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HealthSpring of Alabama, Inc.

Pages 1--64 from HealthSpring of Alabama, Inc.

Enrollment codes for this Plan:
DF1 Self Only
DF2 Self and Family

RI 73-349

www. healthspringofalabama. com
(formerly The OATH of Alabama.) 1.
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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.
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Notice of the Office of Personnel Management s
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

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

OPM will use and give out your personal medical information:
° To you or someone who has the legal right to act for you ( your personal representative) , ° To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
° To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and ° Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
° To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
° To review, make a decision, or litigate your disputed claim. ° For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
° For Government healthcare oversight activities ( such as fraud and abuse investigations) , ° For research studies that meet all privacy law requirements ( such as for medical research or education) , and
° To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an authorization ) to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back ( revoke ) your written permission at any time, except if OPM has
already acted based on your permission. 3.
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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 healthcare or a disputed claim.
° Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

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

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

Privacy Complaints
United States 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
United States Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice are affected April 14, 2003. 4.
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5.
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2004 HealthSpring of Alabama, Inc. 2 Table of Contents
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Stop Healthcare Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Preventing medical mistakes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 1. Facts about this HMO plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
° Co-payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
° Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
° Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your catastrophic protection out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 5. Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
( a) Medical services and supplies provided by physicians and other healthcare professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
( b) Surgical and anesthesia services provided by physicians and other healthcare professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
( 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 6.
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( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Nutritional Counseling Immunization Awareness
Breast Cancer Awareness Preventative Health Guidelines
Health Journal Magazine Preventative Care Reminder Letters
( 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 claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 8. The disputed 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 plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
TRICARE and CHAMPVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Workers' Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
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 get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Children s Equity Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
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 Ð FSAFEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The Federal Long Term Care Insurance Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 7.
7 Page 8 9
2004 HealthSpring of Alabama, Inc. 4 Table of Contents
Index............................................................................................................................................................................................................... 54
Summary of benefits...................................................................................................................................................................................... 55
Rates................................................................................................................................................................................................ Back cover 8.
8 Page 9 10
2004 HealthSpring of Alabama, Inc. 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of HealthSpring of Alabama, Inc. ( HealthSpring) under our contract ( CS 2156) with the
United States Office of Personnel Management ( OPM) , as authorized by the Federal Employees Health Benefits law. The
address for HealthSpring s administrative offices is:

HealthSpring of Alabama, Inc.
Two Perimeter Park South, Suite 300 West
Birmingham, Alabama 35243

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 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; ;
" we" means HealthSpring .

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 the structure of this brochure, let OPM know. Visit OPM' s " Rate
Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Insurance Services Programs, Program Planning and Evaluation Group, 1900 E Street, NW
Washington, DC 20415-3650 . 9.
9 Page 10 11
2004 HealthSpring of Alabama, Inc. 6 Introduction/ Plain Language/ Advisory
Stop Healthcare Fraud!
Fraud increases the cost of healthcare 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 205-968-1400 or toll free at 1-800-947-5093
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.

CALL --THE HEALTHCARE FRAUD HOTLINE
202-418-3300

OR WRITE TO:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 10.
10 Page 11 12
2004 HealthSpring of Alabama, Inc. 7 Introduction/ Plain Language/ Advisory
° 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. ° 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?
ÿ 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.
ÿ www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and

your family.
ÿ 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.
ÿ www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.

ÿ www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals

working to improve patient safety.
ÿ 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. 11.
11 Page 12 13
2004 HealthSpring of Alabama, Inc. 8 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 healthcare 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 co-payments
or coinsurance described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit
claim forms.

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

How we pay providers
We contract with 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 co-payments or coinsurance.

