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Unviversal Care

Federal Employees Health Benefits Program
2004 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud
Section 1. Facts about this HMO plan
Section 2. How we change for 2004
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits
Section 6. General exclusions � things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- Coverage information
- When you lose benefits
Two new Federal Programs complement FEHB benefits
- The Federal Flexible Spending Account Program � FSAFEDS
- The Federal Long Term Care Insurance Program
Index
Summary of benefits
Rates

Pages 1--68 from Universal Care

Page 1 2

Universal Care 2004 http:// www. universalcare. com
A Health Maintenance Organization

Serving: Southern California
Enrollment in this Plan is limited. You must live in or work in our
Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
6Q1 Self Only
6Q2 Self and Family

RI 73-796

For changes
in benefits
see page 9.

This Plan has a three (3) year
commendable accreditation from the
NCQA. See the 2004 Guide for more
information on NCQA. 1.
1 Page 2 3

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

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

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

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

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

Sincerely, 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the 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. 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 are effective April 14, 2003. 4.
4 Page 5 6

2 2004 Universal Care Table of Contents 5.
5 Page 6 7

3 2004 Universal Care Table of Contents 6.
6 Page 7 8

Introduction
This brochure describes the benefits of Universal Care under our contract (CS2855) with the United States Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Universal Care
administrative offices is:

Universal Care
1600 E. Hill Street
Signal Hill, California 90755-3682

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,
and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2004, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and changes are
summarized on page 9. Rates are shown at the end of this brochure.

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

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

� We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
� Our brochure and other FEHB plans' 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
United States Office of Personnel Management, Insurance Services Programs, Program, Planning and Evaluation Group, 1900 E
Street, NW, Washington, DC 20415-3650.

Stop Health 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.

4 2004 Universal Care Introduction/ Plain Language/ Advisory 7.
7 Page 8 9
5 2004 Universal Care Introduction/ Plain Language/ Advisory
� 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 1-800-635-6668 and explain the situation.
� If we do not resolve the issue:

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

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

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

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

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

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10

4. Talk to your doctor about which hospital is best for your health needs.
� Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.

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

Want more information on patient safety?
� www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging
list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve
the quality of care you receive.
� www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your
family.
� www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is dedicated to improving
communication about the safe, appropriate use of medicines.
� www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
� www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals working to
improve patient safety.
� www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent
mistakes in the nation's healthcare delivery system.

6 2004 Universal Care Introduction/ Plain Language/ Advisory 9.
9 Page 10 11

Section 1. Facts about this HMO Plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers
that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection
of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition
to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of
treatment.

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. Universal
Care provides covered services through the Universal Care Contracted Participating Medical Groups and Primary Care
Physicians. The location, telephone numbers and hours of service of the Contracted Participating Medical Groups and Primary
Care Physicians are listed in the Universal Care Provider Directory accompanying this Brochure. Emergency Services are
available on a 24-hour basis, seven (7) days a week.

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

� Universal Care began its operations in 1983 and has been providing quality health care services for 17 years to Southern California residents.

� Universal Care is a privately held, family-owned health plan.
� Universal Care currently has approximately 313,000 commercial (group, individual), government programs (Medicaid. Medicare, Healthy Families, and FEHBP) enrollees.

� Universal Care complies with State, Federal, and private accreditation standards that assure confidentiality of medical records and orderly transfer of medical records to caregivers. Universal Care has received 3-year full accreditation from
NCQA.
� Universal Care encourages all of its members to fully participate in all decisions related to healthcare.
If you want more information about us, call 1-800-635-6668 or write to1600 E. Hill Street, Signal Hill, CA 90755-3682. You
may also contact us by fax at 562-490-9419 or visit our website at www. universalcare. 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:
Los Angeles, Orange, Riverside, San Bernardino, San Diego, Kern and Ventura counties.

