Pages 1--72 from Foreign Service Benefit Plan

For changes
in benefits see page 7. Sponsored and administered by: American Foreign Service Protective Association

Who may enroll in this Plan: You must be, or become, a member of the American Foreign Service Protective Association.

To become a member: When you enroll in the Foreign Service Benefit Plan, you automatically become a member of the Protective Association. New membership in the Protective Association is
limited to American Foreign Service personnel and direct hire employees (i. e., eligible for FEHB insurance) working for (1) the Department of State (2) the Department of Defense (3) the Agency
for International Development (4) the Foreign Commercial Service (5) the Foreign Agricultural Service; and to Executive Branch civilian employees assigned overseas or to U. S. possessions and
territories; and the direct hire domestic employees assigned to support those activities.
Direct hire employees and Executive Branch civilian employees must enroll in the Health Plan when actively employed in order to retain or choose the Plan in retirement. Only annuitants who are
eligible under the Foreign Service Retirement System may enroll under this Plan as annuitants.
Membership dues: There are no membership dues. Membership is for life.
Enrollment codes for this Plan:
401 High Option -Self Only 402 High Option -Self and Family

Mutual of Omaha Insurance Company, the underwriter for the FOREIGN SERVICE
BENEFIT PLAN has received accreditation from URAC (also known as the American Accreditation
Healthcare Commission), for Health Utilization Manage-ment Standards. See the 2002 Guide for more informa-tion
on accreditation. 1
1 Page 2 3

Table of Contents
2002 Foreign Service Benefit Plan 2 Table of Contents
Introduction ................................................................................................................................................................................................ 4
Plain Language ........................................................................................................................................................................................... 4
Inspector General Advisory ....................................................................................................................................................................... 4
Section 1. Facts about this fee-for-service plan ................................................................................................................................... 5-6
Section 2. How we change for 2002 ........................................................................................................................................................ 7
Section 3. How you get care ............................................................................................................................................................... 8-12
Identification cards .................................................................................................................................................................. 8
Where you get covered care ................................................................................................................................................ 8-9
Covered providers ......................................................................................................................................................... 8
Covered facilities ........................................................................................................................................................... 9
What you must do to get covered care ................................................................................................................................ 10
How to get approval for .................................................................................................................................................. 10-12
Your hospital stay (precertification) ...................................................................................................................... 10-12
Other services .............................................................................................................................................................. 12
Section 4. Your costs for covered services ...................................................................................................................................... 13-17
Copayments ................................................................................................................................................................. 13
Deductible .................................................................................................................................................................... 13
Coinsurance ................................................................................................................................................................. 13
Differences between our allowance and the bill ................................................................................................... 13-15
Your out-of-pocket maximum .............................................................................................................................................. 15
When government facilities bill us ...................................................................................................................................... 15
If we overpay you ................................................................................................................................................................. 15
When you are age 65 or over and you do not have Medicare ........................................................................................... 16
When you have Medicare ..................................................................................................................................................... 17
Section 5. Benefits ............................................................................................................................................................................. 18-51
Overview ............................................................................................................................................................................... 18
(a) Medical services and supplies provided by physicians and other health care professionals ................................. 19-27
(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................. 28-31
(c) Services provided by a hospital or other facility, and ambulance services ............................................................ 32-36
(d) Emergency services/ accidents .................................................................................................................................. 37-38
(e) Mental health and substance abuse benefits ............................................................................................................ 39-44
(f) Prescription drug benefits ......................................................................................................................................... 45-47
(g) Special features .............................................................................................................................................................. 48
Flexible benefits option ............................................................................................................................................ 48
24 hour nurse line ..................................................................................................................................................... 48
Centers of excellence for tissue and organ transplants ........................................................................................... 48
(h) Dental benefits .......................................................................................................................................................... 49-50
(i) Non-FEHB benefits available to Plan members ........................................................................................................... 51 2
2 Page 3 4

Section 6. General exclusions things we don't cover ...................................................................................................................... 52
Section 7. Filing a claim for covered services ................................................................................................................................. 53-54
Section 8. The disputed claims process ............................................................................................................................................ 55-56
Section 9. Coordinating benefits with other coverage ..................................................................................................................... 57-61
When you have other health coverage ............................................................................................................................ 57
Original Medicare ....................................................................................................................................................... 57-59
Medicare managed care plan ........................................................................................................................................... 60
TRICARE/ Workers Compensation/ Medicaid ............................................................................................................ 60-61
When other Government agencies are responsible for your care .................................................................................. 61
When others are responsible for injuries......................................................................................................................... 61
Section 10. Definitions of terms we use in this brochure ................................................................................................................ 62-64
Section 11. FEHB facts ..................................................................................................................................................................... 65-66
Coverage information ...................................................................................................................................................... 65-66
No pre-existing condition limitation ........................................................................................................................... 65
Where you get information about enrolling in the FEHB Program .......................................................................... 65
Types of coverage available for you and your family ............................................................................................... 65
When benefits and premiums start ............................................................................................................................. 65
Your medical and claims records are confidential ..................................................................................................... 65
When you retire............................................................................................................................................................ 66
When you lose benefits ........................................................................................................................................................ 66
When FEHB coverage ends .......................................................................................................................................... 66
Spouse equity coverage................................................................................................................................................ 66
Temporary Continuation of Coverage (TCC) ............................................................................................................. 66
Converting to individual coverage .............................................................................................................................. 66
Getting a Certificate of Group Health Plan Coverage ................................................................................................ 66
Long term care insurance is coming later in 2002 ................................................................................................................................. 67
INDEX...................................................................................................................................................................................................... 68
Summary of benefits ........................................................................................................................................................................... 70-71
Rates ........................................................................................................................................................................................... Back cover

2002 Foreign Service Benefit Plan 3 Table of Contents 3
3 Page 4 5
2002 Foreign Service Benefit Plan 4 Introduction/ Plain Language/ Advisory
Introduction
Foreign Service Benefit Plan Phone: 202/ 833-4910 1716 N Street, NW Fax: 202/ 833-4918

Washington, DC 20036-2902 E-mail: afspa@ afspa. org
This brochure describes the benefits of the Foreign Service Benefit Plan under our contract (CS 1062) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.
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, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are summarized on page 7. 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 understand-able 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 the Foreign Service Benefit Plan.

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 us 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, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650.

Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital 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 202/ 833-4910 and explain the situation.

If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the
person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 4
4 Page 5 6
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We also have Preferred Provider Organizations (PPO):
Our fee-for-service Plan offers services through a PPO. When you use our PPO providers, you will receive covered services at reduced cost. Contact us for the names of PPO providers and to verify their continued participation. Access our PPO directory
either through Mutual of Omaha's web site, www. mutualofomaha. com, or as a link through our web site www. afspa. org or call 202/ 833-4910 for information concerning the PPO. You can also go to our web page, which you can reach through the FEHB
web site, www. opm. gov/ insure. Do not call OPM or your agency for our provider directory.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a PPO Network Area. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability
of every specialty in all areas. The selection of PPO providers is solely the Plan's responsibility. We cannot guarantee the continued participation of any specific provider. In the PPO Network Areas, if no PPO provider is available, or you do not use a
PPO provider, the standard non-PPO benefits apply. Follow these procedures when you use a PPO provider in order to receive PPO benefits:

Verify with us that your address of record is in a PPO area. Our records must reflect that you reside in a PPO area;
Verify that the provider is in the PPO network when you make your appointment;
Present your PPO Identification Card at the time you visit your healthcare provider, confirming your PPO participation to be eligible for PPO benefits. If you do not present your PPO ID Card, the provider may not accept our
PPO discount;
Do not pay a PPO provider at the time of service. PPO providers must bill us directly. We must reimburse the provider directly. PPO providers will bill you for any balance after our payment to them.

This Plan offers its members in certain areas the opportunity to reduce out-of-pocket expenses by choosing facilities and providers that participate in the Plan's Preferred Provider Organization (PPO). The following are considered PPO Network Areas:
the Washington, D. C. metropolitan and Greater Baltimore areas, and certain areas of the following States
Alabama Indiana New Hampshire South Carolina Arizona Iowa New Jersey Tennessee
Arkansas Louisiana New Mexico Texas California Maine New York Utah
Colorado Maryland North Carolina Virginia Connecticut Massachusetts Ohio Washington
Delaware Michigan Oklahoma West Virginia Florida Minnesota Oregon Wisconsin
Georgia Missouri Pennsylvania Illinois Nevada Rhode Island

Consider the PPO cost savings when you review Plan benefits, and if you live in these areas, check with the Plan to find out which local facilities and providers are PPO providers. Check with your doctor to see if he or she has admitting privileges at a
PPO hospital.

2002 Foreign Service Benefit Plan 5 Section 1 5
5 Page 6 7
2002 Foreign Service Benefit Plan 6 Section 1
How we pay providers
We generally reimburse our PPO providers based on an agreed-upon fee schedule. We do not offer them additional financial incentives based on care provided or not provided to you. Our standard provider agreements do not contain any contractual
provisions that include incentives to restrict the providers' ability to communicate with and advise you of any appropriate treatment options. Also, we have no compensation, ownership or other influential interests that are likely to affect provider advice
or treatment decisions.

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.
Years in existence and profit status -The American Foreign Service Protective Association was established in 1929 and was incorporated in 1941 as a 501( c)( 9) not-for-profit organization. The Foreign Service Benefit Plan is provided in conjunction
with the Mutual of Omaha Insurance Company. The Mutual of Omaha Insurance Company was organized in 1909 as a mutual legal reserve system (private).

