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Preferred Care

Federal Employees Health Benefits Program
2004 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Preventing Medical Mistakes
Section 1. Facts about this HMO plan
- How we pay providers
- Your Rights
- Service Area
Section 2. How we change for 2004
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
- Identification cards
- Where you get covered care
  - � Plan providers
  - � Plan facilities
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- � Copayments
- � Deductible
- � Coinsurance
- Your catastrophic protection out-of-pocket maximum
Section 5. Benefits
- Overview
- (a) Medical services and supplies provided by physicians and other health care professionals
- (b) Surgical and anesthesia services provided by physicians and other health care professionals
- (c) Services provided by a hospital or other facility, and ambulance services
- (d) Emergency services/accidents
- (e) Mental health and substance abuse benefits
- (f) Prescription drug benefits
- (g) Special features
- (h) Dental benefits
- (i) Non-FEHB benefits available to Plan members
Section 6. General exclusions � things we don�t cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- Coverage information
- When you lose benefits
Two new Federal Programs complement FEHB benefits
- The Federal Flexible Spending Account Program � FSAFEDS
- The Federal Long Term Care Insurance Program
Index
Summary of benefits
Rates

Pages 1--58 from Preferred Care

Page 1 2

2004 Preferred Care 36 Section
Preferred Care 2004
Serving: Greater Rochester and Surrounding Counties
Enrollment in this Plan is limited. You must live or work
in our Geographic service area to enroll.
See page 7 for requirements.

Enrollment codes for this Plan: GV1 Self Only
GV2 Self and Family

A Health Maintenance Organization
This Plan has excellent accreditation
from the NCQA. See the 2004 Guide
for more information on accreditation.

http:// www. preferredcare. org

RI 73-467
For changes
in benef
its

see page
8. 1.
1 Page 2 3

2004 Preferred Care 36 Section
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
WASHINGTON, DC 20415-0001

CON 131-64-4
September 1993

OFFICE OF THE DIRECTOR
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 additionl 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 Healthier Feds campaign is another way the carriers are working
with us to ensure Federal employees and retirees are informed on healthy living and best-treatment
strategies. You can help to contain healthcare costs and keep premiums down by living a healthy
life style.

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

Sincerely,

Kay Coles James
Director 2.
2 Page 3 4
2004 Preferred Care 36 Section
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.

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. 3.
3 Page 4 5

Section 36 2004 Preferred Care
By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information
is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your
personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not
cover your personal medical information that was given to you or your personal representative, any information that
you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or
a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place ( for example, by sending materials
to a P. O. Box instead of your home address) .
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to
agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

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

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60
days of the change. The privacy practices listed in this notice are effective April 14, 2003. 4.
4 Page 5 6

Table of Contents 2 5.
5 Page 6 7

Table of Contents 3 6.
6 Page 7 8

2004 Preferred Care 36 Section
Introduction
Preferred Care
259 Monroe Avenue
Rochester, New York 14607

This brochure describes the benefits of Preferred Care under our contract ( CS 2371) with the United States Office
of Personnel Management ( OPM) , as authorized by the Federal Employees Health Benefits law. The address for
Preferred Care administrative offices is:

Preferred Care
259 Monroe Avenue
Rochester, New York 14607

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 for 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 54. 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 Preferred Care. .

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans brochure 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 Program, Program Planning and Evaluation

Group, 1900 E Street, NW Washington, D. C. 20415-3650.

Section 1 Introduction/ Plain Language 4 7.
7 Page 8 9
Section 36 2004 Preferred Care
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits ( FEHB)
Program premium. OPM s Office of the Inspector General investigates all allegations of fraud, waste and abuse in the
FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud: :
Be wary of giving your plan identification ( ID) number over the telephone or to people you do not know, except to
your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professional 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 ( 585) 325-3113 and explain the situation.
If we do not resolve the issue:

CALL � THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Do not maintain as a dependent 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 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.

Stop Health Care Fraud! 5 8.
8 Page 9 10

2004 Preferred Care 36 Section
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,
long recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you
can improve the safety of your own health care, and that of your family members. Take these simple steps:

1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers.
Choose a doctor with whom you feel comfortable talking.
Take a relative or friend with you to help you ask questions and understand answers.
2. Keep and bring a list of all the medicines you take.
Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription
medications.
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 tests 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 doctor has the best care and results for your condition if you have more than one
hospital to choose from to get the health care you need.
Be sure you understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
Ask your doctor, Who will manage my care when I am in the hospital?
Ask your surgeon:
Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any
medications you are taking.

Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide

ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare
providers and improve the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you

and your family.
www. talk aboutrx. org/ consumer. htm1. The National Council on Patient Information and Education is dedicated to

improving communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals
working to improve patient safety.
www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent

mistakes in the nation s healthcare delivery system.

Preventing Medical Mistakes 6 9.
9 Page 10 11

Section 36 2004 Preferred Care
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible
for the selection of these providers in your area. Contact the Plan for a copy of the most recent provider directory.

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

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the
copayments 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 copayments 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.

More than 3,500 doctors and area health professionals participate with Preferred Care to provide primary care as well
as specialty services to the membership. In addition to doctors, the Plan has arranged for hospital, skilled nursing
facility, home health, and other covered health services.

All members must choose a primary care doctor who will provide, arrange, and coordinate all medically necessary
services. All female members are strongly encouraged to select an obstetrician/ gynecologist in addition to a primary
care doctor. The obstetrician/ gynecologist will treat you for any gynecological or obstetrical condition. Members do
not need a referral from their primary care doctor to see their obstetrician/ gynecologist. A women s obstetrician/
gynecologist is considered an additional primary care doctor. New York State law does provide coverage with Nurse
Midwives and the Plan maintains Nurse Midwives on the provider panel. Plan members may elect a Nurse Midwife
instead of an obstetrician/ gynecologist.

If you want more information about us, call us at ( 585) 325-3113, toll free at ( 800) 950-3224 or write to 259 Monroe
Avenue, Rochester, New York, 14607. You may also contact us by fax at ( 585) 327-2298, or our e-mail address at
memberservices@ preferredcare. org, or visit our website at www. preferredcare. org.

Service Area
To enroll in this plan, you must live or work in our Service Area. This is where our providers practice. Our service area
is: Monroe, Genesee, Livingston, Ontario, Orleans, Seneca, Wayne, Wyoming, and Yates Counties in New York State.

Ordinarily, you must get care from providers who contract with us. If you receive care outside our service area, we
will pay only for urgent or emergency care benefits. Students attending school or college outside of the service area
are covered for follow up care if required after emergency or urgent care treatment. With prior authorization from the
student s primary care physician and Plan, follow up care for students is covered.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your depen-
dents 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.

Section 1 7 10.
10 Page 11 12
2004 Preferred Care 36 Section
Section 2. How we change for 2004
Do not rely on these change descriptions; this 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 49.

We added information regarding Preventing medical mistakes. See page 6.
We added information regarding enrolling in Medicare. See page 39.
We revised the Medicare Primary Payer Chart. See page 41.

Changes to this Plan
Your share of the non-Postal premium will increase by 9.8% for Self Only or 9.8% for Self and Family.
Your copayment for adult influenza shots has been reduced from $ 15 to $ 0.
Your Primary Care Physician ( PCP) copayment for sick child visits for children ages 5 through 18 has been
reduced from $ 15 to $ 10.

You will be required to pay a $ 15 copayment for provider administered prescription medications if a separate
charge is made by the provider for that medication. This copayment will be in addition to any copayment applied
for that day.

For approved medications purchased through the mail order program, you will be responsible for a $ 25 tier 1
generic prescription or refill, or a $ 50 tier 2 brand name prescription or refill, or a $ 87.50 tier 3 brand name
prescription or refill, for each 90 day supply that you purchase.

Your benefit for durable medical equipment will be subject to a $ 15,000 annual maximum.

You are not covered for smoking cessation deterrents such as Zyban, Nicotrol, and Habitrol, which may be purchased over the counter without a prescription from your doctor.

Section 2 8 11.
11 Page 12 13

Section 36 2004 Preferred Care
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 obtain 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 confirma-
tion ( 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 ( 585) 325-3113
or ( 800) 950-3224, or if you have access to TTY equipment ( 585) 325-2629,
or write to us at 259 Monroe Avenue, Rochester, NY 14607.

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

Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our members.
We credential Plan providers to ensure that they meet strict standards of
quality.

We list Plan providers in the provider directory, which we update periodically.
This list is also on our website at www. preferredcare. org.

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.

To select a primary care physician, either choose one from our provider
directory or contact a Preferred Care Member Services representative
who will assist you.

Primary care Your primary care physician can be a family or general practitioner, an
internist or a pediatrician. Your primary care physician will provide most of
your health care, or give you a referral to see a specialist when a referral is
required. Women may choose an obstetrician/ gynecologist in addition to their
primary care physician.

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

Specialty care Your primary care physician will refer you to a specialist for needed care ( you
may see an obstetrician/ gynecologist without a referral) . When you receive a
referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized
a certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives you a
referral. However, you may see an optometrist or opthamologist for routine
eye exams without referral.