7 2004 Universal Care Section 1 10.
10 Page 11 12
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will
pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the
services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out
of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or
an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open
Season to change plans. Contact your employing or retirement office.

8 2004 Universal Care Section 1 11.
11 Page 12 13

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 56.

� We added information regarding Preventing medical mistakes. See page 5.
� We added information regarding enrolling in Medicare. See page 46.
� We revised the Medicare Primary Payer Chart. See page 48.

Changes to this Plan
� Your share of the non-Postal premium will increase by 5.8% for Self Only or 5.8% for Self and Family.
� The copay for Abortion has changed from $150 to $200.
� The copay for Ambulance has changed from $0 to $50 per trip.
� The copay for Home visits by physicians has changed from $0 to $10.
� Durable Medical Equipment, Orthopedic and Prosthetic devices have a maximum benefit of $2,500 per calendar year.
� The copay for Emergency Care at an urgent care center, within the service area has changed from $25 to $50.
� The copay for Emergency care outside the service area has changed from $25 to $50.
� The copay for Inpatient Hospital has changed from $100 per day up to $300 per person to $300 per admission
� The copay for Skilled Nursing Facility has changed from $100 per day up to $300 per person to $300 per admission
� The limit on Skilled Nursing Facility is 30 days per calendar year
� The copay for Maternity Care has changed from $0 to $10.
� The copay for Tubal Ligation has changed from $100 to $200.
� Medically necessary drugs to treat sexual dysfunction, including, but not limited to, Viagra, Yocon, Muse and Caverjet are limited to eight (8) pills per member per month, with a 50% copay and must be prior authorized by the Contracting

Medical Group.
� Your catastrophic protection out-of-pocket maximum for copay is $2,000 per person and $4,000 per family in any calendar year.

� Hearing testing for children is through age 17.
� We addded a prescription drug mail order benefit.

9 2004 Universal Care Section 2 12.
12 Page 13 14

Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services
from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive
your ID card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 1-800-635-6668 or write to
us at1600, E. Hill Street, Signal Hill, CA 90755.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and you will not have to file claims.

� Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential
Plan providers according to national standards. Universal Care's Plan providers
include Primary Care Physicians, specialty physicians, physician assistants and
nurse practitioners.

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

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

It depends on the type of care you need. First, you and each family member must
choose a primary care physician. This decision is important since your primary
care physician provides or arranges for most of your health care. To select your
Primary Care Physician, call our Member Services Department at 800-635-6668.

What you must do It depends on the type of care you need. First, you and each family member must to get covered care choose a primary care physician. This decision is important since your primary
care physician provides or arranges for most of your health care. To select your
Primary Care Physician, call our Member Services Department at 800-635-6668.

� Primary care Your primary care physician can be a family practitioner, internist, pediatrician, or general practitioner. 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. However,

10 2004 Universal Care Section 3 13.
13 Page 14 15
you may see OB/ GYN or an Internist without a referral. Generally, your Primary
Care Physician will refer you to a specialist within your Contracted Medical Group.
If you require services that are not available within your Contracted Medical Group,
the Primary Care Physician will arrange for a referral to a Contracted Provider
within Universal Care's network. To order certain services, the Primary Care
Physician will give you a written referral authorizing such services. For certain
specialty services, the referral is submitted by the Primary Care Physician for
review for Prior Authorization to Universal Care or to the Contracted Medical
Group's Utilization Review Committee.

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

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

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

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

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

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

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

� Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing
or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800-635-6668. If you are new to the
FEHB Program, we will arrange for you to receive care.

11 2004 Universal Care Section 3 14.
14 Page 15 16
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 part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such
case, the hospitalized family member's benefits under the new plan begin on the
effective date of enrollment.

Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may have our control to delay your services or we may be unable to provide them. In that case, we will
make all reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to refer you for most services. For prior approval certain services, however, your physician must obtain approval from us. Before
giving approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice. We call this review and approval
process Prior Authorization. Your physician must obtain Prior Authorization for the
following services, which include, but are not limited to:

� Referral to specialists
� Laboratory and Radiology services such as Blood Tests, Urinalysis, Non-routine pap tests, Pathology, X-rays, Non-routine mammograms, Cat

Scans/ MRI, Ultrasound, Electrocardiogram and EEG
� Elective procedures -inpatient or outpatient
� Home health care
� Durable Medical Equipment
� Ambulance

Your physician must get our approval before sending you to a hospital, referring
you to a specialist, or recommending follow-up care. Prior Authorization means that
your Primary Care Physician must contact Universal Care (or in some cases, the
Contracted Medical Group with which your Primary Care Physician is affiliated) to
request that the service be approved for coverage before services are rendered.
Requests for Prior Authorization will be denied if the requested services are
determined to be not Medically Necessary. Requests for Prior Authorization of
coverage for services by non-contracted providers will also be denied if Universal
Care determines that comparable or more appropriate services are available through
Universal Care's Contracted Providers.

The majority of requests for Prior Authorization of coverage are responded to
within 72 hours of their receipt, and urgent matters are expedited. Those requests
which require investigation and/ or physician review sometimes take longer as they
may be needed for additional information and communication directly to you and
your Primary Care Physician and the referral specialist along with an authorization
number. Requests for coverage that are approved by Universal Care are
communicated directly to you and your Primary Care Physician and the referral
specialist along with an authorization number. Requests for Prior Authorization of

12 2004 Universal Care Section 3 15.
15 Page 16 17
13 2004 Universal Care Section 3
coverage that are denied by Universal Care are communicated in writing to your
Primary Care Physician and you.

In the event that Prior Authorization of coverage has been denied by Universal Care
(or in some cases, the Utilization Review Committee of your Contracted Medical
Group), you, or your Primary Care Physician on your behalf may appeal the denial
by following the appeals process outlined on page 40 of this brochure. If you would
like a more detailed description of Universal Care's Criteria for Authorizing or
Denying Health Care Services, you may contact Universal Care's Member Services
Department at 800-635-6668. 16.
16 Page 17 18
14 2004 Universal Care Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
� Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go in the hospital, you pay $300 per admission.

� Deductible We do not have a deductible.
� Coinsurance We do not have coinsurance.
Your catastrophic protection After your copayments total $2,000 per person or $4,000 per family enrollment in out-of-pocket maximum for any calendar year, you do not have to pay any more for covered services.
deductibles, coinsurance, and However, copayments for the following services do not count toward your copayments catastrophic protection out-of-pocket maximum, and you must continue to pay
copayments for these services:
� Prescription drugs � Durable Medical Equipment
� Diagnosis and treatment of infertility
Be sure to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum. 17.
17 Page 18 19

15 2004 Universal Care Section 5
Section 5. Benefits � OVERVIEW (See page 9 for how our benefits changed this year and page 61 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 800-635-6668 or
at our website at www. universalcare. com.

(a) Medical services and supplies provided by physicians and other health care professionals .................................................... 16
� 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

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16 2004 Universal Care Section 5( a)

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

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

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

including with Medicare.

Benefit Description You pay
Diagnostic and treatment services

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 visits by nurse or health aide Nothing

At home visits by physician $10 per visit

Diagnostic and treatment services � continued on next page 19.
19 Page 20 21
17 2004 Universal Care Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as: Nothing if you receive these services
� Blood tests during your office visit; otherwise, $10
� Urinalysi per office visit
� Non-routine pap tests
� Pathology
� X-rays
� Non-routine Mammograms
� Cat Scans/ MRI
� Ultrasound
� Electrocardiogram and EEG

Note: All Lab, X-ray and other diagnostic tests require prior approval.