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

If you want more information about us, call toll free at 1-800-947-5093, or in Birmingham at 205-968-1400, or in Mobile at 251-470-
8503, or write to HealthSpring of Alabama, Inc., Two Perimeter Park South, Suite 300 West, Birmingham, Alabama 35243. You may
also contact us by fax at 205-968-1668, or visit our website at http:// www. healthspringofalabama. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our Providers practice. Our service area is:
The Alabama counties of: Autauga, Baldwin, Bibb, Blount, Bullock, Calhoun, Cherokee, Chilton, Clarke, Coosa, Cullman, Dallas,
Dekalb, Elmore, Etowah, Fayette, Jefferson, Lawrence, Lowndes, Macon, Madison, Marion, Marshall, Mobile, Monroe, Montgomery,
Morgan, Pickens, Russell, Shelby, St. Clair, Talladega, Tuscaloosa, Walker, Washington and Winston.

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. 12.
12 Page 13 14
2004 HealthSpring of Alabama, Inc. 9 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

Program-wide changes
° We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending Account Program -FSAFEDS and the Federal Long Term Care Insurance Program. See page 50.

° We added information regarding Preventing medical mistakes. See page 6. ° 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 increase by 14.3% for Self Only and 13.7% for Self and Family.
° The specialist office visit co-payment will increase from $20 to $25.
° The inpatient hospital co-pay will change from $100 per admission to $100 per day for days 1 through 5 (maximum of $500 per admission).

° The outpatient services co-pay will increase from $50 to $100.
° The emergency room co-pay will increase from $50 to $75.
° The inpatient mental health co-pay will change from $100 per admission to $100 per day, for days 1 through 5 (maximum of $500 per admission.

° The outpatient mental health co-pay will increase from $20 to $25.
° The prescription drug co-payments for preferred brand name drugs will increase from $20 to $25 and for non-preferred brand name drugs from $30 to $50.

° The mail order prescription drug co-payments for preferred brand name drugs will increase from $40 to $50 and non-preferred brand name drugs from $60 to $90. 13.
13 Page 14 15
2004 HealthSpring of Alabama, 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 205-968-1400 or toll free at
1-800-947-5093.

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

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

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

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

It depends on the type of care you need. First, you and each family member must choose
a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care.

Primary care Your primary care physician can be an obstetrician/ gynecologist, family practitioner,
internist or pediatrician. Your primary care physician will provide most of your
healthcare, 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 You are not required to obtain a referral from your primary care physician in order to see
a participating Specialist. You can make an appointment directly with a Plan Specialist.

Here are other things you should know about specialty care:
° 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 have a chronic or disabling condition and lose access to your specialist because we:

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

Ðreduce our service area and you enroll in another FEHB Plan,

What you must do
to get covered care 14.
14 Page 15 16
2004 HealthSpring of Alabama, Inc. 11 Section 3
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 205-968-1400 or toll free at 1-800-947-5093. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

° You are discharged, not merely moved to an alternative care center; or
° The day your benefits from your former plan run out; or
° The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan
terminates participation in the FEHB Program in whole or part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such case,
the hospitalized family member'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.

For certain services, your physician must obtain approval from us. Before giving
approval, we consider if the service is covered, medically necessary, and follows
generally accepted medical practice.

We call this review and approval process pre-certification. Your physician must obtain
our approval for certain services. Some of these services include:
° All admissions (elective, emergency, acute, skilled nursing, extended care, rehabilitation, observation, transfer)

° Ambulance (non-emergent, air or ground) ° All home health care
° All mental health and substance abuse services require pre-certification directly from HealthSpring's mental health vendor.
° Chronic pain management procedures (ESI, facet blocks, neurostimulators, muscle stimulators, pumps, vertebroplasty)
° Non-participating providers Ð all services

Services requiring our
prior approval 15.
15 Page 16 17
2004 HealthSpring of Alabama, Inc. 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A co-payment is a fixed amount of money you pay to the provider, facility, pharmacy,
etc. , when you receive services.

Example: When you see your primary care physician you pay a co-payment of $ 20 per
office visit and when you go in the hospital, you pay $ 100 per day for days 1 through 5
with a maximum of $ 500 co-pay per admission.

Deductible A dollar amount which the member must spend on prescription drugs out of his/ her
pocket, before the Plan will pay anything for prescription drugs. The co-pay balance for
each member is automatically tracked by the database accessed by all pharmacists and
will therefore not need to be tracked by the member.