What you
What you must do to get covered care

Section 3 9 12.
12 Page 13 14
2004 Preferred Care 36 Section
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex,
or serious medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number
of visits or a certain period of time without additional referrals. Your
primary care physician will use our criteria when creating your treatment
plan ( the physician may have to get an authorization or approval before-
hand) .

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

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

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

-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits ( FEHB) Program
-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us, or if we drop out of the
Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to
your primary care physician or obstetrician/ gynecologist based on the above,
you can continue to see your primary care physician or obstetrician/ gynecolo-
gist 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
Preferred Care s Member Services Department immediately at ( 585) 325-3113.
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 92nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the hospital benefit of the hospitalized person.
If your plan terminates participation in the FEHB Program in whole or in
part or if OPM orders an enrollment change, this continuation of coverage
provision does not apply. In such a case, the hospitalized family member s
benefits under the new plan begin on the effective date of enrollment.

Section 3 10 13.
13 Page 14 15
Section 36 2004 Preferred Care
Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may our control have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from us.

Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.

We call this review and approval process precertification . Your primary care
physician is familiar with the procedures that require a prior approval and will

make all necessary arrangements on your behalf.

We call this review and approval process precertification . Your primary care
physician is familiar with the procedures that require a prior approval and will
make all necessary arrangements on your behalf.

Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc.

Example: When you see your primary care physician, you pay a copayment of
$ 15 per office visit.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your
care.

Example: In our Plan, you pay 20% of our allowance for durable medical
equipment.

Your catastrophic protection After your copayments and coinsurance total $ 3,300 per person or $ 8,400 out-of-pocket maximum per family enrollment in any calendar year, you do not have to pay any more
for coinsurance and for covered services. However, copayments for the following services do not copayments count toward your out-of-pocket maximum, and you must continue to pay
copayments for this service:
Prescription Drugs .
Be sure to keep accurate records of your copayments since you are responsible
for informing us when you reach these maximums.

11 Section 4 14.
14 Page 15 16

2004 Preferred Care 36 Section
Section 5. Benefits � OVERVIEW
(See page 8 for how our benefits changed this year and page 54 for a benefits summary.)

NOTE This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact
us at ( 585) 325-3113 or ( 800) 950-3224 or if you have access to TTY equipment ( 585) 325-2629 or visit our website at
www. preferredcare. org.

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-20
Diagnostic and treatment services
Lab, , X-ray, and other diagnostic tests
Preventive care, , adult
Preventive care, , children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-23
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-25
Inpatient hospital
Outpatient hospital or ambulatory
surgical center

( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27
Medical emergency

( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-32
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Flexible Benefits Option
Services for Deaf and Hearing Impaired
Travel Benefits/ / Services Overseas

( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

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

Organ/ / tissue transplants
Anesthesia

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

Ambulance

Section 5 12 15.
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Section 36 2004 Preferred Care
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$ 15 per visit ( no primary care
physician copay for sick child
visits under the age of 5; $ 10
primary care physician copay
for sick child visits ages 5
through 18)

Section 5( a)

Section 5( a). Medical services and supplies provided by physicians and
other health care professionals

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

Diagnostic and treatment services
Professional services of physicians
In physician s office

In an urgent care center Nothing
During a hospital stay

In a skilled nursing facility

Office medical consultations $ $ 15 per visit
Second surgical opinions
At home $ $ 15 per visit

Lab, X-ray and other diagnostic tests
X--rays $ 15 per visit
CAT Scans/ / MRI
Ultrasound

13 16.
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2004 Preferred Care 36 Section
Lab, X-ray and other diagnostic tests (Continued) You Pay
Tests, such as: Nothing
Blood tests
Urinalysis
Non--routine pap tests
Pathology
Non--routine Mammograms

Preventive care, adult
Periodic Adult Physicals $ 10 per visit
Routine screenings, such as: Nothing
Complete Blood Count
Total Blood Cholesterol
Colorectal Cancer Screening, , including
-Fecal occult blood test
-Sigmoidoscopy Screenings every five years starting at age 50 $ $ 15 per visit
-Colonoscopy Screenings every ten years $ 15 per visit
Prostate Specific Antigen ( ( PSA test) Nothing
Two gynecological visits per year $ $ 10 per visit
Routine pap test ( ( annually) Nothing
Routine mammograms covered for women age 35 and older, , as follows: Nothing
From age 35 through 39, , one during this five year period
At age 40 and older, , one every year

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

Routine Immunizations, limited to: $ 15 per visit
Tetanus--diphtheria ( Td) booster once every 10 years, , ages 19 and
over ( except as provided for under childhood immunizations)

Pneumococcal vaccines, , annually, age 65 and over
Influenza vaccines, , annually No copay

Section 5( a) 14 17.
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Section 36 2004 Preferred Care Section 5( a)
Preventive care, children You Pay
Childhood immunizations recommended by the American Academy Nothing
of Pediatrics

Well-child care charges for routine examinations, immunizations and Nothing
care ( through age 18)

Examinations, such as:
Eye exams to determine the need for vision correction. . $ 15 per visit
Ear exams as part of a well-child care visit through age 18 to Nothing
determine the need for hearing correction.