Preventive care, adult
Routine screenings, such as: $10 per office visit
� Blood Cholesterol -once every three years

� Colorectal Cancer Screening, including
� Fecal occult blood test
� Sigmoidoscopy, screening -every five years starting at age 50
� Venereal Disease testing, including screening for chlamydial
infection
� Breast Cancer Screening

Prostate Specific Antigen (PSA test) -one annually for men $10 per office visit
age 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. 20.
20 Page 21 22
18 2004 Universal Care Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram � covered 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 � once every 10 years, ages 19 and � over (except as provided for under Childhood immunizations)

� Influenza vaccine, annually
� Pneumococcal vaccines, annually, age 65 and over

Preventive care, children
� Childhood immunizations recommended by the American Academy $10 per office visit � of Pediatrics
� Examinations done on the day of immunizations (through age 22)

� Well-child care charges for routine examinations, immunizations and $10 per office visit � care (up to age 22)
� Examinations, such as:
� eye exams through age 17 to determine the need for vision
correction.

� ear exams through age 17 to determine the need for hearing
correction 21.
21 Page 22 23
19 2004 Universal Care 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 31 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 range of voluntary family planning services, limited to: $10 per office visit
� Voluntary sterilization (See Surgical procedures Section 5 (b)

� Surgically implanted contraceptives (such as Norplant)
� Injectable contraceptive drugs (such as Depo provera)
� Intrauterine devices (IUDs)
� Diaphragms
� Abortion only when the life of the mother would be endangered if $200 copay � fetus is carried to term or if the pregnancy is a result of an act of

� rape or incest.
NOTE: We cover oral contraceptives under the prescription drug benefit.

Not covered: Reversal of voluntary surgical sterilization, genetic All charges.
counseling. 22.
22 Page 23 24
20 2004 Universal Care Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
� Artificial insemination: 50% of charges
� intravaginal insemination (IVI)
� intracervical insemination (ICI)
� intrauterine insemination (IUI)
� Fertility drugs 50% of charges
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:
� in vitro fertilization
� embryo transfer, gamete GIFT and zygote ZIFT
� zygote transfer
� Services and supplies related to excluded ART procedures
� Cost of donor sperm
� Cost of donor egg

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy All charges.
desensitization 23.
23 Page 24 25
21 2004 Universal Care Section 5( a)
Treatment therapies You Pay
� Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 28.

� Respiratory and inhalation therapy
� Dialysis -hemodialysis and peritoneal dialysis
� Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic therapy
� Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Note: -We will only cover GHT when we preauthorize the treatment.
Call 800-635-6668 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.

Physical and occupational therapies
� 60 visits per condition for the services of each of the following:
� qualified physical therapists and $10 per office visit
� occupational therapists. $10 per outpatient visit

Note: We only cover therapy to restore bodily function when there has Nothing per visit during covered inpatient
been a total or partial loss of bodily function due to illness or injury. admission
Occupational therapy is limited to services that assist the member to
achieve and maintain self-care and improved functioning in other activities
of daily living.

� Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 sessions

Not covered: All charges.
� Long-term rehabilitative therapy
� Exercise programs 24.
24 Page 25 26
22 2004 Universal Care Section 5( a)
Speech therapy You Pay
60 visits per year $10 per outpatient visit
nothing per visit during covered inpatient
admission

Hearing services (testing, treatment, and supplies)
� First hearing aid and testing only when necessitated by accidental $10 per office visit
injury

� 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)

� One pair of eyeglasses or contact lenses to correct an impairment $10 per office visit � directly caused by accidental ocular injury or intraocular surgery
� (such as for cataracts)
� Diagnosis and treatment of diseases of the eye.

Note: See Preventive care, children for eye exams for 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 25.
25 Page 26 27
23 2004 Universal Care Section 5( a)
Foot care You pay
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% of allowed charges
� Externally worn breast prostheses and surgical bras, including � necessary replacements, following a mastectomy

� Internal prosthetic devices, such as artificial joints, pacemakers, � cochlear implants, and surgically implanted breast implant following
� mastectomy. Note: See 5( b) for coverage of the surgery to insert � the device.

