Coventry Health Plan of Kansas, Inc.

Pages 1--60 from Coventry Health Plan of Kansas, Inc.

Serving: Wichita, Salina and Central Kansas areas
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 8 for requirements.

Enrollment codes for this Plan:
7W1 Self Only 7W2 Self and Family

A Health Maintenance Organization
For changes in benefits
see page 9.

RI 73-275 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The brochure describes the
benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your plan's brochure every Open
Season – especially Section 2, which explains how the plan changed.

It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our FEHB Guide,
and our web-based resources, make it easier than ever to get information about plans, to compare benefits and to read customer service
satisfaction ratings for the national and local plans that may be of interest. Just click on www. opm. gov/ insure!

The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition to
keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the
test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country.

I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health benefits. We demand
cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the full FEHB
health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue FEHB
coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by
making additional supplies of medications available for emergencies as well as call-up situations and you can help by getting an
Emergency Preparedness Guide at www. opm. gov. OPM's HealthierFeds campaign is another way the carriers are working with us to
ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain
healthcare costs and keep premiums down by living a healthy life style.

Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare needs. Use this
brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if you know someone interested in
Federal employment, refer them to www. usajobs. opm. gov.

Sincerely,

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

By law, the United States 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 health care oversight activities (such as fraud and abuse investigations), . For research studies that meet all privacy law requirements (such as for medical research or education), and
. To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:
. See and get a copy of your personal medical information held by OPM. . Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing,
and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical
information.
. Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized

OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

. Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
. Get a separate paper copy of this notice. 3.
3 Page 4 5
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. 4.
4 Page 5 6
2 0 0 4 Co ventry Health Care o f Kansas, Inc. 2 Table of Co ntents
Table of Contents
Introduction.............................................................................................................................................................................. ...................... 4
Plain Language......................................................................................................................................................................................... 4
Stop Health Care Fraud!.. ....................................................................................................................................................................... 5
Preventing medical mistakes .................................................................................................................................................................. 5
Section 1. Facts about this HMO plan ................................................................................................................................................... 7
How we pay providers .......................................................................................................................................................... 7
Who provides my health care? .................................................................................................. ........................................... 7
Your Rights........................................................................................................................................................................... 8
Service A rea.................................................................................................................. ........................................................ 8
Section 2. How we change for 2004. ..................................................................................................................................................... 9
Program-wide changes.......................................................................................................................................................... 9
Changes to this Plan.............................................................................................................................................................. 9
Section 3. How you get care ................................................................................................... ............................................................. 10
Identification cards.............................................................................................................................................................. 10
Where you get covered care................................................................................................................................................ 10
. Plan providers ............................................................................................................................................................... 10
. Plan facilities ................................................................................................................................................................ 10
What you must do to get covered care ................................................................................................................................ 10
. Primary care.................................................................................................................................................................. 10
. Specialty care................................................................................................................................................................ 10
. Hospital care ................................................................................................................................................................. 11
Circumstances beyond our control ...................................................................................................................................... 12
Services requiring our prior approval.................................................................................................................................. 12
Section 4. Your costs for covered services .......................................................................................................................................... 13
. Copayments .................................................................................................................................................................. 13
. Deductible..................................................................................................................................................................... 13
. Coinsurance .................................................................................................................................................................. 13
Your catastrophic protection out-of-pocket maximum....................................................................................................... 13
Section 5. Benefits ............................................................................................................................................................................... 14
Overview............................................................................................................................................................................. 14
(a) Medical services and supplies provided by physicians and other health care professionals....................................... 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................... 23
(c) Services provided by a hospital or other facility, and ambulance services................................................................. 26
(d) Emergency services/ accidents .................................................................................................................................... 28
(e) Mental health and substance abuse benefits ............................................................................................................... 30
(f) Prescription drug benefits ........................................................................................................................................... 32
(g) Special features........................................................................................................................................................... 34 5.
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2 0 0 4 Co ventry Health Care o f Kansas, Inc. 3 Table of Co ntents
. 24 hour nurse line ............................................................................................................................................. 34
. Services for deaf and hearing impaired............................................................................................................. 34
. Transplant Network........................................................................................................................................... 34
. Flexible Benefits Option ................................................................................................................................... 34
(h) Dental benefits............................................................................................................................................................ 35
(i) Non-FEHB benefits available to Plan members......................................................................................................... 36
Section 6. General exclusions --things we don't cover....................................................................... ................................................ 37
Section 7. Filing a cl aim for covered services ..................................................................................................................................... 38
Section 8. The disput ed claims process................................................................................................................................................ 39
Section 9. Coordinating benefits with other coverage ......................................................................................................................... 41
When you have other health coverage.. .............................................................................................................................. 41
. What is Medicare? .............................................................................................................. ....................................... 41
. Should I enroll in Medicare? ................................................................................................... ................................... 41
. Medicare + Choice .................................................................................................................................................... 44
. TRICARE and CHAMPVA ............................................................................................................ ........................... 44
. Worker's Compensation............................................................................................................................................. 44
. Medicaid .................................................................................................................................................................... 45
. Other Government agencies ....................................................................................................................................... 45
. When others are responsible for injuries.................................................................................................................... 45
Section 10. Definitions of terms we use in this brochure..................................................................................................................... 46
Section 11. FEHB facts........................................................................................................................................................................ 47
Coverage information ......................................................................................................................................................... 47
. No pre-existing condition limitation ........................................................................................................................... 47
. Where you can get information about enrolling in the FEHB Program...................................................................... 47
. Types of coverage available for you and your family................................................................................................. 47
. Children's Equity Ac t.. ............................................................................................................................................... 47
. When benefits and premiums start.............................................................................................................................. 48
. When you retire .......................................................................................................................................................... 48
When you lose benefits ....................................................................................................................................................... 48
. When FEHB coverage ends ........................................................................................................................................ 48
. Spouse equity coverage............................................................................................................................................... 48
. Temporary Continuation of Coverage (TCC) ............................................................................................................. 49
. Converting to individual coverage.............................................................................................................................. 49
. Getting a Certificate of Group Health Plan Coverage................................................................................................. 49
Two new Federal Programs complement FEHB benefits .................................................................................................................... 50
The Federal Flexible Spending Account Program – FSAFEDS ............................................................................................ 50
The Federal L ong Term Ca re Insurance Program ................................................................................................................. 53 Index ..................................................................................................................................................................................................... 54

