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Total Health Choice

Pages 1--56 from Total Health Choice

Serving: Broward, Dade and Palm Beach Counties, Florida
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 8 for requirements.

Enrollment codes for this Plan:
4A1 Self Only
4A2 Self and Family

RI 73-795
Federal Employees Health Benefits Program

For changesin benefitssee
page 9.

This Plan has full accreditation from AAAHC.
See the 2004 Guide for more information on accreditation. 1.
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2004 Total Health Choice
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 Ð 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 United States Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice

to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

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

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
° To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.

° To review, make a decision, or litigate your disputed claim.
° For OPM and the General Accounting Office when conducting audits.

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

acted based on your permission.

By law, you have the right to:
° See and get a copy of your personal medical information held by OPM.
° Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.

° Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized OPM to
release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
° Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

° 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.
2004 Total Health Choice

Federal Employees Health Benefits Program 3.
3 Page 4 5
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

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

2004 Total Health Choice 4.
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2 2004 Total Health Choice Table of Contents
Table of Contents
Page
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Preventing medical mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Who provides my health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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
° Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
° Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
° Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . 21
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
° Flexible benefits option
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5.
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3 2004 Total Health Choice Table of Contents
Table of Contents
Page
Section 6. General exclusions Ñ things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
° What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
° Medicare + Choice plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
° TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
° Workers' Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
° Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° Children's Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Two new Federal Programs complement FEHB benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
The Federal Flexible Spending Account Program Ñ FSAFEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
The Federal Long Term Care Insurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back cover 6.
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2003 Total Health Choice Introduction/ Plain Language
Introduction
This brochure describes the benefits of Total Health Choice under our contract (CS 2854) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Total Health Choice's administrative offices is:
Total Health Choice, Inc. 8701 SW 137th Avenue, Suite 200
Miami, Florida 33183
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 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 are summarized on page 52. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures 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 Total Health Choice.
° 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 Program, Program Planning & Evaluation Group, 1900 E. Street, NW Washington, DC 20415-3650.

4 4 2004 Total Health Choice 7.
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2004 Total Health Choice Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

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

° Let only the appropriate medical professionals review your medical record or recommend services.
° Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
° Carefully review explanations of benefits (EOBs) that you receive from us.
° Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
° If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

° Call the provider and ask for an explanation. There may be an error.
° If the provider does not resolve the matter, call us at 313/ 871-7810 and explain the situation.
° If we do not resolve the issue:

CALL Ñ 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 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.

5 8.
8 Page 9 10
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical
mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and
that of your family members. Take these simple steps:

1. Ask questions if you have doubts or concerns.
° Ask questions and make sure you understand the answers.
° Choose a doctor with whom you feel comfortable talking.
° Take a relative or friend with you to help you ask questions and understand answers.

2. Keep and bring a list of all the medicines you take.
° Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.
° 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?
6 2004 Total Health Choice Preventing Medical Mistakes 9.
9 Page 10 11
° Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.
Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve

the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family.

www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent mistakes in the nation's healthcare delivery system.

7 2004 Total Health Choice Preventing Medical Mistakes 10.
10 Page 11 12
2004 Total Health Choice Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and decuctibles 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 to provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must

make available to you. Some of the required information is listed below.
° Total Health Choice meets State Licensing requirements
° Total Health Choice has been in existence for 6 years
° Total Health Choice has initiated a thorough procedure for handling complaints and grievance
If you want more information about us, call (800) 213-1133 or write to 8701 SW 137th Avenue, Suite 200, Miami, Florida 33183. You may also contact us by fax at (305) 408-5710 or visit our website at www. totalhealthchoiceonline. 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: All of Broward, Dade and Palm Beach Counties, Florida.

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 moves 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 moves, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

8 11.
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2004 Total Health Choice
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 47.

° We added information regarding Preventing medical mistakes. See page 6.
° We added information regarding enrolling in Medicare. See page 38.
° We revised the Medicare Primary Payer Chart. See page 40.

Changes to this Plan
° Your share of the non-Postal premium will increase by 23.9% for Self Only or 24% for Self and Family.