Licensing and certification -The Mutual of Omaha Insurance Company meets all State and Federal licensing and certification requirements.
Fiscal solvency, confidentiality and transfer of medical records -The Mutual of Omaha Insurance Company meets all requirements for fiscal solvency, confidentiality and transfer of medical records.
If you want more information about us, call 202/ 833-4910, or write to the Foreign Service Benefit Plan, 1716 N Street, NW, Washington, DC 20036-2902. You may also contact us by fax at 202/ 833-4918, by e-mail at afspa@ afspa. org or visit our website
at www. afspa. org. 6
6 Page 7 8
2002 Foreign Service Benefit Plan 7 Section 2
Section 2. How we change for 2002
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 changed the address for sending disputed claims to OPM. (Section 8)
The following four states have been added to the list of medically underserved states for 2002: Georgia, Montana, North Dakota and Texas. Louisiana has been removed from the list of medically underserved states for 2002.

Changes to this Plan
Your share of the premium will increase by 7.7% for Self Only and 6.4% for Self and Family.
We clarified the brochure to better explain that the non-PPO benefits are the standard benefits of this Plan, that PPO benefits apply only when you use a PPO provider and that when no PPO provider is available, non-PPO benefits apply.

We have added to your PPO service area. In addition to the states that had PPO providers last year, portions of the following states are now also considered within the PPO service area: Alabama, Arkansas, Louisiana, Maine, Michigan, Minnesota,
Missouri, Nevada, New Mexico, Ohio, Oklahoma, Oregon, Utah, West Virginia and Wisconsin. We have also increased areas in Indiana and Tennessee. (Section 1)

We have increased your routine physical exam benefit from a maximum of $500 per person per calendar year to a maximum of $750 per person per calendar year, subject to the calendar year deductible and appropriate coinsurance. (Section 5( a))
We have changed the current mammogram schedule to allow one mammogram per calendar year, starting at age 35 subject to the calendar year deductible and appropriate coinsurance. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover routine screening for chlamydial infection. (Section 5( a))
We have added Chiropractor benefits, subject to the calendar year deductible and appropriate coinsurance. The Plan limits benefits to a maximum payable of $20 per visit with a 30-visit maximum per person per calendar year. (Section 5( a))

We have expanded covered providers of acupuncture to include Oriental Medical Doctors (O. M. D. 's) and Licensed Acupuncturists (L. Ac. 's). We have limited the benefit to a maximum payable of $20 per visit with a 30-visit maximum per
person per calendar year subject to the calendar year deductible and appropriate coinsurance. (Section 5( a))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech and have added a 90-visit combined maximum per person per calendar year for physical, speech and occupational therapies

subject to the calendar year deductible and appropriate coinsurance. (Section 5( a))
We have increased your Smoking cessation benefit from a maximum payable of $100 for one smoking cessation program per member per lifetime to a maximum payable of $100 for one program per person per 12 months subject to the calendar year

deductible and appropriate coinsurance. Over the counter smoking cessation drugs and supplies are included in the $100 maximum payable per person per 12 months. (Section 5( a)) Prescription drugs for smoking cessation are now covered under
your Prescription drug benefit. (Section 5( f))
We now cover certain intestinal transplants. (Section 5( b)) 7
7 Page 8 9
2002 Foreign Service Benefit Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you a combined Foreign Service Benefit Plan/ PAID Prescription Drug Identification Card (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. Call us if
you need to purchase prescriptions and have not received your card.
If you do not receive your ID card within 60 days after the effective date of your enrollment, or if you need replacement cards, call us at 202/ 833-4910.

Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay and you pay depends on the type of covered provider or facility you use. If you use
our preferred providers, you will pay less.
Covered providers We consider the following to be covered providers when they perform covered services within the scope of their license or certification:

Physician Doctors of medicine (M. D.), osteopathy (D. O.), podiatric medicine (D. P. M.) and for certain specified services covered by this Plan, doctors of dental
surgery (D. D. S.), medical dentistry (D. M. D.), optometry (O. D.), chiropractic (D. C.), and Oriental Medicine (O. M. D.)

Other covered providers include:
Qualified Clinical Psychologist An individual who has earned either a Doctoral or Masters degree in psychology or an allied discipline and who is licensed or certified

in the state where services are performed (such as Licensed Professional Counselors).
Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure

or certification.
Nurse Practitioner / Clinical Specialist A person who 1) has an active R. N. license in the United States, 2) has a baccalaureate or higher degree in nursing, and

3) is licensed or certified as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification.

Clinical Social Worker A social worker who 1) has a Masters or Doctoral degree in social work, 2) has at least two years of clinical social work practice, and
3) in states requiring licensure, certification, or registration, is licensed, certified, or registered as a social worker where the services are rendered.

Licensed Acupuncturist (L. Ac.) An individual who has completed the required schooling and licensure to perform acupuncture in the state where services are
performed (see definition of acupuncture, Section 5( a)).
Nursing School Administered Clinic A clinic that is 1) licensed or certified in the state where the services are performed, and 2) provides ambulatory care in an

outpatient setting primarily in rural or inner city areas where there is a shortage of physicians. Services billed by these clinics are considered outpatient "office"
services rather than facility charges.
Physician Assistant A person who is licensed, registered or certified in the state where services are performed.

Audiologist A person who is licensed, registered or certified in the state where services are performed.

Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in states OPM
determines are "medically underserved." For 2002, the states are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New Mexico, North Dakota, South
Carolina, South Dakota, Texas, Utah, and Wyoming. 8
8 Page 9 10
2002 Foreign Service Benefit Plan 9 Section 3
Covered facilities Covered facilities include:
Birthing Center A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries and to

provide immediate postpartum care.
Day Care Center A facility licensed as a day care center and that provides a planned program of psychiatric services for patients with mental conditions who

must spend their days, but not nights, under psychiatric supervision, and that are not for schooling, custodial, recreational, or training services.

Hospice A public or private agency or organization that:
1) primarily provides inpatient hospice care to terminally ill persons;
2) is certified by Medicare as such, or is licensed or accredited as such by the jurisdiction it is in;

3) is supervised by a staff of M. D. 's or D. O. 's at least one of whom must be on call at all times;
4) provides 24-hour-a-day nursing services under the direction of an R. N. and has a full-time administrator; and
5) provides an ongoing quality assurance program.
Hospital
1) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO); or
2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing services, and that is primarily

engaged in providing:
a) General inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which facilities must be

provided on its premises or under its control; or
b) Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on

its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.

3) For inpatient and outpatient treatment of alcohol and drug abuse, the term hospital also includes a free-standing alcohol and drug abuse treatment facility
approved by the JCAHO.
In no event shall the term hospital include a convalescent nursing home or institution or part thereof that:

1) is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged;
2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or
3) is operated as a school.
Skilled Nursing Facility An institution or that part of an institution, which provides convalescent skilled nursing care 24-hours-a-day and is classified as a
skilled nursing facility under Medicare. 9
9 Page 10 11
2002 Foreign Service Benefit Plan 10 Section 3
What you must do to It depends on the kind of care you want to receive. You can go to any covered get covered care provider you want, but we must approve some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal Employees Health (FEHB) Program and you enroll in another FEHB Plan, or

lose access to your PPO specialist because we terminate our contract with your specialist for other than cause,

you may be able to continue seeing your specialist and receiving any PPO benefits 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

and any PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 202/ 833-4910.
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.
How to Get Approval for Your hospital, skilled nursing
Precertification is the process by which prior to your inpatient hospital, skilled facility or hospice stay, or nursing facility or hospice admission, or receiving home health care we evaluate the

home health care medical necessity of your proposed stay or treatment and the number of days required (See Other services (page 12) for to treat your condition. Unless we are misled by the information given to us, we
obtaining approval for Mental won't change our decision on medical necessity. Health/ Substance Abuse Treatment)
In most cases, your physician, hospital, skilled nursing facility, hospice or home health agency will take care of precertification. Because you are still responsible for ensuring
that we are asked to precertify your care, you should always ask them if they have contacted us.

Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. Also, we will reduce our benefits for skilled nursing facility,
hospice or home health care if no one contacts us for precertification. See below and pages 11-12 for more information on skilled nursing facility, hospice and home health
care. In addition, if the stay or care is not medically necessary, we will not pay any benefits.

How to precertify a hospital, You, your representative, your doctor, hospital, skilled nursing facility, hospice or skilled nursing facility or home health agency must call Mutual of Omaha's Care Review Unit before the
hospice admission, or home admission or care. The toll-free number is 1-800/ 228-0286. health care
Provide the following information:
Enrollee's name and Plan identification number; Patient's name, birth date, and phone number;

Reason for hospitalization or proposed treatment; Name of hospital, facility or home health agency;
Name and phone number of admitting doctor; and Number of planned days of confinement or care. 10
10 Page 11 12
2002 Foreign Service Benefit Plan 11 Section 3
If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your
representative, your doctor or your hospital must telephone us within two business days following the day of the emergency admission, even if you have been
discharged from the hospital.
For hospital confinements, when the preceding requirements are met, the Care Review Unit will tell the doctor and hospital the number of approved days of

confinement for the care of the patient's condition.
For home health care, hospice care or skilled nursing facility care, when the preceding requirements are met, the Care Review Unit will notify the patient, the

doctor, and the facility or agency that the care is, or is not, certified as medically necessary.