Examinations done on the day of immunizations ( ( through age 18) Nothing

Maternity care
Complete maternity ( obstetrical) care, such as: $ 50 per pregnancy
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) .

Not covered: Routine sonograms to determine fetal age, size or sex All charges

Family planning
A broad range of voluntary planning services, limited to: $ 15 per visit
Voluntary sterilization ( See Surgical Procedures Section 5( b) )
Surgically implanted contraceptives ( such as Norplant)
Injectable contraceptive drugs ( such as Depo Provera)
Intrauterine devices ( IUDs)
Diaphragms

Note: You must be between the ages of 21 and 44 to be covered for
Note: infertility benefits.
Note: We cover oral contraceptives under the prescription drug benefit.

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges
15 18.
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2004 Preferred Care 36 Section
$ 15 per visit
Section 5( a)

Infertility services You Pay
Diagnosis and treatment of infertility, such as:
Artificial insemination: :
intravaginal insemination ( IVI)
intracervical insemination ( ICI)
intrauterine insemination ( IUI)

Fertility drugs
Note: Self-administered and oral fertility drugs are covered under the
prescription drug benefit. Drugs for infertility treatment after a medical
condition has been corrected. Pergonal/ Metrodin and other FDA
approved drugs, only after unsuccessful treatment with Clomiphene and
only when very specific clinical indications are met.

Not covered: All charges
� Assisted reproductive technology (ART) procedures, such as:
� in vitro fertilization
� embryo transfer, gamete GIFT and zygote ZIFT
� zygote transfer
� Services and supplies related to excluded ART procedures
� Cost of donor sperm
� Cost of donor egg

Allergy care
Testing and treatment $ 15 per visit
Allergy injection

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

16 19.
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Section 36 2004 Preferred Care
$ 15 per office or outpatient
visit

Nothing during covered
inpatient admission

Section 5( a)

Treatment therapies You Pay
Chemotherapy and radiation therapy. . $ 15 per visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/ Tissue Transplants on page 23.

Respiratory and inhalation therapy
Dialysis--Hemodialysis and peritoneal dialysis
Growth hormone therapy ( ( GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when your physician pre-approves the
treatment. Your physician will submit information that establishes that
the GHT is medically necessary. Your physician must authorize GHT
before you begin treatment. If your physician does not pre-approve or if
we determine GHT is not medically necessary, we will not cover the GHT
or related services and supplies.

Intravenous ( ( IV) / Infusion Therapy Home IV and antibiotic therapy Nothing

Physical and occupational therapies
60 visits per therapy per calendar year for the services of each of the
following:

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

Cardiac rehabilitation following a heart transplant, bypass surgery or $ 15 per visit
a myocardial infarction, is provided for up to 36 visits.

Not covered: All charges
� Long-term rehabilitative therapy
� Exercise programs

Speech therapy
60 visits per therapy per calendar year for medically necessary speech
therapy to restore or acquire functional speech
$ 15 per office visit

Nothing for outpatient visit
Nothing per visit during
covered inpatient admission

17 20.
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2004 Preferred Care 36 Section
Hearing services (testing, treatment, and supplies) You Pay
Hearing aids for children through age 18, up to $ 600 once every Nothing
three years

Hearing screenings as part of a well-child care visit through age 18. Nothing
Not covered: All charges
� all other hearing testing
� hearing aids for adults over age 18.

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct impairment directly 20% of plan allowance
caused by accidental ocular injury or intraocular surgery ( such as for
cataracts) .

One pair of prescription eyeglasses ( frames and lenses) or prescription
daily-wear contact lenses, per member once every year at Plan
providers. Children under age 12 may obtain eyewear as required by
prescription change of at least . 5 diopter.

Annual eye refraction, including lens prescriptions. $ 15 per visit

Not covered: All charges
� Radial keratotomy and other refractive surgery.
� Eye exercises and orthoptics.

Foot care
Routine foot care when you are under active treatment for a metabolic $ 15 per visit
or peripheral vascular disease, such as diabetes.