Section 2 9 12.
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2004 Total Health Choice Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or
fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for
annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 213-1133, Total Health Choice, Inc. 8701 SW

137th Avenue, Suite 200, Miami, Florida 33183.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file claims. If you use our point-of-service
program, you can also get care from non-Plan providers, or from participating providers without a required referral, but it will cost you more.

° Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers
according to national standards.
We list Plan providers in the provider directory, which we update periodically. The provider directory 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.

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. When you enroll in our plan, you will select one of our conveniently located health centers. You and your family member( s) may choose a primary care
physician to attend to your medial needs. All outside referrals and services must be coordinated through your primary care physician.

° Primary care Your primary care physician can be a family practitioner, internist, pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
° Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after
the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up
care. Do not go to the specialist for return visits unless your primary care physician gives you a referral.

Here are other things you should know about specialty care:
° If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with plan, to develop a treatment plan that

allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).
° If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she

decides to refer you to a specialist, ask if you can see your current specialist. If 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.

What you must do to get covered care

10 13.
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2004 Total Health Choice Section 3
° If you have a chronic or disabling condition and lose access to your specialist because we:
Ð terminate our contract with your specialist for other than cause; or
Ð drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

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

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your
postpartum care, even if it is beyond the 90 days.
° Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 213-1133. 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 benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change,

this continuation of coverage provision does not apply. In such case, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable
efforts to provide you with the necessary care.

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

° All transplants (organ, bone marrow)
° Custom durable medical equipment
° Custom prosthetics and esthetics
° Infertility treatment
° Nursing home placement
° Any treatment that is considered experimental
° Mental health/ substance abuse
° Drugs to treat sexual dysfunction

Services requiring our prior approval
Circumstances beyond our control

11 14.
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2004 Total Health Choice
Your catastrophic protection out-of-pocket
maximum for coinsurance and copayments

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

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay $100 per admission.
° 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 50% of our allowance for infertility services and durable medical equipment.

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

Section 4 12 15.
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2004 Total Health Choice
Section 5. Benefits Ñ OVERVIEW
(See page 9 for how our benefits changed this year and page 57 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 (800) 213-1133 or at our website at www. totalhealthchoiceonline. com.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
° Diagnostic and treatment services ° Speech therapy
° Lab, X-ray, and other diagnostic tests ° Hearing services (testing, treatment, and supplies)
° Preventive care, adult ° Vision services (testing, treatment, and supplies)
° Preventive care, children ° Foot care
° Maternity care ° Orthopedic and prosthetic devices
° Family planning ° Durable medical equipment (DME)
° Infertility services ° Home health services
° Allergy care ° Chiropractic
° Treatment therapies ° Alternative treatments
° Physical and occupational therapies ° Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . 21
° Surgical procedures ° Organ/ tissue transplants
° Reconstructive surgery ° Anesthesia
° Oral and maxillofacial surgery

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
° Inpatient hospital ° Hospice care
° Outpatient hospital or ambulatory surgical center ° Ambulance
° Extended care benefits/ skilled nursing care facility benefits

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
° Medical emergency ° Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
° 24 hour EMT Line
° Services for deaf and hearing impairment

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Section 5 13 16.
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2004 Total Health Choice Section 5( a)
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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.
° 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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Professional services of physicians $10 per office visit
° In physician's office

Professional services of physicians $10 per office visit
° In an urgent care center
° During a hospital stay
° In a skilled nursing facility
° Office medical consultations
° Second surgical opinion

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, $10 per office visit

Benefit Description You Pay
Diagnostic and treatment services

14 17.
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2004 Total Health Choice Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as: $10 per office visit
° Total Blood Cholesterol Ñ once every three years
° Colorectal Cancer Screening, including
Ð Fecal occult blood test
Ð Sigmoidoscopy, screening Ñ every five years starting at age 50

Prostate Specific Antigen (PSA test) Ñ one annually for men age $10 per office visit 40 and older

Routine pap test $10 per office visit
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