Summary of benefits ............................................................................................................................................................................. 56
Rates ....................................................................................................................................................................................... Back cover 6.
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2 0 0 4 Co ventry Health Care o f Kansas, Inc. 4 I ntrodu ction / Plain Language / Advisory
Introduction
This brochure describes the benefits of Coventry Health Care of Kansas, Inc. under our contract (CS 2108) with the United Stat es Office of Personnel Management, as authoriz ed by the Federal Employees Health Benefits law. The address for Coventry Health Ca re
of Kansas, Inc. administrative offices is:
Coventry Health Care of Kansas, Inc. 8 301 E. 21 st North, Suite 300
Wichita, Kansas 67206
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, 2004, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and changes are summarized on page 5 5 . Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain lan guage 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 en rollee or family member; "we"
means Coventry Health Care of Kansas, Inc.

. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States
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 this structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov . You may also write to OPM at the United
States Office of Personnel Management, Insurance Services Program, Program Planning & Evaluation Group, 1900 E Street, NW Washington, DC 20415-3650 7.
7 Page 8 9
2004 Coventry Health Care of Kansas, Inc. 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 866/ 320-0697 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, with your
retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary
Continuation of Coverage.
. 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.

Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in
hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical
mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional
treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and
that of your family members. Take these simple steps:

1. Ask questions if you have doubts or concerns.
. Ask questions and make sure you understand the answers. . Choose a doctor with whom you feel comfortable talking.

. Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take.
. Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.

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.
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2004 Coventry Health Care of Kansas, Inc. 6 Introduction / Plain Language / Advisory
. Tell them about any drug allergies you have. . Ask about side effects and what to avoid while taking the medicine.
. Read the label when you get your medicine, including all warnings. . Make sure your medicine is what the doctor ordered and know how to use it.
. Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure.
. Ask when and how you will get the results of test or procedures. . Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
. Call your doctor and ask for your results. . Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
. Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.

. Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery.
. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. . Ask your doctor, "Who will manage my care when I am in the hospital?"
. Ask your surgeon: Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
. Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.

Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging
list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve
the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your
family.
www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is dedicated to improving
communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals working to
improve patient safety.
www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent mistakes
in the nation's healthcare delivery system. 9.
9 Page 10 11
2004 Coventry Health Care of Kansas, Inc. 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

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

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

Who provides my healthcare
Coventry Health Care provides you with a comprehensive benefit package that covers many kinds of health services for a fixed
payroll deduction and minimal copayments. As a participant of Coventry Health Care, you will select a personal doctor for yourself
and each member of your family. Depending on where you live, you will be able to choose from a directory of more than 320 primary
care doctors whose offices are located throughout the Plan's service areas.

The first and most important decision each member must make is the selection of a primary care doctor. Your primary care doctor
will be the manager and coordinator of your health care. If you require additional care, your primary care doctor, with your input, will
select the specialist or hospital that best fits your needs. It is the responsibility of your primary care doctor to obtain any necessary
authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization.

The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with their
locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular
basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1-866-320-0697. You
can also find out if your doctor participates by calling these numbers. The list is also on our website. Visit www. chckansas. com to
utilize our doctor search option. Our doctor search on the web is updated monthly.

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she
still participates with the Plan and is accepting new patients. Important note: When you enroll in the Plan, services (except for
emergency benefits) are provided through the Plan's delivery system; the continued availability and/ or participation of any one doctor,
hospital, or other provider, cannot be guaranteed.