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

After your co-payments total $ 1000 per person or $ 2000 per family in any calendar year,
you do not have to pay any more for covered services. However, co-payments for the
following services do not count toward your out-of-pocket maximum, and you must
continue to pay co-payments for these services:

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

Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance, and
co-payments 16.
16 Page 17 18
2004 HealthSpring of Alabama, Inc. 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 53 for a benefits summary.)

Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 205-968-1400 or toll free at 1-800-947-5093 or
at our website at www. healthspringofalabama. com.

( a) Medical services and supplies provided by physicians and other healthcare professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
° and treatment services ° X-ray, and other diagnostic tests
° care, adult ° care, children
° care ° planning
° services ° care
° therapies ° and occupational therapies

° therapy ° services ( testing, treatment, and supplies)
° services ( testing, treatment, and supplies) ° care
° and prosthetic devices ° medical equipment ( DME)
° health services °
° treatments ° classes and programs

( b) Surgical and anesthesia services provided by physicians and other healthcare professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
° procedures ° surgery ° and maxillofacial surgery ° tissue transplants
°
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
° hospital ° hospital or ambulatory surgical center ° care benefits/ skilled nursing care facility benefits ° care
°
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
° emergency °

( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Nutritional Counseling Immunization Awareness

Breast Cancer Awareness Preventative Health Guidelines
Health Journal Magazine Preventative Care Reminder Letters
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 17.
17 Page 18 19
2004 HealthSpring of Alabama, Inc. 14
Section 5 (a). Medical services and supplies provided by physicians
and other healthcare 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, except for non-preferred brand name prescriptions.
° Be sure to read Section 4, Your costs for covered services, or valuable information about howcost 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

$20 per office visit for Primary Care Physician
$25 per office visit for Specialist

° In an urgent care center
° During a hospital stay
° In a skilled nursing facility
° Office medical consultations
° Second surgical opinion

Nothing

At home Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
° Blood tests
° Urinalysis
° Non-routine pap tests
° Pathology
° X-rays
° Non-routine Mammograms
° CAT Scans/ MRI
° Ultrasound
° Electrocardiogram and EEG

Nothing if you receive these services during
your office visit; otherwise, $20 per office visit

Section 5( a) 18.
18 Page 19 20
2004 HealthSpring of Alabama, Inc. 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Hearing Screening One annually
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test

$ 20 per office visit

Sigmoidoscopy, screening every five years starting at age 50 Nothing
Routine Prostate Specific Antigen ( PSA) test one annually for men age 40
and older
Nothing

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

Nothing

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

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

Nothing

Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, 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 vaccine annually
Pneumococcal vaccine, age 65 and over

Nothing 19.
19 Page 20 21
2004 HealthSpring of Alabama, Inc. 16 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care charges for routine examinations, immunizations and care (through age 22)
Examinations, such as: Eye exams through age 17 to determine the need for vision
correction.
Ear exams through age 17 to determine the need for hearing
correction

Examinations done on the day of immunizations (through age 22)

$20 per office visit

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

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

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

Surgery benefits (Section 5b).

$20 co-payment for initial office visit only

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization [See Surgical procedures Section 5 (b)]
Tubal ligations $250 co-pay

Vasectomy $100 co-pay 20.
20 Page 21 22
2004 HealthSpring of Alabama, Inc. 17 Section 5( a)
Family planning ( Continued) You pay
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

Nothing

Not covered: reversal of voluntary surgical sterilization and genetic
counseling,
All charges.

Infertility services
Diagnosis and treatment of infertility 20% of charges

Artificial insemination: intravaginal insemination (IVI)

intra-cervical insemination (ICI)
intrauterine insemination (IUI)

50% of charges

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
Fertility drugs

Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment $25 per office visit

Allergy injection Nothing
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 21.
21 Page 22 23
2004 HealthSpring of Alabama, Inc. 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 24.