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

Not covered: All charges
� 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)

Section 5( a)

The remaining cost after a
discount of 20% and a credit
of $ 60

18 21.
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Section 36 2004 Preferred Care
Orthopedic and prosthetic devices You Pay
Custom made shoe inserts up to $ 250 ( One pair every three years) Nothing
Internal prosthetic devices, such as artificial joints, pacemakers, Nothing
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See 5( b) for coverage of the surgery to insert
the device

Orthotic devices 20% of plan allowance
Artificial limbs and eyes; stump hose
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint ( TMJ) pain dysfunction syndrome.

Orthopedic devices, such as braces.
Note: External prosthetic and orthopedic devices are covered up to a
maximum per person payment of $ 15,000 per calendar year.

Externally worn breast prostheses and surgical bras, including 20% of plan allowance
replacements following a mastectomy with no maximums

Not covered: All charges
� arch supports
� heel pads and heel cups
� lumbosacral supports
� corsets, trusses, elastic stockings, support hose, and other supportive
devices

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of 20% of plan allowance up to a
durable medical equipment prescribed by your Plan physician, such as $ 15,000 annual maximum
oxygen and dialysis equipment. Under this benefit, we also cover:

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

Not covered: All charges
� Motorized wheel chairs, unless medically necessary
� Air conditioners, dehumidifiers, humidifiers
� Breast pumps
� Electric hospital bed (unless medically necessary)
� Hypo-allergenic bedding
� Visual aids (e. g., CCTV, magnifying glasses)
� Environmental control units, such as control units to turn on a
television or air conditioner, etc.

Section 5( a) 19 22.
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2004 Preferred Care 36 Section Section 5( a)
Home health services You Pay
Home health care ordered by a Plan physician and provided by a $ $ 15 per day
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.

Not covered: All charges
� 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.

Chiropractic
The detection and correction by manual or mechanical means of $ 15 per visit
structural imbalance, distortion or subluxation in the human body for the
purposes of removing nerve interference, and the effects thereof, where
such interference is the result of or related to distortion, misalignment
or subluxation or in the vertebral column.

Not covered: All charges
� Maintenance treatment for conditions that does not result in significant
clinical improvement or lead toward resolution of the condition.

Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for: : anesthesia, pain 50% of plan allowance
relief up to 10 visits per calendar year

Not covered: All charges
� naturopathic services
� hypnosis

Educational classes and programs
Smoking Cessation
Professional services for outpatient nicotine dependency, including $ 15 per visit
diagnostic evaluations to determine the nature and extent of illness,
counseling and therapy.

Diabetes self management $ 15 per visit

20 23.
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Section 36 2004 Preferred Care Section 5( b)
You Pay Benefit Description
Section 5( b). Surgical and anesthesia services provided by physicians
and other health care professionals

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

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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 amblyopic and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( ( see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight
according to current underwriting standards; eligible members must
be age 18 or over.

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

Voluntary sterilization
Treatment of burns

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

$ 15 per office visit; nothing
for inpatient or outpatient
hospital procedures

$ 15 per office visit; nothing
for inpatient or outpatient
hospital procedure

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2004 Preferred Care 36 Section
Reconstructive surgery You Pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member s appearance and
the condition can reasonably be expected to be corrected by
such surgery

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

All stages of breast reconstruction surgery following a mastectomy, Nothing
such as:

surgery to produce a symmetrical appearance on the other breast; ;
treatment of any physical complications, , such as lymphoedemas;
breast prostheses and surgical bras and replacements ( ( see Prosthetic 20% of plan allowance
devices)

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

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

� Surgeries related to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; ;
Surgical correction of cleft lip, , cleft palate or severe functional
malocclusion;

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

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

Not covered: All charges
� Oral implants and transplants
� Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)

$ 15 per office visit.
Nothing for inpatient/ outpatient
surgery

$ 15 per outpatient surgery
Nothing for inpatient surgery

Section 5( b) 22 25.
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Section 36 2004 Preferred Care Section 5 (b)
Organ/ tissue transplants You Pay
Limited to: Nothing
Cornea
Heart
Heart/ / lung
Kidney
Kidney/ / Pancreas
Liver
Lung: : Single Double
Pancreas
Allogeneic 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.

Not covered: All charges
� Donor screening tests and donor search expenses, except those
performed for the actual donor

� Implants of artificial organs
� Transplants not listed as covered

Anesthesia
Professional services provided in Nothing
Hospital ( inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Section 5 (b) Section 5( b) Section 5( b) 23 26.
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2004 Preferred Care 36 Section
You Pay Benefit Description
Section 5( c). Services provided by a hospital or other facility,
and ambulance services

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

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

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

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Inpatient hospital
Room and board, such as Nothing
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.

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

Other hospital services and supplies, such as: Nothing
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
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home.