� Orthopedic devices, such as braces
� Corrective orthopedic appliances for non-dental treatment of � temporomandibular joint (TMJ) pain dysfunction syndrome.

� Maximum benefit of $2,500 per Calendar Year
Note: The maximum benefit is $2,500 per calendar year per member

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 26.
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24 2004 Universal Care Section 5( a)
Durable medical equipment (DME) You Pay
Rental or purchase, at our option, including repair and adjustment, of 10% of allowed charges
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.
� Wigs are covered only for members undergoing chemotherapy or � radiation treatment.

Note: Call us at 800-635-6668 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.

Note: The maximum benefit is $2,500 per calendar year per member

Not covered: All charges.
� Motorized wheel chairs

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.

Chiropractic
No Benefit All charges. 27.
27 Page 28 29
25 2004 Universal Care Section 5( a)
Alternative treatments You pay
No benefit All charges.
Educational classes and programs
Coverage is limited to: Nothing
� Smoking Cessation -Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.

� Diabetes self-management
� Weight Loss
� Cholesterol control
� Exercise
� Parenting
� Healthy kids
� Breast feeding
� Healthy Living: Fast foods/ Dining out
� Hypertension management
� Stress Management
� Healthy Living Back
� Asthma control: Children (ages 4-8)
Teens (ages 9-14)
Adults (ages 15+) 28.
28 Page 29 30
26 2004 Universal Care Section 5( b)
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Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

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.).
� YOU MUST GET PRIOR AUTHORIZATION FOR ALL SURGICAL PROCEDURES

Benefit Description You pay
Surgical procedures
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 procedures
� Biopsy procedures
� Removal of tumors and cysts
� Correction of congenital anomalies (see reconstructive surgery)
� Surgical treatment of morbid obesity. A condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible
members must be age 18 or over. Surgery for morbid obesity will be
performed only as a last resort, when the member's health is
endangered and more conservative medical measures, including
prescription drugs such as appetite suppressants, have not been
successful.

� Insertion of internal prosthetic devices. See 5( a) -Orthopedic and prosthetic devices for device coverage information. 29.
29 Page 30 31
27 2004 Universal Care Section 5( b)
Surgical procedures (continued) You Pay
� Voluntary sterilization (e. g., Tubal ligation, Vasectomy) $100 per office visit � Vasectomy
� Treatment of burns $200 per office vist -Tubal ligation

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.

Note: All elective procedures must be prior approved by the Plan.
Not covered: All charges.
� Reversal of voluntary sterilization
� Routine treatment of conditions of the foot; see Foot care.

Reconstructive surgery
Surgery to correct a functional defect $10 per office visit
� Surgery to correct a condition caused by injury or illness if:
� the condition produced a major effect on the member's
appearance and

� the condition can reasonably be expected to be corrected by
such surgery

� Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

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

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

� surgery to produce a symmetrical appearance on the other
breast;

� treatment of any physical complications, such as lymphedemas;
� breast prostheses and surgical bras and replacements (see
prosthetic devices)

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

Not covered:
� Cosmetic surgery -any surgical procedure (or any portion of a All charges. procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
� Surgeries related to sex transformation 30.
30 Page 31 32
28 2004 Universal Care Section 5( b)
Oral and maxillofacial surgery You Pay
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.
� Treatment of TMJ, including surgical and non-surgical intervention

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)

� Orthopedic appliances

Organ/ tissue transplants
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 Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors.

� Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

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

Note: We cover related medical and hospital expenses of the donor when
we cover the recipient. 31.
31 Page 32 33
29 2004 Universal Care Section 5( b)
Organ/ tissue transplants You Pay
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 32.
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Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

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

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

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

charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).
� YOU MUST GET PRIOR AUTHORIZATION FOR ALL HOSPITAL STAYS.