Routine mammogram Ðcovered for women age 35 and older, as follows: $10 per office visit
° 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

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

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

° Influenza/ Pneumococcal vaccines, annually, age 65 and over
Preventive care, children
° Childhood immunizations recommended by the American $10 per office visit Academy of Pediatrics

° Well-child care charges for routine examinations, immunizations and $10 per office visit care (through age 22)
° Examinations, such as:
Ð Eye exams through age 17 to determine the need for vision correction
Ð Ear exams through age 17 to determine the need for hearing correction
Ð Examinations done on the day of immunizations (through age 22)

15 18.
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2004 Total Health Choice Section 5( a)
Maternity care You Pay
Complete maternity (obstetrical) care, such as: $10 per office visit
° Prenatal care
° Delivery
° Postnatal care
Note: Here are some things to keep in mind:
° You do not need to precertify your normal delivery; see page xx for other circumstances, such as extended stays for you or your baby.

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

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

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

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to: $10 per office visit
° Voluntary sterilization (See surgical procedures Section 5 (b))
° Surgically implanted contraceptives
° Injectable contraceptive drugs (such as Depo provera)
° Intrauterine devices (IUDs)
° Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit

Not covered: Reversal of voluntary surgical sterilization, genetic counseling All charges
Infertility services
Diagnosis and treatment of infertility, such as: $10 per office visit
° Artificial insemination:
Ð intravaginal insemination (IVI)
Ð intracervical insemination (ICI)
° Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

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

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2004 Total Health Choice Section 5( a)
Treatment therapies
° Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under

Organ/ Tissue Transplants on page xx.
° Respiratory and inhalation therapy
° Dialysis Ñ Hemodialysis and peritoneal dialysis
° Intravenous (IV)/ Infusion Therapy Ñ Home IV and antibiotic therapy
° Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. Call (800) 213-1133 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.

Allergy care You Pay
Testing and treatment $10 per office visit
Allergy injection

Allergy serum Nothing

Not covered: Provocative food testing and sublingual allergy desensitization All charges

Physical and occupational therapies
° 60 visits per condition for the services of each of the following: $10 per office visit
Ð qualified physical therapists and $10 per outpatient visit
Ð occupational therapists. Nothing per visit during covered inpatient admission

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 21 days per condition

Not covered: All charges
° long-term rehabilitative therapy
° exercise programs

Speech therapy
° 60 visits per condition $10 per office visit

Not covered: All charges
° long-term rehabilitative therapy
° exercise programs

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2004 Total Health Choice Section 5( a)
Hearing services (testing, treatment, and supplies) You Pay
° First hearing aid and testing only when necessitated by accidental injury $10 per office visit
° Hearing testing for children through age 17 (see Preventive care, children)

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

Vision services (testing, treatment, and supplies)
° Eye exam to determine the need for vision correction for children $10 per office visit through age 17 (see Preventive care, children)

Not covered: All charges
° Eyeglasses or contact lenses and, after age 17, examinations for them
° Eye exercises and orthoptics
° Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic $10 per office 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)

Orthopedic and prosthetic devices
° Artificial limbs and eyes; stump hose $10 per office visit
° Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

° Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment information.
See Section 5( b) for coverage of the surgery to insert the device.
° Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

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2004 Total Health Choice Section 5( a)
Not covered: All charges
° orthopedic and corrective shoes
° arch supports
° foot orthotics
° heel pads and heel cups
° lumbosacral supports
° corsets, trusses, elastic stockings, support hose, and other supportive devices

° prosthetic replacements provided less than 3 years after the last one we covered

Orthopedic and prosthetic devices (Continued) You Pay

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of $10 per office visit durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
° hospital beds;
° wheelchairs;
° crutches;
° walkers;
° blood glucose monitors; and
° insulin pumps
Note: Call us at (800) 213-1133 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.

Not covered: All charges
° motorized wheel chairs
° insulin pumps

Home health services
° Home health care ordered by a Plan physician and provided by a $10 per office visit 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.