Not covered: All charges
Custodial care
Non-covered facilities, such as nursing homes and schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds

Private nursing care

Section 5( c) 24 27.
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Section 36 2004 Preferred Care
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms Nothing
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.

Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility ( SNF) : 120 days per calendar year. Nothing
Covered services include:
Bed, board, and general nursing care.
Drugs, biologicals, supplies, and equipment.

Not covered: custodial care All charges

Hospice care
Care for terminally ill patients ( life expectancy of 6 months or less) . Nothing
Covered services include dietary counseling, home health aid,
occupational therapy, speech therapy, and skilled nursing.

Drugs and medical supplies.

Not covered: Independent nursing, homemaker services All charges

Ambulance
Local professional ambulance service when medically appropriate $ 15 per visit

Section 5( c) 25 28.
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2004 Preferred Care 36 Section
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endan-
gers 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/ outside our service area: Emergencies, as defined above, do not require prior authori-
zation. Even so, we encourage you to always contact your primary care physician for direction and advice
before seeking medical treatment. In the event, however, that you are faced with a situation you are sure is an
emergency as defined above, you should go directly to the emergency room.

In the event that you are faced with a situation that you are not sure is an emergency as defined above, you
should contact your primary care physician first. Your primary care physician will help you determine the
most appropriate course of treatment. As your partner in health care, your primary care physician needs to be
kept informed of any health care services that you receive. We require that you contact your primary care
physician to facilitate his or her ability to oversee your health care and ensure that you may receive any
necessary follow-up treatment in connection with your emergency room visit.

Urgent Care within/ outside our service area: Urgent care is intended to treat minor illness or injury a
sprain, a minor cut or burn, the flu, or other ailment that is not quite an emergency but does require prompt
care. It differs from emergency care, which is designed to treat sudden, serious health problems ( for example,
a heart attack or stroke) . When used correctly, urgent care is an appropriate, convenient, and affordable
alternative to emergency care.

You are required to obtain a referral from your primary care physician before going to an urgent care center.
Without a referral, you may be responsible for all costs incurred.

Section 5( d). Emergency services/ accidents
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.

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Section 36 2004 Preferred Care
You Pay Benefit Description
Emergency within our service area
Emergency care at a doctor s office $ 15
Emergency care at an urgent care center $ 25
Emergency care as an outpatient at a hospital, $ 50 ( waived if admitted)
including doctors services

Not covered: Elective care or non-emergency care All charges

Emergency outside our service area
Emergency care at a doctor s office $ 15
Emergency care at an urgent care center $ 25
Emergency care as an outpatient at a hospital, including $ 50 ( waived if admitted)
doctors services

Not covered: All charges
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

Ambulance
Professional ambulance service when medically appropriate $ 15 per visit
See 5 ( c) for non-emergency service

Not covered: Air ambulance, unless determined to be medically All charges
necessary and approved by our medical director

Section 5( d) 27 30.
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2004 Preferred Care 36 Section
You Pay Benefit Description
Section 5( e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost
sharing and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, , limitations, and exclusions in this brochure.
We have no deductible. .
Be sure to read Section 4, , Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

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

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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.

Professional services, including individual or group therapy by $ 15 per visit
providers such as psychiatrists, psychologists, or clinical social workers

Medication management

Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, and facility based intensive
outpatient treatment

Not covered: Services we have not approved. All charges
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.

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

Section 5( e) 28 31.
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Section 36 2004 Preferred Care
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
For mental health treatment, you or your primary care physician are required
to contact Preferred Care s Behavioral Health Services Unit and speak with a
mental health specialist who will ask basic information about your mental
health history to determine the need for a referral for outpatient care. For
inpatient care, your primary care physician makes a referral to Preferred
Care s Preauthorization Department for inpatient hospitalization or partial
hospitalization ( day treatment) .

For chemical dependency treatment, you are required to contact the Preferred
Care Behavioral Health Services Unit and speak with an intake coordinator
who will ask basic information about your chemical dependency history to
determine the need for an assessment. If an assessment is appropriate, an
appointment for you will be arranged with an independent Preferred Care
Chemical Dependency Assessor. Once the assessment is completed, a clinical
quality coordinator will contact you to make specific recommendations for
treatment, and will arrange inpatient or outpatient services as needed.

The Behavioral Health Services Unit telephone number is ( 585) 327-2477 or
( 800) 836-1430 ext. 477. For the names of plan providers or a provider
directory, contact a Preferred Care Member Services representative at
( 585) 325-3113 or ( 800) 950-3224 or visit our website at
www. preferredcare. org.

Limitation We may limit your benefits if you do not follow your treatment plan.

Section 5( e) 29 32.
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2004 Preferred Care 36 Section
Section 5( f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, , as described in the chart beginning on the
next page.