The Plan will send you, your doctor, and the hospital written confirmation of our certification decision. If the length of stay or care needs to be extended, follow the
procedure below.
Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery

or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are
discharged, then your physician or the hospital must contact us within 2 business days for precertification of additional days for your baby.

If your hospital stay If your hospital stay including for maternity care needs to be extended, you, your needs to be extended: representative, your doctor or the hospital must ask us to approve the additional days.
What happens when you When we precertified the hospital admission but you remained in the hospital do not follow the beyond the number of days we approved and did not get the additional days
precertification rules precertified, then:
for the part of the admission that was medically necessary, we will pay inpatient benefits, but

for the part of the admission that was not medically necessary, we will pay only covered medical services and supplies otherwise payable on an outpatient basis
and will not pay inpatient benefits.
When we precertified the care in a skilled nursing facility, hospice or for home health care, you received treatment beyond the approved care and did not get the
additional care precertified, then:
for the part of the admission or care that was medically necessary, we will provide full benefits as stated on pages 26 and 35, but

for the part of the admission to the skilled nursing facility that was not medically necessary, we will pay only covered medical services and supplies otherwise
payable on an outpatient basis; and
for the part of the home health care that was not medically necessary, we will not pay benefits.

If no one contacted us, we will decide if the hospital, skilled nursing facility or hospice stay, or home health care was medically necessary.
If we determine that the hospital stay was medically necessary, we will pay the inpatient hospital charges, less the $500 penalty.
If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will pay only covered medical
supplies and services that are otherwise payable on an outpatient basis.
If we determine that the care you received in a skilled nursing facility or hospice was not medically necessary, we will pay only covered medical supplies and

services that are otherwise payable on an outpatient basis.
If we determine that the home health care you received was not medically necessary, we will not pay benefits. 11
11 Page 12 13
2002 Foreign Service Benefit Plan 12 Section 3
If we denied the precertification request
for hospitalization, we will not pay inpatient hospital benefits, we will pay only covered medical supplies and services that are otherwise payable on an outpatient

basis;
for skilled nursing facility or hospice admission, we will pay only covered medical supplies and services that are otherwise payable on an outpatient basis; and

for home health care, we will not pay benefits.
Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the 50 United States.
You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days or you have no Medicare lifetime reserve days left, then we will become the primary payer and you must precertify.

Other services Some services require prior authorization.
Mental Health and Substance Abuse Benefits
You must precertify all inpatient admissions for mental health and substance abuse treatment. See sections on preceding pages for details and the penalty.

You must preauthorize outpatient mental health and substance abuse treatment for all levels of care whether in or out-of-network. You or your health care
provider must call our preauthorization number at 1-800/ 228-0286 to preauthorize.

You must obtain concurrent review (which means review of continuing treatment) and follow your treatment plan for all levels of care whether in or out-of-
network. You or your health care provider must call our preauthorization number at 1-800/ 228-0286 to obtain concurrent review.

Note: We conduct concurrent review (which means review of continuing treatment) to determine the medical necessity and/ or appropriateness of ongoing
services. Review frequency is based on the severity and complexity of your condition. We may perform an on-site review of your medical records to ensure
continuity of care.
Note: A treatment plan is a detailed statement of the objectives and goals to be achieved within a clinical setting developed by your treating professional. The
plan may also include the therapeutic modality to be used as well as the frequency of services and estimated length of treatment.

If you do not preauthorize your care, obtain concurrent review, or do not follow your treatment plan, we will reduce any available benefits by 50% of what we
would have paid had you preauthorized, obtained concurrent review or followed your treatment plan. See pages 39-44 for details.

Note: We do not require precertification, preauthorization or concurrent review if you receive treatment outside of the United States or when Medicare Part A and/
or Part B, or another group health insurance policy is the primary payer. Precertification, preauthorization and concurrent review is required, however,
when Medicare or the other group health insurance policy stops paying benefits for any reason. 12
12 Page 13 14
2002 Foreign Service Benefit Plan 13 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example:
When you purchase prescriptions from a network pharmacy with the use of your combination Foreign Service Benefit Plan/ PAID Prescription Drug Identification

Card, you pay a copayment of $10 for generic or $20 for brand name prescriptions. When you purchase prescriptions from the Merck-Medco Home Delivery Pharmacy
service by mail, you pay a copayment of $15 for generic or $25 for brand name prescriptions.

When you are confined in a non-PPO hospital or an Out-of-Network hospital, you pay $200 per person per confinement.

We do not reimburse you for copayments.
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 them. We do not reimburse
you for the deductible. Benefits paid by us do not count towards the deductible. Copayments and the amount you pay after coinsurance does not count toward any
deductible.
The calendar year deductible is $300 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses

applied to the calendar year deductible for family members reach $600. Expenses are "incurred" on the date on which the service or supply is received.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new
plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. We will base this percentage on either the billed charge or the Plan allowance, whichever
is less.
Example: You pay 10% of the Plan allowance for surgery performed by a PPO provider.

Note: If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the provider's fee by the amount waived.

For example, if your non-PPO physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49
(70% of the actual charge of $70).
Differences between Our "Plan allowance" is the amount we use to calculate our payment for covered our allowance and services. Fee-for-service plans arrive at their allowances in different ways, so their
the bill allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.

Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on
the provider you use.
When you live in the Plan's PPO area, you should use a PPO provider. The following two examples explain how we will handle your bill when you go to a PPO provider

and when you go to a non-PPO provider. When you use a PPO provider, the amount you pay is much less. 13
13 Page 14 15
2002 Foreign Service Benefit Plan 14 Section 4
PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your
deductible and coinsurance. Here is an example about coinsurance: You live in one of our PPO areas and you see a PPO physician who charges $150, but our
allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 10% of our $100 allowance ($ 10). Because
of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill. Follow these procedures when you use a PPO
provider in order to receive PPO benefits:
Verify with us that your address of record is in a PPO area;
When you phone for an appointment, verify that the physician or facility is still a PPO provider;

Present your PPO ID card confirming your PPO participation in order to receive PPO benefits; and
Do not pay a PPO provider at the time of service. PPO providers must bill us directly. We must reimburse the provider directly. PPO providers will
bill you for any balance after our payment to them.
Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. If you live in one of our PPO areas and you use a non-PPO provider, you

will pay your deductible and coinsurance plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who
charges $150 and our allowance is again $100. If you have met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance
($ 30). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill.

When you live outside of the PPO Network Area in the United States or outside of the United States, and use Out-of-Network providers the following example explains how
we will handle your bill:
Providers outside the PPO Network Area also have no agreement to limit what they bill you. When you live overseas, for example, you will pay your deductible

and coinsurance plus any difference between our allowance and charges on the bill. However, because you do not have a choice of PPO providers, the Plan does not
penalize you and your coinsurance in this next example is less: You live overseas and see an Out-of-Network physician who charges $150. Our allowance in this case
is $150. If you have met your deductible, you are responsible for your coinsurance, so you pay 20% of our $150 allowance ($ 30). You do not have any additional
amount to pay. If you live in an area in the United States where we do not have PPO providers, your coinsurance is still only 20%, but the Plan allowance for the
doctor's charge might be less. You might have an additional amount to pay, if his charge exceeds our allowance.

The following table illustrates the examples of how much you have to pay out-of-pocket for medical services from a PPO physician vs. a non-PPO physician vs. a
domestic Out-of-Network physician and vs. an overseas physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100.
The table shows the amount you pay if you have met your calendar year deductible.

EXAMPLE PPO physician Non-PPO physician Domestic Out-of-Network Overseas Physician Physician
Physician's charge $150 $150 $150 $150
Our allowance We set it at: 100 We set it at: 100 We set it at: 100 We set it at: 150
We pay 90% of our allowance: 90 70% of our allowance: 70 80% of our allowance: 80 80% of our allowance: 120
You pay:
Coinsurance 10% of our allowance: 10 30% of our allowance: 30 20% of our allowance: 20 20% of our allowance: 30
+Difference up to charge? No: 0 Yes: 50 Yes: 50 No: 0
TOTAL YOU PAY 10 80 70 30 14
14 Page 15 16
2002 Foreign Service Benefit Plan 15 Section 4
Regardless of the provider you choose, we subject benefits to all provisions of the Plan. Also, we do not supervise, control or guarantee the health care services of a
preferred provider or any other provider.
Your catastrophic protection For those services with coinsurance, we pay 100% of the Plan allowance for the out-of-pocket maximum remainder of the calendar year when out-of-pocket expenses for coinsurance,

for deductibles, coinsurance, deductibles and inpatient hospital copayment in that calendar year exceed and copayments $3,000 for Self Only and $3,500 for Self and Family enrollment (PPO providers)
$4,000 for Self Only and $4,500 for Self and Family (non-PPO providers and out-of-network area).