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2004 Total Health Choice Section 5( a)
Alternative treatments
Not covered: All charges
° naturopathic services
° hypnotherapy
° biofeedback

Educational classes and programs
Coverage is limited to: Nothing
° Smoking Cessation Ð Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.

° Diabetes self-management
° Pre-Natal classes
° CPR heart saver course
° CPR for infants and children
° Asthma education
° Hypertension education
° Prognosis newsletter
° Catastrophic management plan

Chiropractic You Pay
° Manipulation of the spine and extremities $10 per office visit
° Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Not covered: All charges

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2004 Total Health Choice Section 5( b)
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Section 5 (b). Surgical and anesthesia services 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.
° Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.
° The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility

(i. e. hospital, surgical center, etc.).

A comprehensive range of services, such as: $10 per office visit
° Operative procedures
° Treatment of fractures, including casting
° Normal pre-and post-operative care by the surgeon
° Correction of amblyopia and strabismus
° Endoscopy procedure
° Biopsy procedure
° Removal of tumors and cysts
° Correction of congenital anomalies (see reconstructive surgery)
° Surgical treatment of morbid obesity Ñ a condition in which an individual weighs 100 pounds or 100% over his or her normal

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

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

° Voluntary sterilization (e. g., Tubal ligation, Vasectomy) $10 per office visit
° 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.

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

Benefit Description You Pay
Surgical procedures

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2004 Total Health Choice Section 5( b)
Reconstructive surgery You Pay
° Surgery to correct a functional defect $10 per office visit
° Surgery to correct a condition caused by injury or illness if:
Ð the condition produced a major effect on the member's appearance and
Ð 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:
Ð surgery to produce a symmetrical appearance on the other breast;
Ð treatment of any physical complications, such as lymphedemas;
Ð 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.

Not covered: All charges
° Cosmetic surgery Ñ 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: $10 per office visit
° 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)

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2004 Total Health Choice Section 5( b)
Organ/ tissue transplants You Pay
Limited to: Nothing
° Cornea
° Heart
° Heart/ lung
° Kidney
° Kidney/ Pancreas
°Liver
° Lung: Single-Double
° Pancreas
° Allogeneic (donor) bone marrow transplants
° Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions; acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkins's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myelomia; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors
° Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

and pancreas
° National Transplant Program (NTP)
Limited Benefits Ñ 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)

Professional services provided in: $10 per office visit
° Hospital outpatient department
° Skilled nursing facility
° Ambulatory surgical center
° Office

23 26.
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2004 Total Health Choice Section 5( c)
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Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

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 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 Section 5( a) or (b).

Benefit Description You Pay
Inpatient hospital
Room and board, such as $100 per admission
° 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
° Take-home items
° Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year

deductible applies.)

Not covered: All charges
° 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
24 27.
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2004 Total Health Choice Section 5( c)
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.

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
The Plan provides benefits for up to a maximum of 730 days per condition $100 per admission

Skilled nursing facility (SNF): Nothing
Not covered: custodial care All charges
Hospice care
Hospice care is covered in the home or hospice facility when life Nothing expectancy is 6 months or less and when all necessary medical procedures

have been exhausted. Services include inpatient and outpatient care and family counseling; these services are provided under the direction of a Plan
doctor who certifies that the patient is in the terminal stages of illness.

Not covered: Independent nursing, homemaker services All charges
Ambulance
° Local professional ambulance service when medically appropriate Nothing

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2004 Total Health Choice Section 5( d)
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Benefit Description You Pay
Emergency within our service area
° Emergency care at a doctor's office $10 per visit
° Emergency care at an urgent care center

° Emergency care as an outpatient or inpatient at a hospital $25 per visit at a participating hospital; $75 including doctor's services per visit at a non-participating hospital

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

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.

° 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.

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 Ð what they all have in common
is the need for quick action.

What to do in case of emergency:
Call your primary care doctor. If you are unable to contact your doctor, call 911 or go to the nearest emergency room. Be sure to
tell the emergency room personnel that you are a Plan member so that they can notify the Plan.

