
24 Page 25 26
2003 OSF HealthPlans 22 Section 5(b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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A N
T

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 SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure

which services require precertification and identify which surgeries require precertification.

I M
P O
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A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative Procedures Treatment of fractures, including casting

Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible members must be age 18 or over
Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization 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 office visit to a primary care physician or a specialist
Nothing for hospital visits

Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 25.
25 Page 26 27
2003 OSF HealthPlans 23 Section 5(b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the members appearance and

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

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

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

Nothing

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

Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 26.
26 Page 27 28
2003 OSF HealthPlans 24 Section 5(b)
Organ/tissue transplants You pay
Limited to:
Cornea
Heart
Heart/lung
Kidney
Kidney/Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants

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

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors.
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas
The transplant must be performed at a Plan approved facility.
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 Plans medical director in accordance with the Plans protocols.

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

Nothing

Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Implants of artificial organs
Transplants performed at a non-approved facility
Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in Hospital (inpatient)

Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office

Nothing 27.
27 Page 28 29
2003 OSF HealthPlans 25 Section 5(c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

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

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

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

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

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

I M
P O
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as ward, semiprivate, or intensive care accommodations;

general nursing care; and meals and special diets.

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

$500 per admission

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
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. 28.
28 Page 29 30
2003 OSF HealthPlans 26 Section 5(c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

$150 per surgery

Not covered: blood and blood derivatives not replaced by the member All charges.
Extended care benefits/skilled nursing care facility benefits

Extended care benefit: We cover a full range of benefits up to 45 days per calendar year for full-time skilled nursing care in a skilled nursing
facility. A Plan doctor must determine that confinement is medically necessary and it must be approved by the Plan. All necessary services
are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan

doctor.

Nothing

Not covered: custodial care All charges.
Hospice care

Care for a terminally ill member is covered in the home or a hospice facility. Services include inpatient and outpatient care and family
counseling. A Plan doctor must direct these services and certify the patient is terminally ill with a life expectancy of six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate. Nothing 29.
29 Page 30 31
2003 OSF HealthPlans 27 Section 5(d)
Section 5 (d). Emergency services/accidents
I M

P O
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A N
T

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

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

Medicare.

I M
P O
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A N
T
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:
If you are in an emergency situation, go to the nearest emergency care facility. If you have questions about whether or not it is an emergency, your primary care physician or covering physician will be available 24 hours a day, 7 days a
week to help you.
If you do go to an emergency facility, you or a family member must call the Plans HealthCare Management at 800/284-CARE within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that
the Plan has been timely notified. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be provided in a Plan Hospital, you will be transferred to a Plan Hospital when you are medically able to do so. Any
ambulance charges from this transfer are covered in full.
Within the service area, benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition. Outside the

service area, benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. To be covered by this Plan, any follow-up care recommended by non-Plan providers
must be approved by the Plan.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center

$20 per office visit to your primary care physician or a specialist

$20 per visit to an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $100 per visit, waived if admitted

Not covered: Elective care or non-emergency care All charges. 30.
30 Page 31 32
2003 OSF HealthPlans 28 Section 5(d)
Emergency outside our service area You pay
Emergency care at a doctor's office
Emergency care at an urgent care center

$20 per office visit to your primary care physician or a specialist.

$20 per visit to an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $100 per visit, waived if admitted

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

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

All charges.

Ambulance
Professional ambulance service, including air ambulance, when medically appropriate.

See 5(c) for non-emergency service.
Nothing 31.
31 Page 32 33
2003 OSF HealthPlans 29 Section 5(e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

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

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

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

Medication management

$20 per office visit to a specialist

Mental health and substance abuse benefits -Continued on next page 32.
32 Page 33 34
2003 OSF HealthPlans 30 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, full-day hospitalization, facility based intensive outpatient treatment

$500 per admission

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:
Call our mental health and substance abuse provider, United Behavioral Health (UBH), at 800/420-5729. An intake coordinator will assist you with
your needs. You may then be referred to a participating provider.

Limitation We may limit your benefits if you do not obtain a treatment plan. 33.
33 Page 34 35
2003 OSF HealthPlans 31 Section 5(f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.

I M
P O
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A N
T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication. We contract with AdvancePCS to provide you with full prescription drug

benefits through local pharmacies. Present your AdvancePCS card at any participating pharmacy, and after you pay your copayment for each new or refill prescription, we will pay the rest of the cost
to the pharmacy.
We use a Preferred Drug List (PDL). The PDL is made up of drugs meeting careful clinical and therapeutic standards created by physicians and pharmacists. Preferred drugs include generic and

specific name brand drugs. Generic drugs on the PDL will cost you the least amount of money out-of-pocket. Name brand drugs on the PDL are your next best option if no generic drug is available.
You will pay the most if you use any drugs that are not on the preferred drug list. If you or a family member are currently taking a nonpreferred drug, you should receive a letter showing you what
nonpreferred drugs you are taking and what alternative drugs are available. If you have a question about whether your prescription medications are generic or name brand drugs, contact your doctor or
pharmacist.