Should you decide to enroll, you will be asked to complete a primary care doctor selection and send it to the Plan, indicating the name
of the primary care doctor( s) selected for you and each member of your family. Members may change their doctor selection by
notifying the Plan 30 days in advance. 10.
10 Page 11 12
2004 Coventry Health Care of Kansas, Inc. 8 Section 1
Your Rights
OPM requires that all FEHB Plans to provide certain information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.

. State Insurance Department requirements for external quality review . Years in existence
. Profit status
If you want more information about us, call 866/ 320-0697, or write to Coventry Health Care of Kansas Inc., 8301 East 21 st North,
Suite 300, Wichita, Kansas 67206. You may also contact us by fax at 316/ 634-1266 or visit our website at www. chckansas. com.

Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice. Our service area is: Butler, Harvey,
Lyon, McPherson, Montgomery, Pratt, Saline, Sedgwick, and Sumner Counties.

You may also enroll with us if you live or work in the following places: Cowley, Dickinson, Greenwood, Harper, Kingman, Lincoln,
Marion, Ottawa, and Reno 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 areas. If you or a family member move, you do not have to wait until Open Season to
change plans. Contact your employing or retirement office. 11.
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2 0 0 4 Co ventry Health Care o f Kansas, Inc. 9 Section 2
Section 2. How we change for 2004
Do not rely on these changes descriptions; this page is not an official statement of benefits. For that go to Section 5 Benefi ts. 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
. We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending
A ccount Program -FSAFEDS and the Federal Long Term Care Insurance Program. See page 51. . We added information regarding Preventing medical mistakes. See page 5.

. We added information regarding enrolling in Medicare. See page 41 .
We revised the Medicare Primary Payer Chart. See page 43.

Changes to this Plan
Your share of the non-Postal premium will decrease by 20% for Self On ly or 27. 9% for Self and Family.
. We discontinued our dental benefits with the exception of the accidental injury benefit.
. We added Lyon and Montgomery Counties, Kansas to our service area. 12.
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2004 Coventry Health Care of Kansas, Inc. 10 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 1-866-320-0697 or write us at
Coventry Health Care of Kansas, Inc., 8301 E. 21 st St. North, Ste. 300 Wichita, KS
67206. You may also request replacement cards through our website at
www. chckansas. com.

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. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is
also on our website. Visit www. chckansas. com to utilize our doctor search option. Our
doctor search on the web is updated monthly.

. . . . Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our website www. chckansas. com.
It depends on the type of care you need. First, you and each family member must choose
a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. The Plan's provider directory lists
primary care doctors (generally family practitioners, pediatricians, and internists), with
their locations and phone numbers, and notes whether or not the doctor is accepting new
patients. Directories are updated on a regular basis and are available at the time of
enrollment or upon request by calling the Customer Service Department at 1-866-320-
0697. You can also find out if your doctor participates by calling these numbers.

If you are interested in receiving care from a specific provider who is listed in the
directory, call the provider to verify that he or she still participates with the Plan and is
accepting new patients.

. . . . Primary care Your primary care physician will generally be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give
you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.

. . . . Specialty care Your primary care physician will refer you to a specialist for needed care. You must receive a referral from your primary care doctor before seeing or obtaining special
services, with the following exceptions:, (1) Female members may visit a participating
gynecologist without a referral from their primary care doctor; (2) All members may visit
the Plan's mental health providers for mental conditions and substance benefits without a
referral from their primary care doctor (See "Mental Conditions /Substance Abuse
Benefits").

What you must do to get covered care 13.
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2004 Coventry Health Care of Kansas, Inc. 11 Section 3
Referral to a participating specialist is given at your primary care doctor's discretion; if
specialists or consultants are required beyond those participating in the Plan, your
primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the
primary care doctor after the consultation. All follow-up care must be provided or
arranged by the primary care doctor. On referrals, the primary care doctor will give
specific instructions to the consultant as to what services are authorized. If the consultant
suggests additional services or visits, you must first check with your primary care doctor.
Do not go to the specialist unless your primary care doctor has arranged for and the Plan
has issued an authorization for the referral in advance.

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

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

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

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

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

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

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

. . . . Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 1-866-320-0697. If you are new to the FEHB
Program, we will arrange for you to receive care. 14.
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2004 Coventry Health Care of Kansas, Inc. 12 Section 3
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 hospital benefits of the hospitalized person. If your
plan terminates participation in the FEHB Program in whole or in part, or if OPM orders
an enrollment change, this continuation of coverage provision does not apply. In such
case, the hospitalized family menber's benefits under the new plan begin on the effective
date of enrollment.

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.
Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally
accepted medical practice.

We call this review and approval process prior authorization. Your physician must
obtain, for example, prior authorization from the Plan for outpatient surgeries or inpatient
hospitalization. You may call customer service at 1-866-320-0697 to find out if a
specific procedure treatment requires prior authorization.

Services requiring our prior approval 15.
15 Page 16 17
2 0 0 4 Co ventry Health Care o f Kansas, Inc. 13 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 provider, facility, pharmacy, etc.,
when you receive services.