Benefit Description You pay
Inpatient Hospital
Room and board, such as $300 copay 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

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

30 2004 Universal Care Section 5( c) 33.
33 Page 34 35
Outpatient hospital or ambulatory surgical center You Pay
� Operating, recovery, and other treatment rooms $100 per visit
� 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
Extended care benefit:
Subacute care is provided in either a designated area of an acute Nothing
care hospital, in a comprehensive freestanding rehabilitation facility, or
in a specially designed unit within a skilled nursing facility. Subacute
care is considered a lower level of care in terms of nursing and
physician contact time with the patient, and yet is still a comprehensive
level of care for patients whose condition is likely to continue to improve
and who:

� Have had an acute illness of injury for which acute care is no longer medically necessary.

� Have experienced a recurrence of a chronic disease process for which acute care is no longer necessary.
� Though stable, may still require some diagnostic and/ or invasive procedures and nursing care and/ or monitoring.

Skilled nursing facility (SNF):
The Plan provides a comprehensive range of benefits with no dollar limit, $300 copay per admission
for up to 30 days per calendar year, when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan.
All necessary services are covered, including:

� Bed, board and general nursing care
� Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan

doctor.

Not covered: custodial care All charges.
31 2004 Universal Care Section 5( c) 34.
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32 2004 Universal Care Section 5( c)
Hospice care You Pay
Supportive and palliative care for a terminally ill member is covered in Nothing
the home or a hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately twelve months or
less. Services must be authorized by a Plan doctor and approved by the
Plan.

Not covered: Independent nursing, homemaker services All charges.
Ambulance
� Local professional ambulance service when medically appropriate $50 per trip
Note: Services must be prior approved by the Plan. 35.
35 Page 36 37
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 and are payable only when we determine they are medically necessary.

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

What to do in case of emergency:
If you are in an emergency situation, immediately call "911" or go directly to the nearest emergency room for treatment. Be sure
to tell the emergency room personnel that you are a Universal Care member so they can notify the Plan.

Emergencies within our service area:
You or a family member must telephone your Universal Care medical group within 24 hours (unless it was not reasonably
possible to do so). It is your responsibility to ensure that the Plan has been timely notified. Continuing treatment shall be
covered for only so long as the Medical Director of the Plan, after reviewing any medical records or other relevant information
and conferring with the physician in charge of the patient care, determines that the member cannot be transferred to the care of a
Universal Care Medical Group or contracting provider.

Emergencies outside our service area:
You or a family member must telephone your Universal Care medical group within 24 hours (unless it was not reasonably
possible to do so). It is your responsibility to ensure that the Plan has been timely notified. Continuing treatment shall be
covered for only so long as the Medical Director of the Plan, after reviewing any medical records or other relevant information
and conferring with the physician in charge of the patient care, determines that the member cannot be transferred to the care of a
Universal Care Medical Group or contracting provider.
If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 48 hours or on the first working day
following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in a
non-Plan facility and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.

33 2004 Universal Care Section 5( d)

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34 2004 Universal Care Section 5( d)
� Emergency care at an urgent care center $50 per visit
� Emergency care as an outpatient or inpatient at a hospital, including $50 per visit doctors' services If the emergency results in admission to a

hospital, the copay is waived.

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

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

Ambulance
Professional ambulance service when medically appropriate. $50 per trip
See 5( c) for non-emergency service.

Not covered: air ambulance All charges.

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 $50 per visit
� Emergency care as an outpatient or inpatient at a hospital, $50 per visit including doctors' services If the emergency results in admission to a

hospital, the copay is waived.

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
� Emergency care at a doctor's office $50 per visit 37.
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35 2004 Universal Care 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 are payable only when we determine they are medically
necessary.

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
� YOU MUST GET PRIOR AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider Your cost sharing responsibilities are no
and contained in a treatment plan that we approve. The treatment plan greater than for other illness or conditions.
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

Mental health and substance abuse benefits � continued on next page 38.
38 Page 39 40
36 2004 Universal Care Section 5( e)
Mental health and substance abuse benefits (continued) You Pay
� Diagnostic tests Nothing if you receive these services during your office visit; otherwise, $10
per office visit.