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

Growth hormone therapy ( GHT)
Note: We will only cover GHT when we preauthorize the treatment.
Call 205-968-1400 or 1-800-947-5093 for preauthorization. We will
ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment; otherwise, we will only cover GHT services from the date
you submit the information. If you do not ask or if we determine
GHT is not medically necessary, we will not cover the GHT or
related services and supplies. See Services requiring our prior
approval in Section 3.

GHT is covered under the plan s medical benefit .

Nothing

Physical and occupational therapies
Two consecutive months per condition for the services of each of the following:

qualified physical therapists; and
occupational therapists.

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 36

visits or 6 months sessions.

Nothing

Not covered:
long-term rehabilitative therapy
exercise programs

All charges. 22.
22 Page 23 24
2004 HealthSpring of Alabama, Inc. 19 Section 5( a)
Speech therapy You pay
Two months per condition Nothing
Hearing services (testing, treatment, and supplies)
° Routine hearing screening annually $ 25 per office visit

Not covered:
° hearing aids ° implanted cochlear hearing devices All charges.

Vision services (testing, treatment, and supplies)
° Routine annual eye exam for diabetics
° Eye refraction once every 24 months
° Diagnosis and treatment of diseases of the eye

$ 25 per office visit

Not covered:
° Eyeglasses or contact lenses
° Eye exercises and orthoptics
° Radial keratotomy and other refractive surgery

All charges.

Foot care
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.
$ 25 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
° Artificial limbs and eyes; stump hose
° Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

20% of the charges up to a plan maximum
payment of $ 5000 per member per year.
Any combination of orthopedic and
prosthetic devices or DME can apply to the
$ 5000 maximum. 23.
23 Page 24 25
2004 HealthSpring of Alabama, Inc. 20 Section 5( a)
Orthopedic and prosthetic devices ( continued) You pay
Not covered:
° orthopedic and corrective shoes
° arch supports
° foot orthotics
° heel pads and heel cups
° lumbosacral supports
° corsets, trusses, elastic stockings, support! hose, and other supportive devices

All charges.

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

° hospital beds;
° wheelchairs;
° crutches;
° walkers;
° insulin pumps.

Note: Call us at 205-968-1400 or toll free at 1-800-947-5093 as soon
as your Plan physician prescribes this equipment. We will arrange
with a health care provider to rent or sell you durable medical
equipment at discounted rates and will tell you more about this
service when you call.

20% of the charges up to a plan maximum
payment of $ 5000 per member per year.
Any combination of orthopedic and
prosthetic devices or DME can apply to the
$ 5000 maximum.

Not covered:
° motorized wheel chairs

° maintenance and repairs of durable medical equipment specialty beds

All charges.

Home health services
° Home healthcare ordered by a Plan physician and provided by a registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.
° Services include oxygen therapy, intravenous therapy and medications .

Nothing

Not covered:
° nursing care requested by, or for the convenience of, the patient or the patient s family;

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

All charges. 24.
24 Page 25 26
2004 HealthSpring of Alabama, Inc. 21 Section 5( a)
Chiropractic You pay
° Manipulation of the spine and extremities
° Coverage limited to twelve (12) visits per calendar year

$25 per office visit

Not covered: All charges.
Alternative treatments
No benefit All charges

Not covered:
° naturopathic services ° hypnotherapy

° biofeedback ° acupuncture

All charges.

Educational classes and programs
No benefit All charges 25.
25 Page 26 27
2004 HealthSpring of Alabama, Inc. 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians
and other healthcare professionals

I
M
P
O
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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 onlywhenwedetermine they are medically necessary.

° Plan physicians must provide or arrange your care.
° 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.

° Theamounts listed below are for the charges billed by a physician or other healthcare 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 PRE-CERTIFICATION FOR SOME SURGICAL
PROCEDURES.

I
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T
A
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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) Ð Orthopedic and prosthetic devices for device coverage information.