Example: When you see your primary care physician, you pay a copayment of $15 per office visit. When you go in the hospital, you pay $100 copay per day up to a $3 00
maximum per admission.
. Deductible A deductible is a fixed expense you must incur for certain covered services and supplies
before we start paying benefits for them. We have no deductible.

. Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services and 20% for covered durable medical equipment.

After your copayments and coinsurance total $ 2,000 per person or $ 4,000 per family enrollment in any calendar year, you do not have to pay any more for covered services.
However, copayments for prescription drugs do not count toward your out-of-pocket maximum, and you must continue to pay copayments for prescription drugs.

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

Your catastrophic protection out-of-pocket maximum for
deductibles, coinsurance, and copayments 16.
16 Page 17 18
2 0 0 4 Co ventry Health Care o f Kansas, Inc. 14 Section 5
Section 5. Benefits – OVERVIEW (See page 9 for how our benefits changed this year and page 56 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 8 66-320-0697 or at our website at www. chckansas. com.

(a) Medical services and supplies provided by physicians and other health care professionals.................................................... 15-22
. 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 ................................................ 23-25
. Surgical procedures .
Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue transplants . Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services.............................................................................. 26-27
. Inpatient hospital .
Outpatient hospital or ambulatory surgical center . Extended care benefits/ skilled nursing care facility benefits . Hospice care . Ambulance

(d) Emergency services/ accidents .......................................................................................................................................... 28-29 . Medical emergency . Ambulance
(e) Mental health and substance abuse benefits ............................................................................................................................... 30-31
(f) Prescription drug benefits ........................................................................................................................................................... 32-33
(g) Special features ................................................................................................................................................................................ 34 . 24 hour nurse line . Services for deaf and hearing impaired . Transplant Network . Flexible Benefits Option

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

Summary of benefits............................................................................................................................................................................. 56 17.
17 Page 18 19
2004 Coventry Health Care of Kansas, Inc. 15 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
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T

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

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

Medicare.

I M
P O
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T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office
$15 per office visit

In an urgent care center
. During a hospital stay
. In a skilled nursing facility
. Initial examination of a newborn child covered under a family enrollment

. Office medical consultations
. Second surgical opinion

$15 per office visit

. At home $25 per office visit
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

$15 when the test is not performed during
your office visit. You only pay the office
visit copayment when the test is performed
during your office visit. 18.
18 Page 19 20
2004 Coventry Health Care of Kansas, Inc. 16 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
. Total Blood Cholesterol – once every three years, ages 19 through 64
. Colorectal Cancer Screening, including
. Fecal occult blood test
. Sigmoidoscopy, screening – every five years starting at age 50

$15 per office visit

Routine Prostate Specific Antigen (PSA) test– one annually for men age 40
and older
$15 per office visit

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

$15 per office visit

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

$15 per office visit.

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

Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood Immunizations)

. Influenza vaccines, annually,
. Pneumococal vaccine, age 65 and over

$15 per office visit

Preventive care, children
. Childhood immunizations recommended by the American Academy of Pediatrics

. Examinations done on the day of immunizations (under age 22)
$15 per office visit

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

$15 per office visit 19.
19 Page 20 21
2 0 0 4 Co ventry Health Care o f Kansas, Inc. 17 Sectio n 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 12 for
other circumstances, such as extended stays for you or your baby.

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

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

cover the infant under a Self and Family enrollment.
. We pay hospitalization and surgeon se rvices (delivery) the same as
for illness and injury. See Hospital benefits (Section 5 c) and Surgery benefits (Section 5b) .

$ 15 for initial office visit to confirm pregnancy. All other copayments for
prenatal visits during the course of pregnancy are waived.

No t covered: Rou tine sonograms to determine fetal ag e, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:

. Voluntary sterilization (See Surg ical procedures Section 5 (b))
. Surgically implanted contraceptives (implant only; not removal)
. Intrauterine devices (IUDs – implant only, not removal)
. Injectable contraceptive drugs (such as Depo provera)
. Diaphragms (insertion only)
NOTE: We cover oral contraceptives under the prescription drug benefit.

$100 per sterilization procedure
$15 for office visit applies to implanted contraceptive devices. Benefit does NOT

cover removal of devices.
$ 15 office visit copay applies to the injectable contraceptive drugs.

No t covered: reversal o f volu ntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
. intravaginal inseminatio n (I V I )
. intracervical insemination (ICI)
. intrauterine insemination (IUI)

50% of charges up to a $ 2, 000 annual out-of-pocket maximum for an individual and
$ 4, 000 out of pocket maximum for family. We pay remaining charges.

Infertility services --continued o n next pag e 20.
20 Page 21 22
2004 Coventry Health Care of Kansas, Inc. 18 Section 5( a)
Infertility services (continued) You pay
Not covered:
. Assisted reproductive technology (ART) procedures, such as:
. in vitro fertilization
. embryo transfer, gamete GIFT and zygote ZIFT
. Zygote transfer
. Services and supplies related to excluded ART procedures

. Cost of donor sperm
. Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
50% of cost of testing; you pay $15
copayment for treatment visits, including
allergy serum.