This out-of-pocket maximum is combined for medical/ surgical and mental health/ substance abuse.
The out-of-pocket expenses that apply to your out-of-pocket maximums described above include:
The $200 per confinement copayment you pay for non-PPO and out-of-network area hospitals;
The 20% you pay for room and board and other hospital charges in a non-PPO hospital for medical/ surgical admissions;
The 30% you pay for room and board and other hospital charges in a non-PPO hospital for mental conditions;
The 10% you pay for PPO and out-of-network area surgery, the 30% you pay for non-PPO surgery, and the 20% you pay for assistant surgeons;
The $300 (Self Only) or $600 (Self and Family) calendar year deductible you pay before the Plan begins paying benefits on certain services;
The 10% you pay for PPO providers, the 30% you pay for non-PPO providers, and the 20% you pay for providers outside the network area;
The 30% you pay for non-PPO doctors in-hospital and outpatient visits for mental conditions, subject to dollar and visit limitations;
The 30% you pay for day care in a non-PPO facility subject to visit limitations; The 50% you pay for non-PPO outpatient group therapy subject to the dollar
limitations; and The 20% you pay for purchasing prescriptions from pharmacies outside of the 50
United States or directly from doctors or other covered facilities.
The following cannot be counted toward out-of-pocket expense:
Expenses in excess of Plan allowances or maximum benefit or visit limitations; Expenses for dental care;

Any amounts you pay because benefits have been reduced for non-compliance with cost containment, precertification or authorization requirements (see pages 10-12);
Copayments you pay for prescription drugs; and Expenses for prescriptions purchased at pharmacies in the 50 United States without
using the Plan's combined Foreign Service Benefit Plan/ PAID Prescription Drug Identification Card or purchased from a source other than the Plan's Merck-Medco
Home Delivery Pharmacy service.
Lifetime maximums We have the following lifetime maximums: We limit the Hospice benefit to $7,500 per person when you precertify hospice care
and to $4,500 when you do not precertify. We limit the Orthodontic benefit to $1,000 per person.
We limit diagnosis and treatment of infertility to a maximum benefit of $5,000.
When government facilities Facilities of the Department of Veterans Affairs, the Department of Defense, and the bill us Indian Health Service are entitled to seek reimbursement from us for certain services
and supplies they provide to you or a family member. They may not seek more than their governing laws allow.

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. 15
15 Page 16 17
2002 Foreign Service Benefit Plan 16 Section 4
When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And, your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare.

The following chart has more information about the limits.

If you
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,
the law requires us to base our payment on an amount the "equivalent Medicare amount" set by Medicare's rules for what Medicare would pay, not on the actual charge;

you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.
Our explanation of benefits (EOB) form will tell you how much your hospital can collect from you. If your hospital tries to collect more than allowed by law, ask your hospital to reduce the charges. If you have paid more than allowed, ask for a refund.
If you need further assistance, call us.

And, for your physician care, the law requires us to base our payment and your coinsurance on an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
If your physician Then you are responsible for
Participates with Medicare or accepts your deductibles and coinsurance; Medicare assignment for the claim and is a

PPO provider,
Participates with Medicare and is a non-PPO your deductibles, coinsurance, and any balance or Out-of-Network provider, up to the Medicare approved amount;

Does not participate with Medicare (PPO, your deductibles, coinsurance, and any balance non-PPO or Out-of-Network providers), up to 115% of the Medicare approved amount
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much your physician can collect from you. If your physician tries to collect more than allowed by law, ask your physician to reduce the charges. If you have paid more than allowed, ask for a
refund. If you need further assistance, call us. 16
16 Page 17 18
2002 Foreign Service Benefit Plan 17 Section 4
When you have the We limit our payment to an amount that supplements the benefits that Medicare would Original Medicare Plan pay, under Medicare Part A (Hospital insurance) and Medicare Part B (Medical
(Part A, or Part B, or both) insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not
participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
If your physician accepts Medicare assignment, then you pay nothing for covered charges.

If your physician does not accept Medicare assignment, then you pay the difference between our payment combined with Medicare's payment and the charge.
Note: The physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the "limiting
charge." The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than
allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to your Medicare carrier who sent you the MSN form. Call us if
you need further assistance.

When you have a Medicare A physician may ask you to sign a private contract agreeing that you can be billed Private Contract with a directly for services Medicare ordinarily covers. Should you sign an agreement,
physician Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after
Medicare's payment.

Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare. 17
17 Page 18 19
2002 Foreign Service Benefit Plan 18 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and pages 70 -71 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 by phone at 202/ 833-4910 or e-mail at afspa@ afspa. org or at our website at www. afspa. org.

(a) Medical services and supplies provided by physicians and other health care professionals ................................................ 19-27
Diagnostic and treatment services Hearing services (testing, treatment, and supplies) Lab, X-ray, and other diagnostic tests Vision services (testing, treatment, and supplies)

Preventive care, adult Foot care Preventive care, children Orthopedic and prosthetic devices
Maternity care Durable medical equipment (DME) Family planning Home health services
Infertility services Chiropractic Allergy care Alternative treatments
Treatment therapies Educational classes and programs Physical, occupational and speech therapies

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................................ 28-31
Surgical procedures Organ/ tissue transplants Reconstructive surgery Anesthesia

Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services ........................................................................... 32-36
Inpatient hospital Hospice care Outpatient hospital or ambulatory surgical center Ambulance

Extended care benefits/ Skilled nursing care facility benefits
(d) Emergency services/ Accidents ................................................................................................................................................ 37-38 Medical emergency Ambulance
Accidental injury
(e) Mental health and substance abuse benefits ........................................................................................................................... 39-44
(f) Prescription drug benefits ........................................................................................................................................................ 45-47
(g) Special features .............................................................................................................................................................................. 48
Flexible benefits option Centers of excellence for tissue and organ transplants 24 hour nurse line Disease management programs

(h) Dental benefits ......................................................................................................................................................................... 49-50
(i) Non-FEHB benefits available to Plan members ........................................................................................................................... 51
SUMMARY OF BENEFITS ........................................................................................................................................................... 70-71 18
18 Page 19 20
2002 Foreign Service Benefit Plan 19 Section 5 (a)
Here are some important things you should 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.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to
show when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area. When no PPO provider is available

in a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between

our allowance and the billed amount
Lab, X-ray and other diagnostic tests continued on next page

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of physicians during a hospital stay, in the physician's office, at home, or consultations

Second opinion
Psychological tests and pharmacological visits
Medication provided in a physician's office
Drugs and medical supplies billed by a doctor or other covered facility (not including pharmacies) for use at home

Not covered: All charges.
Telephone consultations
Procedures, services, drugs, and supplies related to impotency, sex transformations, sexual dysfunction, or sexual inadequacy

Office visits by a dentist in relation to the removal of impacted teeth and other dental services. Office visits by a dentist in relation to covered oral
and maxillofacial surgical procedures are covered.

Lab, X-ray and other diagnostic tests
X-ray, laboratory and pathology services and machine diagnostic tests
not related to surgery or preadmission testing 19
19 Page 20 21
Lab, X-ray and other diagnostic tests (continued) You pay
X-ray, laboratory and pathology services and machine diagnostic tests

performed within 72 hours before admission to a hospital (preadmission testing)

X-ray, laboratory and pathology services and machine diagnostic tests
performed within 72 hours of an outpatient surgical procedure

Preventive care, adult
Routine physical examination limited to a maximum charge of $750 per person, per calendar year

In addition Routine Cancer Screenings limited to: Colorectal Cancer Screening, limited to
Fecal occult blood test one annually for members age 40 and older
Sigmoidoscopy, screening one every five years for members age 50 and older

Breast Cancer Screening (Mammogram) one annually for women age 35 and older
Cervical Cancer Screening Pap smear one annually for women age 18 and older
Prostate Cancer Screening Prostate Specific Antigen (PSA) one annually for men age 40 and older

Other Routine Services limited to:
Non-fasting total blood cholesterol test once every three consecutive calendar years

Chlamydial screening
Routine immunizations limited to
Tetanus-diphtheria (Td) booster one every 10 consecutive calendar years from age 19 and over

Influenza vaccine and pneumococcal vaccine one every calendar year, age 65 and over

2002 Foreign Service Benefit Plan 20 Section 5 (a)

PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount (No
deductible)
Out-of-Network Area: Only the difference between our allowance and the billed
amount (No deductible)
PPO: 10% of the Plan allowance (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our
allowance and the billed amount (No deductible)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount 20
20 Page 21 22
2002 Foreign Service Benefit Plan 21 Section 5 (a)
Maternity care continued on next page

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount (No

deductible)
Out-of-Network Area: Only the difference between our allowance and the billed amount

(No deductible)

PPO: 10% of the Plan allowance (No Deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No Deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No Deductible)

See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).
Note: If your child stays after your discharge and is covered under a Self and Family
enrollment, you must pay a separate hospital copayment of $200 for non-PPO and
Out-of-Network facilities. If your child is not covered under a Self and Family
enrollment you pay all of your child's
charges after your discharge.

Preventive care, children You pay
Preventive care for children is limited to:

Well-child visits through 18 months of age.

Note: Well child visits after 18 months of age are covered the same as
routine physical examinations. (See page 20, Preventive care, adult.)

Immunizations for children are limited to:
Childhood immunizations recommended by the American Academy of Pediatrics are covered for members under age 22.

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 11 for other circumstances when you must precertify, 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 cover an extended stay, if

medically necessary, but you, your representative, your doctor or your hospital must precertify.