Nothing

Surgical procedures continued on next page. 26.
26 Page 27 28
2004 HealthSpring of Alabama, Inc. 23 Section 5( b)
Surgical procedures (Continued) You pay
° Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
° Tubal ligation $250 copay
° Vasectomy $100 copay
° Treatment of burns

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

Nothing

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

Reconstructive surgery
° Surgery to correct a functional defect
° Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the member's

appearance and
the condition can reasonably be expected to be corrected by
such surgery
° Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

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

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

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

Nothing

Not covered:
° Cosmetic surgery Ð 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. 27.
27 Page 28 29
2004 HealthSpring of Alabama, Inc. 24 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
° Reduction of fractures of the jaws or facial bones; ° Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
° Removal of stones from salivary ducts; ° Excision of leukoplakia or malignancies;

° Excision of cysts and incision of abscesses when done as independent procedures; and
° Other surgical procedures that do not involve the teeth or their supporting structures.
° Temporamandibular joint disorder (TMJ)Ð Note: Limited to non-surgical and surgical management for TMJ disorders, including office visits, x-rays,
orthopedic/ orthodontic appliances, pharmacological therapy, joint
splints, physical therapy and all hospital related services.

Nothing.

Not covered:
° Oral implants and transplants ° Procedures that involve the teeth or their supporting structures (such as

the periodontal membrane, gingiva, and alveolar bone)

All charges.

Organ/ tissue transplants
Limited to:
° Heart/ lung
° Kidney/ Pancreas
° Lung: Single ÐDouble
° Pancreas
° Cornea
° Heart
° Kidney
° Liver
° Allogeneic (donor) bone marrow transplants ° Autologous bone marrow transplants (autologous stem cell and

peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
° Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

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

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

Nothing 28.
28 Page 29 30
2004 HealthSpring of Alabama, Inc. 25 Section 5( b)
Organ/ tissue transplants (continued) You pay
Not covered:
° Donor screening tests and donor search expenses, except those performed for the actual donor

° Implants of artificial organs
° Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in Ð
° Hospital (inpatient)
Nothing

° Hospital outpatient department ° Skilled nursing facility
° Ambulatory surgical center ° Office
Nothing 29.
29 Page 30 31
2004 HealthSpring of Alabama, Inc. 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

I
M
P
O
R
T
A
N
T

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

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

with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge

(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I
M
P
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A
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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 co-pay per day for days 1 through 5
(maximum of $500 per admission)

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
Custodial care Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges. 30.
30 Page 31 32
2004 HealthSpring of Alabama, 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.

$ 100 copay for outpatient procedures

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit:
° 90 days per calendar year
° bed
° board
° general nursing care
° meals
° drugs
° biologicals
° supplies

$ 100 per day for days 1 through 5
( maximum of $ 500 per admission)

Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for a terminally ill member in a home or
hospice facility. Services include inpatient and outpatient care and
family counseling when plan doctor certifies that the patient is in the
terminal stages of illness, with a life expectancy of six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Emergency ambulance transport! ( air or ground) to a hospital when
medically appropriate.
Nothing 31.
31 Page 32 33
2004 HealthSpring of Alabama, Inc. 28 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

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

What to do in case of emergency:
Emergencies within our service area. If you are in an emergency situation, please call your primary care doctor. In extreme
emergencies, if you are unable to contact your doctor, contact the local emergency system ( e. g. , the 911 telephone system) or
go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they
can notify the Plan. You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do
so. It is your responsibility to ensure that the Plan has been timely notified.

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

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 was 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. 32.
32 Page 33 34
2004 HealthSpring of Alabama, Inc. 29 Section 5( d)
Benefit Description You pay
Emergency within our service area
° Emergency care at a doctor' s office

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

$ 20 co-pay per visit -Primary Care
Physician

$ 25 co-pay per visit -Specialist
$ 75 co-pay per visit
$ 75 co-pay per visit
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

$ 20 co-pay per visit -Primary Care
Physician

$ 25 co-pay per visit -Specialist
$ 75 co-pay per visit
$ 75 co-pay per visit
Not covered:
° Elective care or non-emergency care
° Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges.

Ambulance
Professional ambulance service ( air or ground) when medically
appropriate.

See 5( c) for non-emergency service.

Nothing 33.
33 Page 34 35
2004 HealthSpring of Alabama, Inc. 30 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.

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

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.