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

Treatment therapies
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants 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 medical benefit.
Note: – We will only cover GHT when the treatment is prior authorized
by your Primary Care Physician. It is a good idea to call us at 1-866-
320-0697 to confirm that prior authorization has been done before
starting treatment. If we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior authorization in Section 3.

$15 per office visit 21.
21 Page 22 23
2004 Coventry Health Care of Kansas, Inc. 19 Section 5( a)
Physical, occupational therapies and chiropractic You pay
60 days per condition for the services of each of the following:
. qualified physical therapists
. occupational therapists and
. chiropractors (coverage limited to subluxation and manipulation)
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.

. Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 days per

condition.

$15 copay for each outpatient session;
Nothing per visit during covered inpatient
admission

Not covered:
. Long-term rehabilitative therapy
. Exercise programs

All charges.

Speech therapy
60 days per condition $15 copay for each outpatient session.
Nothing per visit during covered inpatient
admission

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

. Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit

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

Vision services (testing, treatment, and supplies)
. Eye refraction every two years $10 per office visit

. One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$15 per office visit

. Eye exam to determine the need for vision correction for children through age 17 (see preventive care) $15 per office visit
Vision services --continued on next page 22.
22 Page 23 24
2004 Coventry Health Care of Kansas, Inc. 20 Section 5( a)
Vision services (testing, treatment, and supplies) (continued) You pay
Not covered:
. Eyeglasses or contact lenses 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.

$15 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.

Orthopedic and prosthetic devices
We limit coverage to $1,000 per member per calendar year.
. Orthopedic devices such as braces
. Artificial limbs and eyes; stump hose
. Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy. External

prosthetic devices, except those associated with reconstructive
surgery after a mastectomy, are limited to one per member per
lifetime.

. Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.

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

20% of charges

Orthopedic and prostetic devices --continued on next page 23.
23 Page 24 25
2 0 0 4 Co ventry Health Care o f Kansas, Inc. 21 Sectio n 5( a)
Orthopedic and prosthetic devices (continued) You pay
Not covered:
. o rthopedic and corrective shoes
. arch su pports
. f oot orthotics
. heel pads and heel cups
. lu m bosacral su p p orts
. corsets, trusses, elastic stockings, su p p ort ho se, and other supp o rtive
devices

. p rosthetic replacements p ro v ided less than 3 years after the last o ne
we covered

All charges.

Durable medical equipment (DME)
We limit coverage to $1, 000 per member per calendar year.
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
. hospital beds;
. wheelchairs;
. crutches;
. walkers;
. insulin pumps; and

20% of charges

. blood glucose monitors for those members with diabetes.
Note: Call us at 1-866-795-3995 as soon as your Plan physician prescribes this equipment. We will arrange with a contracting health

care provider to provide you with the necessary equipment, according to the benefit.

Nothing.

Not covered:
. Motorized wheel chairs
All charges. 24.
24 Page 25 26
2004 Coventry Health Care of Kansas, Inc. 22 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 patient's family;

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

All charges

Chiropractic
See Physical and Occupational therapies

Alternative treatments
No benefit All charges.

Educational classes and programs
Coverage is limited to:

. Diabetes Self-Management educational classes, as referred by your Plan physician

. Prenatal education classes

Nothing 25.
25 Page 26 27
2004 Coventry Health Care of Kansas, Inc 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services 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.
. 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.

I M
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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting
. Normal pre-and post-operative care by the surgeon
. Correction of amblyopia and strabismus
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and cysts
. Correction of congenital anomalies (see reconstructive surgery)
. Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible
members must be age 18 or over

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

. Treatment of burns

$15 per office visit;

. Voluntary sterilization (e. g. Tubal ligation, Vasectomy) $100 copayment per procedure
Not covered:
. Reversal of voluntary sterilization . Routine treatment of conditions of the foot; see foot care. All charges 26.
26 Page 27 28
2004 Coventry Health Care of Kansas, Inc 24 Section 5( b)
Reconstructive surgery You pay
. Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if:
. the condition produced a major effect on the member's appearance and

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

. All stages of breast reconstruction surgery following a mastectomy, such as:

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

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

$15 per office visit

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.
. Treatment of TMJ

$15 per office visit

Not covered:
. Oral implants and transplants . Procedures that involve the teeth or their supporting structures

(such as the periodontal membrane, gingiva, and alveolar bone)
. TMJ related dental work

All charges. 27.
27 Page 28 29
2 0 0 4 Co ventry Health Care o f Kansas, Inc 25 Sectio n 5( b )
Organ/ tissue transplants You pay
Limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Lung: Single –Double
. Pancreas
. A llogeneic (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

. National Transplant Program (NTP) -URN
Limited Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an National Cancer

Institute-or National Institutes of Health-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.

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

Nothing

Not covered: . Donor screening tests and donor search expenses, except those
performed fo r the actu al do no r . Imp lants o f artificial organs

. Transplants not listed as covered

All charges

Anesthesia You pay
Professional services provided in –
. Hospital (inpatient)
Nothing.