We consider bassinet or nursery charges during the covered portion of the mother's maternity stay to be the expenses of the mother and not expenses
of the newborn child. We consider expenses of the child after the mother's discharge to be the expenses of the child. We cover these expenses only if
the child is covered by a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. 21
21 Page 22 23
Maternity care (continued) You pay
Special Outpatient Care Benefit. When you receive services:
on an outpatient basis;
at a licensed birthing center; or
as an inpatient resulting in a hospital confinement of one day (overnight) or less and no more than one day's room and board charge

the Plan pays 100% of our allowance for covered facility services at the time of delivery, not subject to the calendar year deductible or inpatient hospital
copayment.
Note: If you or your newborn child is transferred from a birthing center to a hospital due to medical complications, we will pay the birthing center expenses
as shown above. If you or your child leave the hospital against medical advice before a one-day confinement (overnight) is completed, we will pay our
regular benefits and not our special Outpatient Care Benefit.
Not covered: All charges.
Reversal of voluntary surgical sterilization
Procedures, services, drugs, and supplies related to impotency, sex transformations, sexual dysfunction or sexual inadequacy

Assisted Reproductive Technology (ART) procedures, such as artificial
insemination, in vitro fertilization, embryo transfer, and gamete intrafallopian transfer (GIFT), and services and supplies related to ART

procedures
Procedures, services, drugs, and 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

Family planning
A broad range of voluntary family planning services limited to surgery, medicine and IUD's

Surgery limited to:
Voluntary sterilization
Surgery to implant contraceptives (such as Norplant)

Medicine and IUDs limited to:
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

Note: We cover FDA-approved drugs, prescriptions, and devices for birth control covered under the Prescription benefit in Section 5( f).

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

2002 Foreign Service Benefit Plan 22 Section 5 (a)

PPO: Nothing (No deductible or hospital copayment)
Non-PPO: Only the difference between our allowance and the billed amount (No
deductible or hospital copayment)
Out-of-Network Area: Only the difference between our allowance and the billed amount

(No deductible or hospital copayment)

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

PPO: 10% of the Plan allowance (No deductible on surgery)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible on surgery)
Out-of-Network: 20% of the Plan allowance and any difference between our allowance and

the billed amount (No deductible on surgery) 22
22 Page 23 24
Infertility services You pay
Diagnosis and treatment of infertility, except as shown in Not covered. The maximum payment the Plan can make is $5,000 per person per lifetime for

the diagnosis and treatment of infertility as defined below.
Diagnosis of infertility includes:
The initial diagnostic tests and procedures done solely to identify the cause or causes of the inability to conceive.

The treatment of infertility includes:
Hormone therapy and related services; and
Medical or surgical services performed solely to create or enhance the ability to conceive.

Hormone therapy to diagnose or treat infertility is not available under any other Plan provisions.

Not covered: All charges.
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination
in vitro fertilization
embryo transfer and gamete intrafallopian transfer (GIFT)
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

Services and supplies related to ART procedures
Cost of donor sperm
Cost of donor egg

Allergy care
Testing, treatment, and injections including materials (such as allergy serum)

Not covered: provocative food testing, end point titration techniques and All charges.
sublingual allergy desensitization

2002 Foreign Service Benefit Plan 23 Section 5 (a)

PPO: 10% of the Plan allowance until benefits stop at $5,000; All charges after the Plan's
maximum payment of $5,000
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount until benefits stop at $5,000; All charges after the Plan's maximum
payment of $5,000
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount until benefits stop at $5,000; All charges after the Plan's
maximum payment of $5,000

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed
amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount 23
23 Page 24 25
Treatment therapies You pay
Chemotherapy and radiation therapy (includes radium and radioactive isotopes)

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 31.

Intravenous (IV)/ Infusion Therapy (supplies) Home IV and antibiotic therapy (supplies)
Note: See page 26 for home health services
Growth hormone therapy
Respiratory and inhalation therapies (includes oxygen and equipment for its administration)

Renal dialysis
Note: This benefit includes only the actual charge for the dialysis treatment. Other covered charges associated with the dialysis treatment are payable

under section 5( a) Lab, X-ray and other diagnostic tests not related to surgery or preadmission testing.

Not covered: All charges.
Chelation therapy, except for acute arsenic, gold, mercury, or lead poisoning

Physical, occupational and speech therapies
Physical therapy, occupational therapy, and speech therapy when rendered by a registered physical or occupational therapist or licensed speech therapist for

up to a total combined visit maximum of 90 visits per person per calendar year for the three listed therapies

Note: We only cover therapy when a physician:
1) orders the care;
2) identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

3) indicates the frequency and length of time the services are needed.
Note: We only cover physical and occupational therapy to restore bodily function when there has been a total or partial loss of bodily function due to
illness or injury.
You must submit the above information from your doctor, along with the therapist's initial evaluation and treatment plan and therapist's progress
(therapy) notes for each date of service.
Not covered: All charges.
Custodial care (see definition page 62)
Exercise programs

2002 Foreign Service Benefit Plan 24 Section 5 (a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount

PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount (No

deductible)
Out-of-Network Area: Only the difference between our allowance and the billed

amount (No deductible)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount 24
24 Page 25 26
Hearing services (testing, treatment, and supplies) You pay
Limited to:

Initial hearing exam

Not covered: All charges.
Hearing aids and examinations for them, except for the initial exam

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses per incident if required to correct an impairment directly caused by

accidental ocular injury or
specifically ordered by the doctor in connection with a diagnosis of
cataract
keratoconus or
glaucoma

Not covered All charges.
Routine eye examinations
Eyeglasses and contact lenses, except as shown above
Eye exercises and visual training (orthoptics)
Refractions
All refractive surgeries

Foot care
We do not provide benefits for routine foot care. Routine foot care would All charges. include such items as

treatment or removal of corns and calluses, or trimming of toenails
orthopedic shoes, orthotics and other supportive devices for the feet.

Orthopedic and prosthetic devices
Artificial eyes or limbs required to replace natural eyes and limbs
External breast prostheses, including surgical bras and replacements, following a mastectomy

Internal prosthetic devices such as pacemakers, artificial hips, intraocular lenses and surgically implanted breast implant following mastectomy.
Note: See 5( b) for coverage of the surgery to insert the device.
Note: A prosthetic device is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.

Not covered: All charges.
Orthopedic shoes, orthotics and other supportive devices for the feet

2002 Foreign Service Benefit Plan 25 Section 5 (a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount 25
25 Page 26 27
Durable medical equipment (DME) You pay
Rental, up to the purchase price, or purchase (at our option), including necessary repair and adjustment, of durable medical equipment such as:

Wheelchairs
Hospital-type beds
Oxygen and equipment for its administration
Crutches
Braces
Casts, splints, and trusses

Durable medical equipment (DME) is equipment and supplies that:
Are prescribed by your attending physician (i. e., the physician who is treating your illness or injury);

Are medically necessary;
Are primarily and customarily used only for a medical purpose;
Are generally useful only to a person with an illness or injury;
Are designed for prolonged use; and
Serve a specific therapeutic purpose in the treatment of an illness or injury.

Not covered: All charges.
Other items that do not meet the definition of durable medical equipment such as sun or heat lamps, whirlpool baths, heating pads, air purifiers,

humidifiers, air conditioners, and exercise devices
Home health services
You must precertify home health care (see Section 3 "How to get approval for" on pages 10 -12) in order to get maximum benefits.

If you precertify your home health care, we pay 100% of our allowance up to $80 per visit for a maximum of 90 visits per calendar year, limited to
one visit per day, if such care is an alternative to hospitalization.
If you do not precertify your home health care, we pay 100% of our allowance up to $40 per visit for a maximum of 40 visits per calendar year,

limited to one visit per day, if such care is an alternative to hospitalization.
Note: A home health care visit consists of one of the following:
Less than an 8 hour shift of nursing care provided on a part-time basis by a registered nurse (R. N.) or a licensed practical nurse (L. P. N.);

One session of physical, occupational or speech therapy provided by a licensed therapist;
One visit from a licensed social worker (limited to two visits per calendar year); or
Less than an 8 hour shift of a home health aide's services that are performed under the supervision of a registered nurse (R. N.) and that
consists mainly of medical care and therapy provided solely for the care of the insured person.

A home health agency (or visiting nurses where services of a home health agency are not available) must furnish the care in accord with a home health
care plan (see definition below). The home health care plan must be certified by your doctor and furnished in your home.

Note: We define a home health care plan as a plan of continued medical care and treatment ordered by a doctor who certifies that without home health care,
you would need to be confined in a hospital or skilled nursing care facility. A public agency or private organization that is licensed as a home health agency
by the State and is certified as such under Medicare must provide the care.

2002 Foreign Service Benefit Plan 26 Section 5 (a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount

For precertified home health care, nothing (No deductible) up to $80 per visit up to
90 visits per calendar year; All charges above $80 per visit and/ or 90 visits per
calendar year and all charges above one visit per day.

For non-precertified home health care, nothing (No deductible) up to $40 per visit
up to 40 visits per calendar year; All charges above $40 per visit and/ or 40 visits per
calendar year and all charges above one visit per day

Home health services continued on next page 26
26 Page 27 28
2002 Foreign Service Benefit Plan 27 Section 5 (a)
Nothing (No deductible) up to $12 per unit; All charges after $12 per unit and all
charges after 500 units per calendar year

PPO: 10% of Plan allowance and all charges above $20 per visit and/ or 30 visits per
person per calendar year
Non-PPO: 30% of Plan allowance and all charges above $20 per visit and/ or 30 visits

per person per calendar year
Out-of-network: 20% of Plan allowance and all charges above $20 per visit and/ or 30

visits per person per calendar year

PPO: 10% of Plan allowance and all charges above $20 per visit and/ or 30 visits per
person per calendar year
Non-PPO: 30% of Plan allowance and all charges above $20 per visit and/ or 30 visits

per person per calendar year
Out-of-network: 20% of Plan allowance and all charges above $20 per visit and/ or 30

visits per person per calendar year

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount

Home health services (continued) You pay
Private Duty Nursing at home:
When you receive care by a registered nurse (R. N.) or licensed practical nurse (L. P. N.) in your home, we will cover up to 500 units of nursing care

per calendar year. One unit equals up to one hour of private duty nursing care. We pay $12 per unit.