Emergencies within our service area: If you or a family member needs to be hospitalized, the Plan must be notified within 48 hours, unless it is not possible. If you or a family member are hospitalized in a non-Plan facility and the Plan doctor
believes care can be better provided in a Plan hospital, you will be transferred when medically feasible.
$25 per hospital emergency room visit for emergency services that are covered under this Plan, If the emergency results in
admission to a hospital, the copay is waived.

Emergencies outside our service area: Benefits are available for any medically necessary health services outside our service area that is immediately required because of unforeseen illness.

26 29.
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2004 Total Health Choice Section 5( d)
Emergency outside our service area You Pay
° Emergency care at a doctor's office $10 per visit
° Emergency care at an urgent care center

° Emergency care as an outpatient or inpatient at a hospital, including $75 per visit doctor's 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 {If you cover full-term
deliveries outside the service area delete this exclusion}

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

Not covered: air ambulance {If covered, show above} All charges.

Ambulance

27 30.
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2004 Total Health Choice Section 5( e)
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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.
° 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 $10 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, half-way house, residential treatment, full-day

hospitalization, 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 illness or conditions.
Benefit Description You Pay

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2004 Total Health Choice Section 5( e)
Mental health and substance abuse benefits Ñ (Continued)
Preauthorization To be eligible to receive these benefits you must obtain your treatment plan and follow all of the following authorization processes:
Contact your primary care provider or call us at (305) 408-5700. We will assist you in the authorization process.

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

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2004 Total Health Choice Section 5( f)
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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.

° 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.

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

° Where you can obtain them. You must fill the prescription at a Plan pharmacy,
° We use a formulary. The formulary is developed by the Plan's Pharmacy and Therapeutic Committee and is based on the Michigan Medicaid formulary. The drugs shown on the Plan's formulary are evaluated for their therapeutic value

and cost. New drugs are added or deleted from the formulary based on determinations made by the Michigan Medicaid program, and the Pharmacy and Therapeutics Committee.

° These are the dispensing limitations. Prescription drugs will be dispensed for up to a 31-day supply.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, 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.

° If you are called to active duty or are a member requiring a supply of medication during a national or other emergency, call us at (800) 213-1133 for assistance with obtaining your medication.

° Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a name-brand drug.
° When you have to file a claim. Contact us at (800) 213-1133. We will assist you in your claim.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy:
° Drugs and medicines that by Federal law of the United States $5 per generic/$ 15 brand name prescription require a physician's prescription for their purchase, except those
listed as Not covered
° Insulin
° Disposable needles and syringes for the administration of covered medications

° Drugs for sexual dysfunction (see Preauthorization)
° Contraceptive drugs and devices 50% of Charges

Covered medications and supplies
Benefit Description You Pay

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2004 Total Health Choice Section 5( f)
Covered medications and supplies (continued) You Pay
Not covered: All charges
° Drugs and supplies for cosmetic purposes
° Drugs to enhance athletic performance
° Fertility drugs
° Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

° Vitamins, nutrients and food supplements even if a physician prescribes or administers them
° Nonprescription medicines

31 34.
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2004 Total Health Choice Section 5( g)
Section 5 (g). Special features
For any of your health concerns, 24 hours a day, 7 days a week, you may call (305) 408-
5700 and talk with an emergency technician who will discuss treatment options and answer
your health questions.
If you have a hearing impairment, you may call Total Health Choice by using the TTY/ TTD

line at (800) 649-3777 for assistance.

Feature Description
24 hour Emergency Medical Technician (EMT) line

Services for deaf and hearing impaired

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2004 Total Health Choice Section 5( h)
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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.

° Plan dentists must provide or arrange your care.
° We cover hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the patient; 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.

Accidental injury benefitYou Pay
We cover restorative services and supplies necessary to promptly repair Nothing (but not replace) sound natural teeth. The need for these services must

result from an accidental injury.

Dental benefits
We have no other dental benefits.