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

. Office

$15 per office visit 28.
28 Page 29 30
2 0 0 4 Co ventry Health Care o f Kansas, Inc 26 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, Y our costs fo r co vered serv ices, 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 MU ST GET PRECERTIFICATION OF HOSPIT AL STAYS .
Please refer to Section 3 to be sure which services require precertification.

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

. general nursing care; and .
meals and special diets.

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

$ 100 per day up to a maximum of $300 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
. No n-covered facilities, such as nu rsing ho mes, and schools .
Personal comfo rt items, such as telephone, television, barber services, guest meals and beds

. Private nursing care

All charges. 29.
29 Page 30 31
2 0 0 4 Co ventry Health Care o f Kansas, Inc 27 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.

$5 0 per surgery

No t covered: bloo d and b lood derivatives not replaced b y the m emb er All charges
Extended care benefits/ skilled nu rsing care facility benefits
A comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary and confinement in a skilled

nursing facility is medically appropriate as determined by a Plan doctor and 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

No t covered: custodial care All charg es
Hospice care
Supportive and Palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient

care and family counseling. These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or less.

Nothing

N o t covered: Independent nursing, homemaker services All charges
Ambulance
. Land ambulance service when medically appropriate. We limit
coverage to $400 per transport.

. Air ambulance when me dically appropriate

30% of covered charges per transport up to our $ 400 coverage limit.

30% of covered charges 30.
30 Page 31 32
2004 Coventry Health Care of Kansas, Inc. 28 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor, for First Help, the Plan's 24-hour advice line at 1-800-622-9528. In extreme emergencies, if you are unable to contact your doctor,

contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure
to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must
notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it is not reasonably possible to notify the Plan within that time. If you are hositalized in non-Plan facilities
and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with
any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant jeopardy to your condition.

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

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it is not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better
provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan. 31.
31 Page 32 33
2 0 0 4 Co ventry Health Care o f Kansas, Inc. 29 Sectio n 5( d)
Benefit Description You pay
Emergency within our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital,
including doctors' services

$15 per office visit
$25 per office visit
$ 7 5 per visit; waived if admitted to hospital

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services

$15 per office visit
$25 per office visit
$ 7 5 per ER visit; waived if admitted to hospital

Not covered:
. Elective care or non-em ergency care
. Emergency care pro v ided ou tside the service area if the need for
care co uld hav e been fo reseen befo re leaving the service area . Medical and hospital costs resulting from a no rmal full-term

delivery of a baby outside the service area .

All charges.

Ambulance
. Land ambulance service when medically appropriate. We limit
coverage to $400 per transport

. Air ambulance when me dically appropriate
See 5( c) for non-eme rgency service.

3 0% coinsurance per transport up to our $400 coverage limit.
30% of covered charges 32.
32 Page 33 34
2004 Coventry Health Care of Kansas, Inc 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

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

Here are some important things to keep in mind about these benefits:
. Please remember that 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.
. YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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

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

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

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

$15 per visit

. Diagnostic tests $15 when the test is not performed during your office visit. You only pay the office
visit copayment when the test is performed
during your office visit.

Mental health and substance abuse benefits -Continued on next page 33.
33 Page 34 35
2004 Coventry Health Care of Kansas, Inc 31 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
. Services provided by a hospital or other facility
. Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day

hospitalization, facility based intensive outpatient treatment

Nothing
$100 copay per day up to a maximum of
$300 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 follow your treatment plan and all the following authorization processes:
Call 1-866-607-5970. When you call, be prepared to give your name and member I. D.
number. You will be asked some general questions about why you are seeking services,
and you will be referred to a provider for treatment.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2004 Coventry Health Care of Kansas, Inc. 32 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the next page.
. All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

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

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

. We use a formulary. We cover non-formulary drugs prescribed by a Plan doctor. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31-day
supply or 100-unit dosage, whichever is less. You pay a $5 copay per prescription unit or refill for formulary
generic drugs or a $15 copay for formulary name brand drugs or a $45 copay for non-formulary prescription
drugs requested by the prescribing doctor.

We have an open formulary. If your physician believes a name brand product is necessary or there is no
generic available, your physician may prescribe a name brand drug from a formulary list. This list of name
brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call 1-866-320-0697. When generic substitution is permissible (i. e., a generic
drug is available and the prescribing doctor does not require the use of a name brand drug), but you request
the name brand drug, you pay the price difference between the average wholesale prices of the generic and
name brand drug as well as the $15 copay per prescription unit or refill.

. You can obtain through Mail Order covered "maintenance" prescription drugs used to treat chronic or long-term health conditions (such as high blood pressure or diabetes) for a 93-day supply. You pay $10 copay per
prescription unit or refill for formulary generic drugs, and $30 copay for formulary name brand drugs. Note:
Our mail order benefit is limited to two tiers. Non formulary prescription drugs are not covered under the
maintenance mail order.

. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's formulary is based on effectiveness and cost of drugs. Nonformulary drugs under the retail pharmacy benefit
will be covered when prescribed by a Plan doctor.

. These are dispensing limitations. Retail Pharmacy Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31-day supply or 100-unit dosage, whichever is
less. If a 90-day supply is prescribed, you will be able to pick up a 31-day supply at the pharmacy. The
balance of the script will be dispensed on a 31-day basis. Mail Order-Covered Mail Order "maintenance"
prescription drugs use to treat chronic or long-term health conditions (such as high blood pressure or
diabetes) for a 93-day supply. Members called to active military duty in a time of national or other
emergency who need to obtain a greater-than-normal supply of prescribed medications should call us at 1-
866-320-0697. 35.
35 Page 36 37
2004 Coventry Health Care of Kansas, Inc. 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 physician's prescription for their purchase, except those

listed as Not covered.
. Insulin
. Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution, or equivalent, and acetone

test tablets are each available for the $10 copay.
. Disposable needles and syringes for the administration of covered medications.

. Drugs for sexual dysfunction
. Contraceptive drugs. (Contraceptive devices, see Section 5 (a) )

Retail Pharmacy
$5 per generic formulary drug
$15 per brand name formulary drug
$45 per non formulary drug

Mail Order (93-day supply)
$10 per generic formulary drug
$30 per brand name formulary drug
Note: Our mail order benefit is limited to
the two tiers listed above.

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

If there is a generic equivalent and you
choose the brand name drug, you will pay
the brand name copay plus the difference in
the average wholesale price between the
generic and the brand name drug. This
applies to both the formulary and non-formulary
drugs.

Not covered:
. Drugs available without a prescription or for which a non-prescription is available

. Drugs and supplies for cosmetic purposes
. Vitamins, nutrients and food supplements even if a physician prescribes or administers them

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

. Medical supplies such as dressings and antiseptics
. Drugs to enhance athletic performance
. Drugs to aid in smoking cessation, include nicotine patches
. Fertility drugs
. Appetite suppressants and other drugs to assist in weight control (except for the treatment of morbid obesity when authorized by us

and your primary care physician).

All charges. 36.
36 Page 37 38
2004 Coventry Health Care of Kansas, Inc. 34 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
. We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

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

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

24 hour nurse line Call FirstHelp anytime you or a family member experience health symptoms that need attention. Nurses are available to you and your family 24 a day, 7 days a
week and are trained to handle your questions. Any member who visits an
emergency room or urgent care center as a result of advice from FirstHelp will
automatically have associated claims approved. With FirstHelp authorization, you
will know in advance if medical services will be covered. You may call 1-800-
622-9528 or for the hearing impaired call 1-800-735-2966.

Services for deaf and hearing impaired The Kansas TDD relay number is 1-800-766-3777.

Transplant Network In order to provide members requiring a transplant the opportunity for the best outcomes and experiences, We have contracted with United Resource Networks
for access to a network of transplant programs with proven expertise. United
Resource Networks evaluates transplant programs throughout the United States,
and has built a nationally-recognized network of programs called the United
Resource Networks Transplant Network.

Flexible Benefits Option Under the flexible benefits option, we determine the most effective way to provide services.
. We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

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

. The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
. Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. 37.
37 Page 38 39
2004 Coventry Health Care of Kansas, Inc.. 35 Section 5 (h)
Section 5 (h). Dental benefits
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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 dentally necessary.

. Plan dentists must provide or arrange your care.
. We have no calendar year deductible.
. We cover hospitalization for dental procedures only when a non-dental physical impairment exist which makes hospitalization necessary to safeguard the health of the patient. See section 5 ( c ) for inpatient benefits. We do

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

$15 per office visit

Dental benefits
We have no other dental benefits. 38.
38 Page 39 40
2004 Coventry Health Care of Kansas, Inc.. 36 Section 5 (i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Vision One Discount Program:
Contact Vision One for a participating Vision One Provider near you, 1-800-804-4384

Vision One You pay
Frames-Retail
Priced up to $60.99
Priced $61.00-$ 80.99
Priced $81.00-$ 100.99
Priced $101.00 and over

$25.00
$35.00
$45.00
65%

Lenses (uncoated plastic)
Single Vision
Bifocal
Trifocal
Lenticular

$30.00
$50.00
$60.00
$100.00

Lens Options (add to lens cost)
Standard Progressive (no line)
Polycarbonate
Scratch Resistant Coating
Anti-Reflective Coating
Ultraviolet Coating
Solid Tint
Gradient Tint
Photochromic
Glass

$50.00
$30.00
$12.00
$35.00
$12.00
$8.00
$8.00
$30.00
$15.00

Eye Examinations
Note: Your medical plan may already cover eye exams. This fee is
for subsequent eye exams once your existing eye exam benefit is
exhausted.

$35.00 (Fixed eye exam rate)

Contact Lenses
Use the Vision One Contact Lens Replacement program for
additional savings and convenience.