We administer an open PDL. 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 the PDL. This list of
name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost.
These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will either be dispensed for up to a 34-day supply or for a 35-90 day
supply, depending on the pharmacy you receive them at. You will pay a $10 copay per prescription unit or refill for up to a 34-day supply of preferred generic drugs and a $20 copay per prescription
unit or refill for a 35-90 day supply. You will pay a $20 copay for up to a 34-day supply of preferred name brand drugs when no generic drug is available and a $40 copay for a 35-90 day
supply. You will pay a $40 copay for up to a 34-day supply of non-preferred name brand drugs when no generic drug is available and a $80 copay for a 35-90 day supply. You will pay a $10
copay plus the price difference in the cost of the name brand drug over the generic drug for up to a 34-day supply of preferred or non-preferred name brand drugs when you or your physician requests
a name brand drug and a generic drug is available. You will pay a $20 copay plus the price difference in the cost of the name brand drug over the generic drug for a 35-90 day supply of
preferred or non-preferred name brand drugs when you or your physician requests a name brand drug and a generic drug is available.

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available,
you have to pay the difference in cost between the name brand drug and the generic, as well as the applicable $10 or $20 copay. 34.
34 Page 35 36
2003 OSF HealthPlans 32 Section 5(f)
Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding name brand drug. Generic drugs are less expensive than name brand
drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.

When you have to file a claim. Normally you will not have to file a claim. If you do, contact us at 800/OSF-5222 and we can send you a claim form that must be completed. You will then send the
claim to the address on the form.

Prescription drug benefits begin on the next page. 35.
35 Page 36 37
2003 OSF HealthPlans 33 Section 5(f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:

Drugs and medicines that by Federal law of the United States require a physicians prescription for their purchase, except as excluded below.
Insulin; a copay charge applies to each vial Disposable needles and syringes for the administration of covered
medications; a copay charge applies to each 34-day supply Drugs for sexual dysfunction are subject to dosage limits set by the
Plan. Contact the Plan for details. Fertility drugs

FOR UP TO A 34-DAY SUPPLY
A $10 copay for a preferred generic drug;
A $20 copay for a preferred name brand drug when no
generic drug is available; A $40 copay for a non-preferred
name brand drug when no generic drug is available; and
A $10 copay plus the price difference in the cost of the
name brand drug over the generic drug for a preferred or
non-preferred name brand drug when you or your physician
requests a name brand drug when a generic drug is available.

FOR A 35-90 DAY SUPPLY
A $20 copay for a preferred generic drug;
A $40 copay for a preferred name brand drug when no
generic drug is available; A $80 copay for a non-preferred
name brand drug when no generic drug is available; and
A $20 copay plus the price difference in the cost of the
name brand drug over the generic drug for a preferred or
non-preferred name brand drug when you or your physician
requests a name brand drug when a generic drug is available.

Covered medications and supplies -Continued on next page. 36.
36 Page 37 38
2003 OSF HealthPlans 34 Section 5(f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, and nutritional substances that can be purchased without a prescription

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
Contraceptive drugs and devices; including, but not limited to, oral contraceptives; Intrauterine devices (IUDs); diaphragms;
Norplant; and Depo Provera
Diabetic supplies, except needles, syringes, and insulin (Additional equipment, i.e., blood glucose monitors, insulin pumps, and
supplies, i.e., lancets and test strips, are covered under "Durable medical equipment," see page 20)

Smoking cessation drugs and medication
Drugs prescribed for weight loss and appetite suppressants, except for treatment of Morbid Obesity

All Charges. 37.
37 Page 38 39
2003 OSF HealthPlans 35 Section 5(g)
Section 5 (g). Special Features
Feature Description

Services for deaf and hearing impaired We offer a TDD line at 1-888/817-0139

Centers of excellence We utilize centers of excellence for transplants. It is a national organ and tissue network consisting of 48 transplant medical centers and 120 transplant programs. In order to become a center of excellence, the program is strictly
credentialed using program and physician experience, transplant volume, outcomes, comprehensive services, quality assessment and complications
rate. 38.
38 Page 39 40
2001 OSF HealthPlans 36 Section 5(h)
Section 5 (h). Dental benefits
I M
P O
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A N
T

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 impatient

hospital benefits. We do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
Restorative services and supplies necessary to promptly repair and replace sound natural teeth due to accidental injury within 90 days of

the injury are covered. The need for these services must result from an accidental injury. Accidental injury does not include injury caused by
or arising out of the act of chewing.