� Services provided by a hospital or other facility $300 copay per admission
� 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.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:

To get a referral, contact your Primary Care Physician. If you have an emergency
and are unable to contact your PCP, call the Triage service at 800-377-7012.
In order to obtain a provider directory, call our Member Services Department at
800-635-6668.

Limitation We may limit your benefits if you do not follow your treatment plan. 39.
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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.

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

with Medicare.

37 2004 Universal Care Section 5( f)
There are important features you should be aware of. These include:
� Who can write your prescription. A licensed physician must write the prescription � or � A licensed Plan or referral physician must write the prescription.

� Where you can obtain them. You must fill the prescription at a Plan pharmacy. Universal Care approved maintenance drugs for chronic conditions can be ordered through the mail.
� We use a formulary. Universal Care uses a comprehensive formulary as a method of evaluating various drug products available to treat illnesses. The formulary is a preferred list of generic & name brand drugs that we
have selected to meet patient needs at a lower cost and are:
� FDA approved for specified indications;
� Reviewed by Universal Care with participation by practicing physicians;
� Safe and effective as well as being medically necessary for the treatment of maintenance of a medical condition; and

� Cost effective for the treatment of the medical condition.
Your physician may prescribe a name brand drug or a generic drug from a formulary list. A generic equivalent
will be dispensed if it is available, unless your physician specifically requires a name brand. If your physician
prescribes a drug that is not on our formulary, you pay the non-formulary copay. Non-formulary drugs that are
prior approved by us will be subject to the applicable formulary copay.

To order a prescription drug formulary, call 800-635-6668.
These are the dispensing limitations. Up to a one-month supply of prescription drug will be dispensed. Certain
drugs such as vitamins with fluoride for infants may be limited for up to one year. A 90-day supply of a
prescription drug for chronic conditions ordered through the mail. If a member sends in an order too soon after the
last one was filled, the new order will not go through. Only maintenance medications for conditions such as
hypertension, diabetes, etc. are available through mail order. Plan members called to active military duty (or
members in time of national emergency) who need to obtain prescribed medications, should call our Member
Services Department at 800-635-6668.

� Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer
advertises and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for
safety, purity, strength, and effectiveness. A generic prescription costs you-and us-less than a name brand
prescription.

� When you have to file a claim. Submit all claims to: Universal Care, P. O. Box 16420, Signal Hill, CA 90755-3682 40.
40 Page 41 42
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

� Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not
covered.
� Oral contraceptive drugs
� Insulin; a copay charge applies to each vial
� Insulin syringes, needles and blood glucose monitoring strips
� Prenatal vitamins
� Vitamins with fluoride for infants up to one year of age
� Intravenous fluids and medications for home use
� "Off-label" medication will be covered only if the Prescribing Plan Physician provides pre-reviewed medical literature or if the "off-label"

medication has become a community standard.
� Oral fertility drugs
� Disposable needles and syringes for the administration of covered medications

� Medically necessary drugs for sexual dysfunction including, but not limited to Viagra, Yocon, Muse and Caverjet are limited to a maximum
of eight (8) pills per member per month with a 50% copayment and
must be prior authorized by your Contracting Medical Group.

Note: Implantable drugs, such as Norplant, and some injectable drugs,
such as Depo Provera, are covered under Medical and Surgical Benefits.

Not covered: All charges.
� Drugs and supplies for cosmetic purposes
� Drugs to enhance athletic performance
� 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, except for prenatal vitamins and vitamins with
fluoride for infants up to one year of age.
� Medical supplies such as dressings and antiseptics
� Diabetic supplies, except for insulin syringes, needles and blood glucose monitoring strips

� Smoking cessation drugs and medication
� Over the counter medications prescribed by a physician

38 2004 Universal Care Section 5( f)

Retail Pharmacy
$ 10 for generic drugs listed on our
formulary

$ 20 for brand name drugs with no generic
equivalent listed on our formulary�

$30 for generic or brand name drugs not
listed on our formulary.