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2004 Total Health Choice Section 6
Section 6. General exclusions Ñ things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.
We do not cover the following:
° Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
° Services, drugs, or supplies you receive while you are not enrolled in this Plan;
° Services, drugs, or supplies that are not medically necessary;
° Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
° Experimental or investigational procedures, treatments, drugs or devices;
° Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

° Services, drugs, or supplies related to sex transformations;
° Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
° Services, drugs, or supplies you receive without charge while in active military service.

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2004 Total Health Choice Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance.
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:

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims
questions and assistance, call us at (800) 213-1133.
When you must file a claim Ñ such as for out-of-area care Ñ 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 Ñsuch as the Medicare Summary Notice (MSN); and

° Receipts, if you paid for your services
Submit your claims to: Total Health Choice, Inc.

8701 SW 137th Avenue, Suite 200 Miami, Florida 33183

Prescription drugs Submit your claims to:
Total Health Choice, Inc. 8701 SW 137th Avenue, Suite 200
Miami, Florida 33183

Other supplies or services Submit your claims to:
Total Health Choice, Inc. 8701 SW 137th Avenue, Suite 200
Miami, Florida 33183

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.

Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

Medical and hospital benefits
When we need more information
Deadline for filing your claim

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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: Total Health Choice, Inc., 8701 SW 137th Avenue, Suite 200, Miami, Florida 33183; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial Ñ 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 Ñ if we did not answer that request in some way within 30 days; or
° 120 days after we asked for additional information.

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

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

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

Note: if you want OPM to review different claims, 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, 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.
2004 Total Health Choice Section 8 36 39.
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2004 Total Health Choice Section 8
Section 8. The disputed claims process (continued)
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 (800) 213-1133 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 can call OPM's Health Insurance Group 3 at (202) 606-0737 between 8 a. m. and 5 p. m. eastern time.

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2004 Total Health Choice Section 9
Section 9. Coordinating benefits with other coverage
You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is
called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers,

determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

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

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

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

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

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

and decide if it makes sense for you to buy the Medicare Part B coverage.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available to

Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare + Choice plan you have.

When you have other health coverage

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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.

Claims process when you have the Original Medicare Plan Ñ You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
° When we are the primary payer, we process the claim first.
° When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the balance of covered

charges. You will not need to do anything. To find out if you need to do something about filing your claims, call us at (800) 213-1133.

We do not waive any costs if the Original Medicare Plan is your primary payer.
(Primary payer chart begins on next page.)

39 2004 Total Health Choice Section 9

° The Original Medicare Plan (Part A or Part B) 42.
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40 2004 Total Health Choice Section ? Section 9 40
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely
because of a disability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when . . .
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
Ask your employing office which of these applies to you.

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

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

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty, related to Workers' Compensation)

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely becaue of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and . . .
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you Ñ or your covered spouse Ñ are age 65 or over and . . . Then the primary payer is . . . Original Medicare This Plan 43.
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41 2004 Total Health Choice Section ?
° Medicare + Choice plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare + Choice plan Ñ a Medicare + Choice plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare + Choice plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare + Choice
plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare + Choice plan, contact
Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare + Choice plan, the following options are available to you:
This Plan and another plan's Medicare + Choice plan: You may enroll in another plan's Medicare + Choice plan and also remain enrolled in our FEHB plan. We will still provide

benefits when your Medicare + Choice plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan providers), but we will not waive any of our
copayments, coinsurance,.
If you enroll in a Medicare + Choice plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare + Choice plan so we can correctly coordinate benefits

with Medicare.
Suspended FEHB coverage to enroll in a Medicare + Choice plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare + Choice plan,

eliminating your FEHB premium. (OPM does not contribute to your Medicare + Choice plan premium.) For information on suspending your FEHB enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of Medicare + Choice
plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free

Part A, we will not ask you to enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. Both TRICARE and this Plan cover
you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE programs.