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

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

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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy, a non-network pharmacy, or by
mail for medications that are available through the mail order program.

We use a formulary. A formulary is a list of selected FDA approved prescription medications. Use of
formulary helps control out of pocket costs. The Preferred Care formulary is an open, clinically comprehensive
guide that was developed by a nationally recognized independent group of clinicians and reviewed by Preferred
Care s P & T Committee ( a group of local physicians, pharmacists, and Preferred Care clinical pharmacy and
medical personnel) . Our formulary provides access to all FDA approved drugs with various coverage levels.

These are the dispensing limitations. You may purchase up to a 90-day supply at a Plan or non-network
pharmacy and are required to pay a copayment for each 30-day supply you purchase. The amount you pay is
based upon a three-tier copayment structure. The tiers determine the amount you pay for each 30-day supply
purchased. The three tiers are categorized as: Tier 1 Generic; Tier 2 Brand Name; and Tier 3 Brand Name.

You may purchase certain medications for up to a 90-day supply through the mail order pharmacy. A list of
therapeutic categories of prescriptions, that may be purchased through the mail order program, is available by
contacting Medco Health at ( 800) 233-7063 or a Preferred Care Member Services Representative at
( 585) 325-3113 or ( 800) 950-3224, or by visiting our website at www. preferredcare. org.

You are required to pay a copayment for each 90-day supply purchased through the mail order pharmacy. The
amount you pay for medications purchased through the mail order pharmacy is also based upon the three-tier
copayment structure. You may obtain a list of the medications covered through the mail order program by
contacting Medco Health at ( 800) 233-7063 or a Preferred Care Member Services Representative at ( 585) 325-
3113 or ( 800) 950-3224 or by visiting our website at www. preferredcare. org.

When an A-rated generic drug can be substituted for a name brand drug, the patient s drug benefit will be
based upon the cost of the generic drug. If the name brand drug is dispensed, the patient will pay the generic
copayment plus the difference in cost between the lower priced generic drug and the higher priced name brand
drug. If there is no A-rated generic substitute, the patient s drug benefit will be based upon the cost of the name
brand drug less the name brand copayment.

We reserve the right to determine Medical Necessity for all drugs, and may require Prior Justification of certain
drugs. Prior justification may occur prior to the drug being dispensed in any amount or only if more than a
standard quantity limit is prescribed. To learn more about this process you may contact Medco Health at ( 800)
233-7063 or a Preferred Care Member Services Representative at ( 585) 325-3113 or ( 800) 950-3224.

Plan members called to active military duty ( or members in time of national emergency) who need to obtain
prescribed medications, should call Medco Health at ( 800) 233-7063.

Why use generic drugs? Generic drugs are typically lower priced drugs that are the therapeutic equivalent to
more expensive name brand drugs. They must contain the same active ingredients and must be equivalent in
strength and dosage to the original brand name product. Generics cost less than the equivalent name brand drug.

The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet
the same standards of quality and strength as name brand drugs.

Section 5( f) 30 33.
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Section 36 2004 Preferred Care Section 5( f)
You Pay Benefit Description
At a Pharmacy
(for each 30 day supply)
$ 10 per tier 1 generic prescription
$ 20 per tier 2 brand name
prescription
$ 35 per tier 3 brand name
prescription

At Mail Order Pharmacy
(for each 90 day supply)
$ 25 per tier 1 generic prescription
$ 50 per tier 2 brand name
prescription
$ 87.50 per tier 3 brand name
prescription

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

$ 15 for each 30-day supply
$ 15 for each 90-day supply
from the mail order pharmacy

When you have to file a claim. If you use a non-Plan pharmacy or do not present your identification card at a
Plan pharmacy, you are required to submit a claim. You must submit original receipts along with a claim form.
You will be reimbursed at the network rate less the applicable copayment.

31
Covered medications and supplies
We cover the following medications and supplies prescribed by a licensed
physician and obtained from a Plan pharmacy or non-network pharmacy, or
through our mail order program:

FDA approved medications for FDA approved indications that by Federal
law of the United States require a physician s prescription for their purchase.

Compounded prescriptions are a covered item only if the main therapeutic
ingredient is a Federal Legend Drug with a National Drug Code ( NDC)
Number.

Disposable needles and syringes for the administration of covered
medications.

Drugs for sexual dysfunction have dispensing limits. Contact us for details.
Contraceptive drugs.
Drugs for infertility treatment after a medical condition has been
corrected. Pergonal/ Metrodin and other FDA approved drugs, only after
unsuccessful treatment with Clomiphene and only when very specific
clinical indications are met.

Growth hormone.