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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

$ 25 co-pay per visit

Mental health and substance abuse benefits -continued on next page 34.
34 Page 35 36
2004 HealthSpring of Alabama, Inc. 31 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing if you receive these services
during your office visit; otherwise, $25
per office visit

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

$100 co-pay per day for days 1 through 5
(maximum of $500 per admission)

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all
of the following authorization processes: Contact MHNET at 1-800-272-2030 for
referral and provider information. A referral authorization will be made for you to see
an appropriate participating provider of your choice for mental health and substance
abuse treatment.

Limitation We may limit your benefits if you do not obtain a treatment plan. 35.
35 Page 36 37
2004 HealthSpring of Alabama, 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.

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

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There are important features you should be aware of. These include:
Who can write your prescription. A plan or referral physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication. Maintenance medications (only) are available through mail order.

We use a formulary. HealthSpring offers a "three tier" pharmacy co-payment benefit that provides quality pharmaceutical care for the lowest out-of-pocket costs. The co-payment amount is determined by the
medication prescribed.
Preferred brand name medications are selected by the HealthSpring Pharmacy and Therapeutics Committee and
are considered the most appropriate for use based upon safety standards, effectiveness and cost.

Non-preferred medications will have a higher co-pay than preferred brand name medications. New
medications will be considered non-preferred until evaluated by the Pharmacy and Therapeutics Committee.

These are the dispensing limitations. Prescription drugs prescribed by a plan referral physician and obtained at a plan pharmacy will be dispensed for up to a 31-day supply or (100 unit) supply, whichever is less; 240

milliliters of liquid (8 oz.); 60 grams of ointment, creams or topical preparation; or one commercially prepared
unit (i. e. one inhaler, one vial of ophthalmic medication or insulin). The mail order program is limited to
certain maintenance medications. The plan follows standard FDA dispensing guidelines. If you are called to
Active Duty, please call 1-800-947-5093 for further information.

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

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name drugs; therefore, you

may reduce your out-of-pocket costs by choosing to use a generic drug.

When you have to file a claim. If you file a claim, please send all documents and/ or receipts for your claim as soon as possible. 36.
36 Page 37 38
2004 HealthSpring of Alabama, Inc. 33 Section 5( f)
You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:
Drugs for which a prescription is required by Federal law Oral contraceptive drugs and diaphragms

Insulin Diabetic supplies limited to insulin syringes, needles and blood glucose
strips
Disposable needles and syringes needed to inject covered prescribed medication

Intravenous fluids and medications for home use are provided under home health services at no cost
Prenatal vitamins and oral infant vitamin drops by prescription only Drugs for sexual dysfunction (Viagra is limited to 6 pills per 31
days)

Limited Benefits:
Smoking cessation drugs and medication. Nicotrol is limited to six (6) weeks and a $15 co-pay per seven (7) day supply. Zyban is limited to

twelve (12) weeks. Pre-authorization is required
Toradol therapy limited to 28 tablets per month Diflucan 150mg limited to 1 tablet per co-pay

Sedative hypnotics limited to 15 tablets or capsules per co-pay Zoloft limited to 100mg strength scored tablet
Migraine therapy is limited to a quantity of dosage units as indicated per product package labeling for treatment of one
episode of care per co-pay
A generic equivalent will be dispensed if it is available. If you receive a
name brand drug when a Federally approved generic drug is available, you
have to pay the difference in cost between the name brand drug and the
generic

31-day supply:
$10 generic co-pay

$25 preferred brand name co-pay
$50 non-preferred brand name co-pay

90-day supply (mail order):
$25 generic co-pay

$50 preferred brand name co-pay
$90 non-preferred brand name

The prescription drug deductible of $50
(fifty dollars) per member per calendar year
must be satisfied before the plan will pay
anything on generic, brand name preferred
or brand name non-preferred prescriptions

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

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

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes
Drugs to enhance athletic performance Fertility drugs
Nicorette Implanted time-release medications, except Norplant
Contraceptive jellies, ointments or foams Injectable drugs, excluding insulin and Imitrex
Anorexiants and other drugs FDA approved or utilized for weight loss

All charges. 37.
37 Page 38 39
2004 HealthSpring of Alabama, Inc. 34 Section 5( g)
Section 5 (g). Special features
Feature Description

Nutritional Counseling Coverage provided by a certified diabetes educator associated with a plan provider, to assist in controlling diabetes, high blood pressure and high cholesterol.