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

Workers' Compensation We do not cover services that:
° you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must

provide; or
° OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

If you do not enroll in Medicare Part A or Part B

Section 9 44.
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42 2004 Total Health Choice Section ? Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB

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

We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

When other Government agencies
are responsible for your care

When others are responsible for injuries 45.
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43 2004 Total Health Choice Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is defined to be non-medically necessary care that has been determined to be primarily for your maintenance or care that has been designed essentially to assist you in
meeting your activities of daily living. Activities of daily living include, but are not limited to, bathing, turning, dressing, walking, taking oral medications, and feeding. Custodial care that
lasts 90 days or more is sometimes known as Long term care.

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

The Plan's Medical Director and Board of Directors review experimental or investigational cases based on specific information. Consultation with other outside physicians within a
specialty is often sought as a part of the review process. The experimental/ investigational status of a treatment, procedure, or technique is evaluated based on publications made available
through New Technologies Assessment. The Plan's Pharmacy and Therapeutics Committee reviews information on a regular basis regarding new experimental/ investigational medical
technologies to determine potential treatments which should be made available to you.

Group health coverage A body of subscribers who are eligible for health care insurance by virtue of some common identifying attribute such as common employment by an employer, or membership in a union,
association, or other such organization who can purchase health care insurance as a group. Generally, all members of such a body of subscribers has similar health care benefits or may
receive a core benefit package, similar exclusions, and have the ability to purchase riders of additional areas of coverage such as prescription drugs or eyeglasses.

Medical necessity Medically necessary services and supplies are medical, hospital, and emergency services and supplies for the treatment of your active illness or injury which have been established in
accordance with generally accepted professional standards, and are determined by a physician, medical group, or health plan medical director to be: (a) rendered for the treatment or diagnosis
of your injury or disease, (b) appropriate for the symptoms, consistent with diagnosis, and otherwise of your injury or disease, (c) not furnished primarily for your convenience, the
physician, or other provider of service, (d) not for cosmetic purposes, (e) not experimental or investigational. Inpatient services and suppies are medically necessary only if they require the
acute bed-patient setting and could not be provided in the physician's office, the outpatient department of a hospital, or in another facility without negatively affecting your condition or
the quality of medical care rendered. To be determined to be medically necessary does not constitute a covered benefit.

Us/ We Us and we refer to Total Health Choice
You You refers to the enrollee and each covered family member.

Experimental or investigational services 46.
46 Page 47 48
Section 11. FEHB facts
Coverage information
We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before
to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to
Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be
available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when you add or

remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the Federal Employees
Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your
employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

° If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,
° if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and
Family in the same option of the same plan; or
° if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue

Shield Service Benefit Plan's Basic Option.
44 2004 Total Health Choice Section 11

No pre-existing condition limitation
Where you can get information about
enrolling in the FEHB Program

Types of coverage available for you and
your family 47.
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45 2004 Total Health Choice Section 11
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment,
change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the
court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if
eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that doesn't serve the area in which your children live as long as the court/ administrative order is in effect.
Contact your employing office for further information.
The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after

January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your
claims will be paid according to the 2004 benefits of your old plan or option. However, if your old plan left the FEHB Program at the end of the year, you are covered under that plan's 2003
benefits until the effective date of your coverage with your new plan. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing
office will tell you the effective date of coverage.

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

When you lose benefits
° When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
° Your enrollment ends, unless you cancel your enrollment, or
° You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
° Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. But, you may be eligible for your own FEHB coverage

under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees,
or other information about your coverage choices. You can also download the guide from OPM's website, www. opm. gov/ insure.

° TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example,
you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former

Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It
explains what you have to do to enroll.

You may convert to a non-FEHB individual policy if:
° Your coverage under TCC or the spouse equity law ends. (If you canceled your coverage or did not pay your premium, you cannot convert);

° You decided not to receive coverage under TCC or the spouse equity law; or
° You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice. However, if you are a

family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

° Converting to individual coverage

When benefits and premiums start 48.
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46 2004 Total Health Choice
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting period or limit
your coverage due to pre-existing conditions.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability and continuity to people who
lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You
can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related
conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months,
but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site (www. opm. gov/ insure/ health);
r