Not covered: All charges.
Nursing care requested by, or for the convenience of, the patient or the
patient's family

Custodial care (see definition page 62)
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative

Chiropractic
Covered services are limited to:
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy and cold pack application

Benefits are limited to a maximum payable of $20 per visit up to 30 visits per person per calendar year.
Note: The Plan defines Chiropractic as a system of therapeutics that attributes disease to dysfunction of the nervous system and attempts to restore normal
function by manipulation and treatment of the body structures, especially those of the vertebral column.

Alternative treatments
Acupuncture only when performed by an M. D, D. O., O. M. D., or L. Ac.

The benefit is limited to a maximum payable of $20 per visit and a maximum of 30 visits per person per calendar year.

Note: The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical
anesthesia, or for therapeutic purposes.

Not covered: All charges.
Naturopathic services and medicines
Homeopathic services and medicines

(Note: Benefits of certain alternative treatment providers may be covered in
medically underserved areas; see page 8)

Educational classes and programs
Coverage is limited to:
Smoking Cessation Office visits, individual and group counseling and purchase of over-the-counter smoking cessation drugs and supplies up to

a maximum payable of $100 for one program per person per 12 months.
Note: Prescription drugs are covered only under the Prescription benefit not subject to the $100 limitation (see Section 5( f)).

Note: Over-the-counter smoking cessation drugs and supplies you receive in conjunction with a smoking cessation program cannot be purchased with
your drug card. You must file a claim for them. 27
27 Page 28 29
2002 Foreign Service Benefit Plan 28 Section 5 (b)
Here are some important things you should 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.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year deductible does not apply to any benefits in this Section. We added "( No deductible)" to
show that the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area. When no PPO provider is available in

a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. 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.).

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our
allowance and the billed amount (No deductible)

Surgical procedures continued on next page

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible does not apply to benefits in this Section. We say "( No deductible)" when it does not apply.
Surgical procedures
A comprehensive range of services, such as: Operative procedures

Treatment of fractures, including casting Normal post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Surgical treatment of morbid obesity a condition in which an individual: 1) weighs 100 pounds or 100% over the standard weight as determined by
us and has complicating medical condition( s); and 2) has been so for at least five years, despite documented unsuccessful attempts to reduce under
a doctor-monitored diet and exercise program. Eligible members must be age 18 or over.
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization Surgical implantation of Norplant (a contraceptive) and intrauterine
devices (IUDs) Treatment of burns
Amniocentesis Routine circumcision of a newborn child (only when the child is covered
under a Self and Family enrollment)
Note: Drugs, medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a provider for use at home are

covered only under Section 5( a) and the calendar year deductible and coinsurance apply.

Note: Second opinion is covered under Section 5( a) Diagnostic and treatment services

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Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals 28
28 Page 29 30
Surgical procedures (continued) You pay
Assistant Surgeon (inpatient/ outpatient)

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, we pay:
For the primary procedure:
PPO: 90% of the Plan allowance
Non-PPO: 70% of the Plan allowance
Out-of-Network: 90% of the Plan allowance

For the secondary procedure( s):
PPO: 90% of 50% of the Plan allowance
Non-PPO: 70% of 50% of the Plan allowance
Out-of-Network: 90% of 50% of the Plan allowance.

Note: For certain surgical procedures, we may apply a value of less than 50% for subsequent procedures.

Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary surgery. That is, the procedure would
not add time or complexity to patient care. We do not pay extra for incidental procedures.

Not covered: All charges.
Cosmetic surgery except for the repair of accidental injuries sustained while covered under the FEHB Program; to correct a congenital

anomaly; or for the reconstruction of a breast following a mastectomy
Note: We define cosmetic surgery as any operative procedure or any
portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through change in bodily form.

All refractive surgeries
Routine surgical treatment of conditions of the foot (see Section 5( a)
Foot care)

Services of a standby surgeon
Reversal of voluntary sterilization
Surgeries related to impotency, sex transformation, sexual dysfunction or sexual inadequacy

2002 Foreign Service Benefit Plan 29 Section 5 (b)

PPO: 20% of the Plan allowance (based on 20% of the Plan allowance allocated to the
surgery charge) (No deductible)
Non-PPO and Out-of-Network Area: 20% of the Plan allowance (based on 20% of the

Plan allowance allocated to the surgery charge) and any difference between our
allowance and the billed amount (No deductible)

PPO: 10% of the Plan allowance for the primary procedure and 10% of 50% of the
Plan allowance for the secondary procedure( s) (No deductible)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of 50% of the
Plan allowance for the secondary procedure( s); and any difference between our
payment and the billed amount (No deductible)

Out-of-Network Area: 10% of the Plan allowance for the primary procedure and 10%
of 50% of the Plan allowance for the secondary procedure( s); and any difference
between our allowance and the billed amount (No deductible) 29
29 Page 30 31
2002 Foreign Service Benefit Plan 30 Section 5 (b)
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our
allowance and the billed amount (No deductible)

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

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

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm (Congenital

anomaly). Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and
toes and other conditions that we may determine to be congenital anomalies. We will not consider the term congenital anomaly to include
conditions relating to teeth or intra-oral structures supporting the teeth.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
surgical treatment of any physical complications, such as lymphedemas;
breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage)

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 except for the repair of accidental injuries sustained
while covered under the FEHB Program; to correct a congenital anomaly; or for the reconstruction of a breast following a mastectomy

Note: We define cosmetic surgery as any operative procedure or any
portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through change in bodily form.

Surgeries related to impotency, sex transformation, sexual dysfunction or sexual inadequacy

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones

Surgical correction of cleft lip, cleft palate or severe functional malocclusion (when we determine the correction of the malocclusion to
be medically necessary) Removal of stones from salivary ducts
Excision of leukoplakia or malignancies Excision of non-dentigerous cysts and incision of non-dentigerous abscesses
Excision of impacted teeth only Other surgical procedures that do not involve the teeth or their supporting
structures
Not covered: All charges. Oral implants and transplants

Procedures that involve any tooth or tooth structure, alveolar process,
abscess, periodontal disease or disease of gingival tissue except as provided under Dental Benefits (see page 50)

Non-surgical treatment of Temporomandibular joint (TMJ) disorders
including dental appliances, study models, splints and other devices Excision of non-impacted teeth 30
30 Page 31 32
2002 Foreign Service Benefit Plan 31 Section 5 (b)
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Note: Mutual of Omaha has special arrangements with facilities to provide
services for tissue and organ transplants its Medical Specialty Network. The network was
designed to give you an opportunity to access providers that demonstrate high quality
medical care for transplant patients. Your physician can coordinate arrangements by
calling a case manager in Mutual of Omaha's Medical Management Department at 1-800/
228-0286. For additional information regarding the transplant network, please call
this number.

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Organ/ tissue transplants You pay
Limited to the following transplants:
Cornea Heart
Kidney Liver
Pancreas Heart/ lung
Single and double lung
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

and pancreas for irreversible intestinal failure
Bone marrow and stem cell support as follows:
Allogeneic bone marrow transplants
Autologous bone marrow transplants (autologous stem cell support) and autologous peripheral stem cell support for

1) Acute lymphocytic or non-lymphocytic leukemia;
2) Advanced Hodgkin's and non-Hodgkin's lymphoma;
3) Advanced neuroblastoma;
4) Testicular, mediastinal, retroperitoneal and ovarian germ cell tumors;
5) Breast cancer;
6) Multiple myeloma; and
7) Epithelial ovarian cancer

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. You are a recipient when you surgically receive a body

organ( s) transplant. You are a donor when you surgically donate a body organ( s) for transplant surgery. Transplant surgery means transfer of a body
organ( s) from the donor to the recipient.
Not covered: All charges.
Donor screening tests and donor search expenses, except those performed for the actual donor

Services or supplies for, or related to, surgical transplant procedures for artificial or human organ transplants not listed as covered
Transplants not listed as covered
Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Note: Anesthesia rendered by a dentist only in relation to covered oral and maxillofacial surgery is also covered (see page 30) 31
31 Page 32 33
Here are some important things you should 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.

Unlike the other subsections in Section 5, in this section, the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible
applies)". The calendar year deductible is: $300 per person ($ 600 per family).
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area. When no PPO provider is available in

a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. 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 in Sections 5( a), (b), (d) or (e).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information

shown in Section 3 for additional details on precertification.
YOU MUST ALSO GET PRECERTIFICATION OF CARE YOU RECEIVE IN SKILLED NURSING FACILITIES and HOSPICE and also HOME HEALTH CARE.

Please refer to this section (Skilled Nursing Facilities and Hospice) and section 5( a) (Home Health Care) for details on how your benefits are affected if you do not precertify. Also,
please refer to the precertification information shown in Section 3 for additional details on precertification.

2002 Foreign Service Benefit Plan 32 Section 5 (c)
PPO: Nothing
Non-PPO: $200 copayment per confinement and 20% of charges.

Out-of-Network Area: $200 copayment per confinement

Inpatient hospital continued on next page

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Benefit Description You pay
NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital's average charge for
semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average semiprivate rate of the most comparable
hospital in the area.