Immunization Awareness A reminder letter is sent to members with children under the age of two regarding the importance of childhood immunizations.
Preventive Care Reminder
Letters

Happy Birthday mailed each month to women age 20 and above regarding the
importance of check-ups and scheduled mammograms.

Diabetic Eye Exam mailed annually to all diabetics regarding the importance of
an annual eye exam.

Flu Shot mailed annually to members over the age of 65 regarding the
importance of an annual flu shot. 38.
38 Page 39 40
2004 HealthSpring of Alabama, Inc. 35 Section 5 (h)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. (See Page 17.)

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

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

$100 copay for outpatient surgery, or $25
copay for an office visit.

Dental benefits
We have no other dental benefits. 39.
39 Page 40 41
2004 HealthSpring of Alabama, 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 out-of-pocket maximums.

Eyewear: 25% discount at Participating Providers
Medicare prepaid plan enrollment Ð This Plan offers Medicare recipients the opportunity to enroll in a Medicare plan, Seniors
First. Annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and
enroll in a Medicare prepaid plan when one is available in their area. They may then later reenroll in the FEHB Program.
Most Federal annuitants have Medicare Part A. Those without Medicare Part A may join this Medicare prepaid plan, but will
probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether the plan
covers hospital benefits and, if so, what you will have to pay. Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan. Contact Seniors First at 1-800-888-7647 for information on
Seniors First.

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your
enrollment in this Plan's FEHB Plan, please call 1-800-888-7647 for information on the benefits available under the Medicare
HMO. 40.
40 Page 41 42
2004 HealthSpring of Alabama, 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.

° 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. 41.
41 Page 42 43
2004 HealthSpring of Alabama, 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 co-payment or coinsurance.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the
form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 205-968-1400 or toll free at
1-800-947-5093.

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

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

° Receipts, if you paid for your services.
Submit your claims to: HealthSpring of Alabama, Inc.
Two Perimeter Park South, Suite 300 West
Birmingham, Alabama 35243

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. 42.
42 Page 43 44
2004 HealthSpring of Alabama, 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 Ð including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: HealthSpring of Alabama, Inc., Two Perimeter Park South, Suite 300 West, Birmingham,
Alabama 35243; 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 healthcare 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 requestÑ 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 Programs, Health Insurance Group 3,
1900 E Street, NW, Washington, DC 20415-3630. 43.
43 Page 44 45
2004 HealthSpring of Alabama, Inc. 40 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
° A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
° Copies of documents that support! your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits ( EOB) forms;

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must include a copy of your specific written consent with the review request.

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

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

If you do not agree with OPM s decision, your only recourse is to sue. If you decide to sue, you must file the suit against
OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or from the year in which 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 205-968-1400 or
toll free at 1-800-947-5093 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. 44.
44 Page 45 46
2004 HealthSpring of Alabama, 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 coverageunder another group
health plan or have automobile insurance that pays healthcare 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.

Should I enroll in Medicare? 45.
45 Page 46 47
2004 HealthSpring of Alabama, Inc. 42 Section 9
If you are eligible for Medicare, you may have choices in how you get your healthcare.
Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or pre-certified as required.

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

° When we are the primary payer, we process the claim first.
° When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your claim will be coordinated automatically and we will
then provide secondary benefits for covered charges. You will not need to do
anything. To find out if you need to do something to file your claim, call us at
1-800-947-5093 or visit our website at http: / / www. theoathofalabama. com.

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

( Primary payer chart begins on next page. )

The Original Medicare Plan
(Part A or Part B) 46.
46 Page 47 48
2004 HealthSpring of Alabama, 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.

PrimaryPayerChart
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 M