Mail-order
$15 for generic drugs
$30 for brand name drugs
90-day supply of prescribed maintenance
drugs obtained through our mail order
program

Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay. 41.
41 Page 42 43
39 2004 Universal Care Section 5( g)
Centers of excellence for Universal Care has contracts with centers of excellence including UCLA Medical transplants/ heart Center, Loma Linda University Medical Center, and Cedars Sinai Medical Center.
surgery/ etc

Travel benefit/ services Universal Care covers all travel immunizations required for travel by the country of overseas destination.

Section 5 (g). Special features
Feature Description

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 800-377-7012 and talk with a registered nurse who will discuss treatment options
and answer your health questions.

Services for deaf and The hearing and speech impaired may use Universal Care's toll-free telephone hearing impaired number (866)-321-5955 (TTY).

High risk pregnancies Universal Care has a Women's Health Department that monitors and manages high-risk pregnancies. 42.
42 Page 43 44
40 2004 Universal Care 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 have no calendar year deductible.
� We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; 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 benefit You pay
We cover restorative services and supplies necessary to promptly repair $35 for initial stabilization services
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury. $10 for follow-up visits

Dental benefits
No dental benefits. 43.
43 Page 44 45
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file
an FEHB disputed claim about them. Fees you pay for these services do not count toward
FEHB deductibles or catastrophic protection out-of-pocket maximums.

You and your family can receive Dental benefits for an annual fee payable to Universal Care.
� Subscriber $48.00 per year � Subscriber and Dependent $96.00 per year

� Subscriber and Family $144.00 per year
You and each covered member of your family are entitled to enrollment in our Dental Plan. You must enroll in
Universal Care's Dental plan to receive these benefits. The following sample copayments apply.

� Adult Oral Examination No charge � Child Oral Examination No charge
� Adult Cleaning $20.00 � Child Cleaning $15.00

The Dental Plan is currently available to all members. To receive further information and enroll in Universal
Care's Dental 700 Plan, please call (800) 257-3087.

41 2004 Universal Care Section 5( i) 44.
44 Page 45 46
42 2004 Universal Care Section 6
Section 6. General exclusions � things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or
condition.

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

� Services, drugs, or supplies related to sex transformations;
� Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
� Services, drugs, or supplies you receive without charge while in active military service. 45.
45 Page 46 47
43 2004 Universal Care Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at 800-635-6668.
When you must file a claim � such as for out-of-area care � submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills and
receipts should be itemized and show:

� Covered member's name and ID number;
� Name and address of the physician or facility that provided the service or supply;

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

� Receipts, if you paid for your services.
Submit your claims to: Universal Care
PO Box 16420
Signal Hill, CA 90755-3682

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 46.
46 Page 47 48
44 2004 Universal Care Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim
or request for services, drugs, or supplies -including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Universal Care
Attn: Grievance Unit
1600 E. Hill Street
Signal Hill, CA 90755-3612

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

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

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

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

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
� 90 days after the date of our letter upholding our initial decision; or
� 120 days after you first wrote to us � if we did not answer that request in some way within 30 days; or
� 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance
Group 3, 1900 E Street, NW, Washington, DC 20415-3630. 47.
47 Page 48 49
The Disputed Claims process (continued)
Send OPM the following information:
� A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
� Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

� Copies of all letters you sent to us about the claim;
� Copies of all letters we sent to you about the claim; and
� Your daytime phone number and the best time to call.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which
claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the review request.

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

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

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in which you received the disputed
services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the
only deadline that may not be extended.

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death
if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800-635-6668 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.

45 2004 Universal Care Section 8 48.
48 Page 49 50
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under another coverage 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 h