Nothing

Dental benefits
We have no other dental benefits. 39.
39 Page 40 41
2003 OSF HealthPlans 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition and we agree, as discussed under What Services Require Our Prior Approval on page 11.

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;
Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2003 OSF HealthPlans 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical 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 800/OSF-5222.

When you must file a claim --such as for services you receive outside of the Plans 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 members name and ID number;
Name and address of the physician or facility that provided the service or supply;

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

Receipts, if you paid for your services.
Submit your claims to: OSF HealthPlans, P.O. Box 5128, Peoria, IL 61601-5128.

Prescription drugs In most cases, participating pharmacies file claims for you. If you need to file a prescription drug claim directly to AdvancePCS, call us at
800/OSF-5222 and we will provide you with a form that must be completely filled out and sent to AdvancePCS.

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 41.
41 Page 42 43
2003 OSF HealthPlans 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: OSF HealthPlans, 7915 N. Hale Ave., Suite D, Peoria, IL 61615; 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 medical provider for more information. If we ask your provider, we will send you a copy of our requestgo to step 3.

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, D.C. 20415-3630.

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. 42.
42 Page 43 44
2003 OSF HealthPlans 40 Section 8
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 OPMs decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/prior approval, then call us at 800/OSF-5222 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 3 at 202/606-0755 between 8 a.m. and 5 p.m.
eastern time. 43.
43 Page 44 45
2003 OSF HealthPlans 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called double coverage.
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

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

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

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

covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on
January 1, 1983, or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-
MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social

Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare+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 (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts
Medicare. 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.

The Original Medicare Plan (Part A or Part B) 44.
44 Page 45 46
2003 OSF HealthPlans 42 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 claim will be coordinated automatically and we will then provide secondary benefits for

covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 309/677-8205,
toll free 877/677-8205, or TDD 888/817-0139.
We do not waive any costs if the Original Medicare Plan is your primary payer.

(Primary payer chart begins on next page.) 45.
45 Page 46 47
2003 OSF HealthPlans 43 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

OriginalMedicare This Plan
1) Areanactiveemployee withtheFederalgovernment (includingwhenyouor afamilymemberare eligibleforMedicaresolely becauseofadisability), !

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. 46.
46 Page 47 48

2003 OSF HealthPlans 44 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 our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive cost-sharing for your FEHB coverage.

This Plan and another plans Medicare managed care plan: You may enroll in another plans 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 plans network and/or service area (if you use our Plan providers), but we will not waive any of our copayments or coinsurance. If you
enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed
care plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-
enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the
Medicare managed care plans service area.

If you do not enroll in If you do not have one or both parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you cant 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 cover you, we
pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in one of these programs, eliminating your FEHB 47.
47 Page 48 49
2003 OSF HealthPlans 45 Section 9
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.
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 a 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 for injuries care for injuries or illness caused by another person, you must reimburse
us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our
subrogation procedures. 48.
48 Page 49 50
2003 OSF HealthPlans 46 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.
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
The Plan uses a range of sources to decide if a new procedure, process, or pharmaceutical is or is not experimental or investigational. These
sources include an independent third party evaluation where valid, an agreement of specialists in the related field, the Food and Drug
Administration, Medicare Guidelines, Hayes Technology Assessment and other available sources of medical information. All information is
given to the Plans Utilization Management Committee by the Plans Medical Director for a decision. The Medical Director also uses the
resources of the Plans Technology Assessment Committee.

Us/We Us and we refer to OSF HealthPlans.
You You refers to the enrollee and each covered family member.

Experimental or investigational services 49.
49 Page 50 51

2003 OSF HealthPlans 47 Section 10
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www.opm.gov/insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

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

employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan.

11 50.
50 Page 51 52
2003 OSF HealthPlans Section 11 48
Childrens 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:
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 Plans Basic Option, if you have a Self Only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same
option of the same plan; or if you are enrolled in an HMO that does not serve the area where the
children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit
Plans Basic Option.
As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact you employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your pay
period that starts on or after January 1. Annuitants coverage and premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.

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

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

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage. 51.
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2003 OSF HealthPlans Section 11 49
Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouses enrollment. This is
the case even when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouses employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download
the guide from OPMs website, www.opm.gov/insure.
Temporary Continuation of If you leave Federal service, or if you lose coverage because you no Coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child an