Section 5 (c). Services provided by a hospital or other facility, and ambulance services 32
32 Page 33 34
Inpatient hospital (continued) You pay
Other services and supplies received while in a hospital, such as: See previous page.
Use of operating, recovery, maternity and other treatment rooms
Surgical dressings
Prescribed drugs and medicines for use in the hospital
X-ray, laboratory and pathology services and machine diagnostic tests
Blood or blood plasma, if not donated or replaced, and its administration
Dressings, splints, casts and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Drugs, medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home (Note:

We cover these items only under Section 5( a) and the calendar year deductible and coinsurance apply.)

Special Overseas Benefit Inpatient private duty nursing services by an R. N. or L. P. N. when the services are rendered outside of North America.

Note: We provide specified benefits for professional services of a doctor, even when billed by the hospital. For example, when the hospital bills for such
professional services as surgery, anesthesiology, medical or therapy services, etc., we pay the specific surgery, anesthesia, medical or therapy benefit.

Note: See Section 5( a) for special preadmission testing benefit.
Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to

safeguard the health of the patient, even though we may not cover the services of dentists or doctors in connection with the dental treatment.

Not covered: All charges.
Confinement in nursing homes, rest homes, places for the aged,
convalescent homes, or any place that is not a hospital, skilled nursing care facility, or hospice (see Section 3, Covered providers and Covered

facilities, pages 8-9)
Cosmetic surgery except for the repair of accidental injuries sustained while covered under the FEHB Program; to correct a congenital anomaly; or for

the reconstruction of a breast following a mastectomy
Note: We define cosmetic surgery as any operative procedure or any portion of a procedure performed primarily to improve physical appearance and/ or

treat a mental condition through change in bodily form.
Custodial care (see definition page 62)
Any part of a hospital admission that is not medically necessary (see
definition page 63), such as when you do not need acute hospital inpatient
(overnight) care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care

Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital physician care at the level we would have covered if provided in an alternative setting.

Inpatient private duty nursing except as provided above
Personal comfort items such as radio, television, beauty and barber services, identification tags, baby beads, footprints, guest cots and meals,

newspapers and similar items

2002 Foreign Service Benefit Plan 33 Section 5 (c) 33
33 Page 34 35
Outpatient hospital or ambulatory surgical center You pay
Services and supplies rendered within 72 hours of outpatient surgery such as:
Operating, recovery and other treatment rooms
Prescribed drugs and medicines for use in the facility
X-ray, laboratory and pathology services and machine diagnostic tests
Blood and blood plasma, if not donated or replaced, and its administration
Dressings, casts and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics and anesthesia service
Drugs, medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home

(Note: We cover these items only under Section 5( a) and the calendar year deductible and coinsurance apply.)

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the
health of the patient, even though we may not cover the services of dentists or doctors in connection with the dental treatment.

Note: See also Section 5( a) Lab, X-ray and other diagnostic tests for benefits for services received within 72 hours of outpatient surgery.

Services and supplies not rendered within 72 hours of outpatient surgery or not related to surgery, such as:
Prescribed drugs and medicines for use in the facility
X-ray, laboratory and pathology services and machine diagnostic tests
Medical supplies and equipment, including oxygen
Drugs, medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home (Note:

We cover these items only under Section 5( a) and the calendar year deductible applies.)

Not covered: All charges.
Cosmetic surgery except for the repair of accidental injuries sustained while covered under the FEHB Program; to correct a congenital anomaly; or for

the reconstruction of a breast following a mastectomy
Note: We define cosmetic surgery as any operative procedure or any portion of a procedure performed primarily to improve physical appearance and/ or

treat a mental condition through change in bodily form.
All refractive surgeries
Cutting, trimming, treatment or removal of corns, calluses or the free edge
of toenails

Surgeries related to impotency, sex transformation, sexual dysfunction or sexual inadequacy

2002 Foreign Service Benefit Plan 34 Section 5 (c)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount
Out-of-Network Area: 10% of the Plan allowance and any difference between our
allowance and the billed amount

PPO: 10% of the Plan allowance (calendar year deductible applies).
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (calendar year deductible applies)

Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount (calendar year deductible applies) 34
34 Page 35 36
Extended care benefits/ Skilled nursing care facility benefits You pay
You must precertify your stay in a skilled nursing facility (see Section 3 "How to get approval for" on pages 10-12) in order to receive maximum benefits.

If you precertify your stay in a skilled nursing facility, we will pay 100% of the Plan allowance for a maximum of 60 days per confinement, when your
confinement:
is for the purpose of receiving medical care;
is under the supervision of a doctor; and
is an alternative to hospitalization.

If you do not precertify your stay in a skilled nursing facility, we will pay 80% of the Plan allowance for a maximum of 30 days per confinement,
when the above conditions are met.
Note: We will restore skilled nursing facility benefits shown above for each new period of confinement. We define a new period of confinement when:

the requirements listed above are met; and
at least 60 days have elapsed since you were last confined in a skilled nursing facility.

Not covered: Custodial care (see definition page 62) All charges.
Hospice care
You must precertify your care in a hospice (see Section 3 "How to get approval for" on pages 10-12 in order to receive maximum benefits.

If you precertify your care in a hospice, we will pay 100% of our allowance up to a lifetime maximum of $7,500 for hospice care provided by a hospice
agency or organization. Your doctor must recommend the care and you must be terminally ill in the final stages of illness.

If you do not precertify your care in a hospice, we will pay 100% of our allowance up to a lifetime maximum of $4,500 for hospice care when you
meet the above requirements.
Note: We will pay for any services covered under our other benefits under those benefits as applicable before we use the Hospice benefit.

Hospice is a coordinated program of home and inpatient pain control and supportive care for the terminally ill patient and the patient's family, provided
by a medically supervised team under the direction of a Plan-approved independent hospice administration.

Not covered: Services shown as covered under any other provisions of All charges. this Plan

2002 Foreign Service Benefit Plan 35 Section 5 (c)

For precertified care: Nothing up to the Plan allowance for up to 60 days per confinement;
All charges after 60 days
For non-precertified care: 20% of the Plan allowance for up to 30 days per confinement;
All charges after 30 days

For precertified care: Nothing up to the Plan allowance until benefits stop at $7,500; All
charges after $7,500
For non-precertified care: Nothing up to the Plan allowance until benefits stop at $4,500;

All charges after $4,500 35
35 Page 36 37
Ambulance You pay
Professional ambulance service to or from the hospital.

Note: See Section 5( d) for Ambulance within 72 hours of an accident.
Note: This benefit includes air ambulance service when medically necessary to transport you to the nearest facility equipped to handle your medical
condition.

Not covered: Ambulance transport for you or your family's convenience All charges.

2002 Foreign Service Benefit Plan 36 Section 5 (c)

PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (calendar year deductible applies)

Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount (calendar year deductible applies) 36
36 Page 37 38
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.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year deductible applies to some benefits in this Section. We added "( No deductible)" to show
when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area. When no PPO provider is available in

a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is an accidental injury?
An accidental injury is a bodily injury caused by an external force such as a blow or a fall and which requires immediate medical attention. We also consider animal bites and poisonings to be accidental injuries. We cover dental care required as a

result of an accidental injury to sound natural teeth. We do not consider an injury to the teeth while eating to be an accidental injury.

PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount (No

deductible)
Out-of-Network Area: Only the difference between our allowance and the billed amount

(No deductible)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount

2002 Foreign Service Benefit Plan 37 Section 5 (d)
Accidental injury continued on next page

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Accidental injury
We pay 100% of our allowance for outpatient emergency treatment (with or without surgery) for the following care you receive within 72 hours of an

accidental injury:
Physician services and supplies
Related outpatient services

Note: We pay Hospital benefits as specified in Section 5( c) if you are admitted.

For care you receive after 72 hours of your accidental injury, we cover:
Non-surgical physician services and supplies
Related outpatient services

Note: We pay Hospital benefits as specified in Section 5( c) if you are admitted.

Section 5 (d). Emergency services/ accidents 37
37 Page 38 39
Accidental injury (continued) You pay
If you receive surgical care for your accidental injury after 72 hours, we pay regular Surgical benefits.

Note: We pay Hospital benefits as specified in Section 5( c) if you are admitted.

Medical emergency
Regular Plan benefits apply to care you receive because of a medical emergency (non-accident). Items covered include:

Outpatient medical services and supplies
Physician services and supplies
X-ray, laboratory and pathology services and machine diagnostic tests

Ambulance
If you use a professional ambulance service within 72 hours of an accident:
Plan pays the first $50 of charges in full.

Note: See Section 5( c) for non-emergency service, for service after 72 hours and in excess of $50.

Not covered: Ambulance transport for you or your family's convenience All charges.

2002 Foreign Service Benefit Plan 38 Section 5 (d)

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our
allowance and the billed amount (No deductible)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount

PPO: Nothing (No deductible) up to $50
Non-PPO: Nothing (No deductible) up to $50

Out-of-Network Area: Nothing (No deductible) up to $50 38
38 Page 39 40
2002 Foreign Service Benefit Plan 39 Section 5 (e)
You may choose to get care from a PPO or non-PPO provider if you live in the PPO area and from an Out-of-Network Area provider if you do not live in the PPO area. When you receive
any care, you must get our approval for services and follow a treatment plan we approve. If you do, cost-sharing and limitations for PPO and Out-of-Network Area 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 and are payable only when we determine they are medically necessary.