Diabetic Drugs & Supplies:
Insulin and oral agents
Supplies, , including disposable needles and syringes

Diabetes education ( see Educational Classes and Programs, Page 20) $ 15 per session
Diabetic medical equipment ( ( including glucose monitors) $ 15 per unit
Provider Administered Medications (if a separate charge is made by the $15 per medication
provider for that medication; this copay will be in addition to any other
applicable physician copay made for that day.)

Not covered: All Charges
� Drugs and supplies for cosmetic purposes
� Vitamins and nutritional supplements that can be purchased without
a prescription.

� Nonprescription medicines
� Drugs to enhance athletic performance
� Non-FDA approved medications (i. e. foreign medications, etc.)
� Prescriptions that may be obtained without a prescription 34.
34 Page 35 36
2004 Preferred Care 36 Section Section 5( g)
Section 5( g). Special features
Feature Description

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

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

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

The decision to offer an alternative benefit is solely ours, , and we may
withdraw it at any time and resume regular contract benefits.

Our decision to offer or withdraw alternative benefits is not subject to
OPM review under the disputed claims process.

Services for deaf and If you have access to TTY equipment, you may contact us at
hearing impaired ( 585) 325-2629.

Travel benefits/ services Urgent and emergency care only.
overseas

32 35.
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Section 36 2004 Preferred Care
Section 5( h). Dental Benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are medically
necessary.

We have no deductible.
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health of the
patient. See Section 5( c) for inpatient hospital benefits. We do not cover the dental
procedure unless it is described below.

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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Section 5( h)
You Pay Benefit Description
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair ( but $ 15 per visit
not replace) sound natural teeth. The need for these services must result from
an accidental injury. Benefits are provided only for a course of treatment that
has begun within 12 months of the injury.

Dental Benefits
We have no other dental benefits.

33 36.
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2004 Preferred Care 36 Section
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.

You're In Charge! ssm from Preferred Care are courses, resources, and discounts available to all members of
the Plan. You're In Charge! ssm provides connections to traditional and complimentary providers, all geared to
giving Plan members tools to make appropriate health and wellness decisions for themselves and their
families. Our You're In Charge! ssm program was developed to encourage appropriate participation in health-
ful activities focusing on preventive care to aid in improving the health status of our members.

You're In Charge! Health Partners
CPR & First Aid,
Diet & Nutrition,
Smoking Cessation,
Women s Issues, and
Childbirth & Parenting.

You're In Charge! Community discounts are provided for purchasing health related, recreation or leisure
merchandise or services from:

Weight Watchers,
Play It Again Sports,
Muxworthy s,
G& G Fitness,
Lori s Natural Foods,
and Rock Ventures to name a few.

Over twenty clubs provide plan members discounted arrangements. Discounts and schedules vary by
participating vendor.

Additional programs are:
Discounts on massage therapy,
20% discount on LASIK laser eye surgery at select locations,
Safe driving and safe boating courses at select locations,
20% discount on teeth whitening at participating dentists,
20% discount on sunglasses and safety glasses at select locations.

To receive You're In Charge! ssm information, call Preferred Care s Member Services Department at ( 585)
325-3113 or toll free at ( 800) 950-3224. Members with access to TTY equipment may call ( 585) 325-2629.
www. preferredcare. org Preferred Care s website provides valuable health information, frequently asked
questions, physician listings, and important links to other sites that can provide you with the most up to date
information on health and wellness.

Programs are subject to change.

Section 5( i). Non-FEHB benefits available to Plan members

Section 5( i) 34 37.
37 Page 38 39
Section 36 2004 Preferred Care
Section 6. General exclusions � things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies ( see Emergency Benefits) ;
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric
practice;

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

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive while in active military service.

Section 6 35 38.
38 Page 39 40
2004 Preferred Care 36 Section
Section 7. Filing a claim for covered services
When you receive services from Plan physicians, receive services at Plan hospitals and facilities, or obtain your
prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay
your copayment 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 In most cases, providers and facilities file claims for you. Physicians must benefits 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
( 585) 325-3113.

When you must file a claim such as for out--of-area care 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, address, and Federal Tax ID # 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:
Preferred Care, 259 Monroe Avenue, Rochester, New York, 14607

Prescription drugs Submit your claims to:
Medco Health Solutions
P. O. Box 2187
Lee s Summit, MO 64063-2187

Deadline for filing your Send us all of the documents for your claim as soon as possible. You must claim 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 Please reply promptly when we ask for additional information. We may delay information processing or deny your claim if you do not respond.

Section 7 39.
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Section 36 2004 Preferred Care
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization: :

Step Description
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: 259 Monroe Avenue, Rochester, N. Y. 14607; 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