20% off regular retail prices; 10%
discount on disposables

All Other Materials (sunglasses, accessories, etc.) 20% discount off regular retail prices
Prices are effective as of 8/ 1/ 02 and subject to change without notice. 39.
39 Page 40 41
2004 Coventry Health Care of Kansas, Inc.. 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

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

. Services, drugs, or supplies related to sex transformations; 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
2004 Coventry Health Care of Kansas, Inc.. 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

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

Medical, hospital and drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92
form. For claims questions and assistance, call us at 1-866-320-0697.
When you must file a claim --such as for services you receive outside of the Plan's
service --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:

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

. Receipts, if you paid for your services.
Submit your claims to: Coventry Health Care of Kansas
P. O. Box 7124
London, KY 40742

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
2004 Coventry Health Care of Kansas, Inc.. 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 90 days from the date of our decision; and
(b) Send your request to us at: Coventry Health Care of Kansas, Inc., Attn: Member Appeals, 1001 East 101 st Terrace, Suite
300, Kansas City, MO 64131; and

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

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

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

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

We will write to you with our decision.

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

Write to OPM at: United States Office of Personnel Management, Insurance Services Program, Health Insurance Group 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:
. A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
. Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

. Copies of all letters you sent to us about the claim;
. Copies of all letters we sent to you about the claim; and
. Your daytime phone number and the best time to call. 42.
42 Page 43 44
2004 Coventry Health Care of Kansas, Inc.. 40 Section 8
The Disputed Claims process (continued)
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must include a copy of your specific written consent with the review request.

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against
OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not
be extended.

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-866-320-0697 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 Insurance Group 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 43.
43 Page 44 45
2004 Coventry Health Care of Kansas, Inc.. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

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

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

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

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

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

check.
The decision to enroll in Medicare is yours. We encourage you to apply for Medicare
benefits 3 months before you turn age 65. It's easy. Just call the Social Security
Administration toll-free number 1-800-772-1213 to set up an appointment to apply. If
you do not apply for one or both Parts of Medicare, you can still be covered under the
FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal
employees and annuitants are entitled to Medicare Part A at age 65 without cost. When
you don't have to pay premiums for Medicare Part A, it makes good sense to obtain the
coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security
Administration can provide you with premium and benefit information. Review the
information and decide if it makes sense for you to buy the Medicare Part B coverage.
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. 44.
44 Page 45 46
2004 Coventry Health Care of Kansas, Inc.. 42 Section 9
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. Your care must continue to be
authorized by your Plan PCP, or precertified as required.

We will waive some copayments, coinsurance, and deductibles, as follows: When
Original Medicare is the primary payor, we will waive your out of pocket costs including
copayments and coinsurance. 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.

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

. When we are the primary payer, we process the claim first.
. When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will then provide
secondary benefits for covered charges. You will not need to do anything. To find
out if you need to do something to file your claims, call us at 1-866-320-0697 or visit
us at www. chckansas. com.

We waive some costs if the Original Medicare Plan is your primary payer --When Original Medicare is the primary payer, we will waive some out-of-pocket costs, as
follows:
. Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare Part B, we will waive your out-of-pocket
costs including copayments and coinsurance. 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.

(Primary payer chart begins on next page)

. . . . The Original Medicare Plan (Part A or Part B) 45.
45 Page 46 47
2004 Coventry Health Care of Kansas, Inc.. 43 Section 9
Medicare always makes the final determination as to whether they are the primary payer. The following chart illustrates whether
Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these
requirements correctly.

Primary Payer Chart

The primary payer for the individual with Medicare is… A. When you -or your covered spouse -are age 65 or over and have Medicare and you…

Medicare This Plan
1) Are an active employee with the Federal government and…
. You have FEHB coverage on your own or through your spouse who is also an active employee
. You have FEHB coverage through your spouse who is an annuitant

2) Are an annuitant and…
. You have FEHB coverage on your own or through your spouse who is also an annuitant
. You have FEHB coverage through your spouse who is an active employee

3) Are a reemployed annuitant with the Federal government and your position is excluded from the
FEHB (your employing office will know if this is the case) *

4) Are a reemployed annuitant with the Federal government and your position is not excluded from
the FEHB (your employing office will know if this is the case) and…
. You have FEHB coverage on your own or through your spouse who is also an active employee
. You have FEHB coverage through your spouse who is an annuitant

5) 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) *

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

7) 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) **

B. When you or a covered family member…

1) Have Medicare solely based on end stage renal disease (ESRD) and…
. It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

. It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and…
. This Plan was the primary payer before eligibility due to ESRD for 30-month coordination period

. Medicare was the primary payer before eligibility due to ESRD
C. When either you or your spouse are eligible for Medicare solely due to disability and you
1) Are an active employee with the Federal government and…
. You have FEHB coverage on your own or through your spouse who is also an active employee
. You have FEHB coverage through your spouse who is an annuitant

2) Are an annuitant and…
. You have FEHB coverage on your own or through your spouse who is also an annuitant

. You have FEHB coverage through your spouse who is an active employee

D. Are covered under the FEHB Spouse Equity provision as a former spouse
* Unless you have