The calendar year deductible or, for facility care, the inpatient copayment apply to almost all benefits in this section. We added "( No deductible)" to show when the calendar year
deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area. When no PPO provider is available in

a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. 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 descriptions below.

PPO mental health and substance abuse benefits are below and on the next page, non-PPO benefits begin on page 41 and Out-of-Network benefits begin on page 43.

Your cost sharing responsibilities are no greater than for other illnesses or conditions.
Note: See pages 40-41 for penalties for not precertifying, preauthorizing, obtaining
concurrent review (which means review of continuing treatment) or following your
treatment plan.

PPO mental health and substance abuse benefits continued on next page

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Section 5 (e). Mental health and substance abuse benefits

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
IN-NETWORK AREA BENEFITS PPO mental health and substance abuse benefits (if you live in the PPO area and use a PPO provider)

All covered diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services, drugs, and
supplies described elsewhere in this brochure.
Note: 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. We will reduce your benefits if you do not precertify, preauthorize, obtain concurrent review (which means
review of continuing treatment) or follow your treatment plan for all levels of care.

Professional services including: PPO: 10% of Plan allowance
Individual and group therapy rendered by providers such as psychiatrists, psychologists, or clinical social workers

Medication management Note: We cover this under Section 5( a) pharmacological visits, no preauthorization required. 39
39 Page 40 41
PPO mental health and substance abuse benefits (continued) You pay
Diagnostic tests including psychological testing PPO: 10% of Plan allowance
Services provided by a hospital or other facility PPO Inpatient Facility: nothing for room and board and other services (No deductible)

Services in approved outpatient care settings such as:
Intensive Outpatient Programs (IOP). These programs offer time-limited services that:

Are coordinated, structured, and intensively therapeutic;
Are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from

psychiatric or addictive disorders; and
Offer 3-4 hours of active treatment per day at least 2-3 days per week.

Partial Hospitalization. Partial hospitalization is a time limited, ambulatory, active treatment program that:

Offers therapeutically intensive, coordinated and structured clinical services within a stable therapeutic milieu; and
Provides at least 20 hours of scheduled programming extended over a minimum of 5 days per week in either a licensed or JCAHO
accredited facility.
Day Care in a day care facility (see definition, page 9) PPO Day Care Facility: 10% of Plan allowance

Not covered: All charges
Services we have not approved
Counseling or therapy for marital, educational, sexual, or behavioral problems

Treatment of mental retardation and learning disabilities
Telephone consultations

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.

Precertification/ Preauthorization To be eligible to receive mental health and substance abuse benefits you must obtain and follow a treatment plan and follow all of our authorization processes and
your treatment plan. This applies to all inpatient and outpatient hospital care, and all inpatient, outpatient or office care you receive from doctors and other covered
providers. See pages 10-12 for more detail. These include:
Precertification to establish the medical necessity of your admission to a hospital or other facility for you to receive full Plan benefits. If you do not

precertify, we will reduce the benefits payable by $500. You must report emergency admissions within two business days following the day of admission
even if you have been discharged.
Preauthorization to establish the medical necessity for all levels of outpatient or office care whether in or out-of-network. If you do not preauthorize, we will

reduce any available benefits by 50% of what we would have paid had you preauthorized your care.

Concurrent review (which means review of continuing treatment) to establish the medical necessity for all levels of continuing outpatient or office care whether
in or out-of-network. If you do not obtain concurrent review or follow your treatment plan, we will reduce any available benefits by 50% of what we would
have paid had you obtained concurrent review or followed your treatment plan.

2002 Foreign Service Benefit Plan 40 Section 5 (e)

PPO IOP Intensive Outpatient Program and PPO Partial Hospitalization facility: 10% of
Plan allowance

Precertification/ Preauthorization continued on next page 40
40 Page 41 42
2002 Foreign Service Benefit Plan 41 Section 5 (e)
Your cost sharing responsibilities are greater and limitations apply when you use a non-PPO
provider.
Note: See pages 40-41 and 42 for penalties for not precertifying, preauthorizing,
obtaining concurrent review (which means review of continuing treatment) or following
your treatment plan.

Non-PPO Professional fees:
Individual therapy inpatient: 30% of Plan allowance plus all charges above $60; and

all visits above 50 per person per calendar year

Group therapy inpatient: Nothing up to $30 per session and all charges above $30
Individual therapy outpatient: 30% of Plan allowance and any difference
between our allowance and the billed amount up to 60 visits per person per
calendar year; and all visits after 60 per person per calendar year

Group therapy outpatient: 50% of Plan allowance plus and all charges above $40

Non-PPO medication management: 30% of Plan allowance and any difference between
our allowance and the billed amount

Non-PPO mental health and substance abuse benefits continued on next page

PPO mental health and substance abuse benefits (continued)
To precertify or preauthorize care and obtain concurrent review for continuing care, you, your representative, your doctor, or your hospital must call

Mutual of Omaha's Care Review Unit at 1-800/ 228-0286 prior to the admission or care.

Note: We do not require precertification, preauthorization or concurrent review for continuing care for services you receive outside of the United States or when
Medicare Part A and/ or B, or another group health insurance policy is the primary payer. Precertification, preauthorization and concurrent review for continuing care is
required, however, when Medicare or the other group health insurance policy stops paying benefits for any reason.

PPO limitation We will limit your benefits if you do not follow all of our preauthorization processes and your treatment plan.
IN-NETWORK AREA BENEFITS You pay
After the calendar year deductible Non-PPO mental health and substance abuse benefits (if you live in the PPO area and use a non-PPO provider

All covered diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services, drugs, and
supplies described elsewhere in this brochure.
Note: 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. We will reduce your benefits if you do not precertify, preauthorize, obtain concurrent review (which means
review of continuing treatment), or follow your treatment plan for all levels of care.

Professional services including:
Individual and group therapy rendered by providers such as psychiatrists, psychologists, or clinical social workers with the following limitations:

Non-PPO inpatient professional services limited to 50 visits per person per calendar year and a maximum payable of $60 per visit
Non-PPO inpatient group therapy limited to actual charges up to a maximum payable of $30 per session
Non-PPO outpatient individual therapy benefits limited to 60 visits per person per calendar year
Non-PPO outpatient group therapy benefits limited to $40 per session

Medication management -Note: We cover this under Section 5( a) pharmacological visits, no preauthorization required and not subject to
the Plan's maximum visit limitation.
Diagnostic tests including psychological testing Non-PPO: 30% of Plan allowance 41
41 Page 42 43
Non-PPO mental health and substance abuse benefits (continued) You pay
Services provided by a hospital or other facility Non-PPO Inpatient Facility: $200 copayment per person per confinement and 30% of

covered charges for room and board and other services (No deductible)

Services in approved outpatient care settings such as:
Intensive Outpatient Programs (IOP). These programs offer time-limited services that:

Are coordinated, structured, and intensively therapeutic;
Are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from psychiatric

or addictive disorders; and
Offer 3-4 hours of active treatment per day at least 2-3 days per week.

Partial Hospitalization. Partial hospitalization is a time limited, ambulatory, active treatment program that:

Offers therapeutically intensive, coordinated and structured clinical services within a stable therapeutic milieu; and
Provides at least 20 hours of scheduled programming extended over a minimum of 5 days per week in either a licensed or JCAHO
accredited facility.
Day Care in a day care facility (see definition, page 9) with the following limitation:

Non-PPO day care facility services limited to 20 visits per person to a day care facility.

Not covered: All charges.
Services we have not approved
Counseling or therapy for marital, educational, sexual, or behavioral
problems

Treatment of mental retardation and learning disabilities
Telephone consultations
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.

Precertification/ Preauthorization We have the same precertification, preauthorization and concurrent review (which means review of continuing treatment) requirements for non-PPO (within Network
Area) services and Out-of-Network Area in the United States as we do for PPO (within Network Area). See pages 40-41 for details.

Non-PPO limitation We will limit your benefits if you do not follow all of our authorization processes and your treatment plan.

2002 Foreign Service Benefit Plan 42 Section 5 (e)

Non-PPO IOP Intensive Outpatient Program and non-PPO partial hospitalization facility:
30% of Plan allowance and any differences between our allowance and the billed amount

Non-PPO Day Care Facility: 30% of Plan allowance and any difference between our
allowance and the billed amount for up to 20 days. After 20 days you pay all charges. 42
42 Page 43 44
2002 Foreign Service Benefit Plan 43 Section 5 (e)
Out-of-Network Area mental health and substance abuse benefits continued on next page

Your cost sharing responsibilities are no greater than for other illness or conditions.
Note: See pages 40-41 and 44 for penalties for not precertifying, preauthorizing or
obtaining concurrent review (which means review of continuing treatment) or following
your treatment plan.

Out-of-Network Area Professional fees:
Individual therapy inpatient and outpatient: 20% of Plan allowance and

any difference between our allowance and the billed amount

Group therapy inpatient and outpatient: 20% of Plan allowance and any difference
between our allowance and the billed amount

Out-of-Network medication management: 20% of Plan allowance and any difference
between our allowance and the billed amount

OUT-OF-NETWORK AREA BENEFITS You pay
Mental health and substance abuse benefits After the calendar year deductible

All covered diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies
described elsewhere in this brochure.
Note: 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. We will reduce your benefits if you do not precertify, preauthorize, obtain concurrent review (which means
review of continuing treatment) or follow your treatment plan for all levels of care.

Note: If you receive care outside of the United States, we do not require precertification, preauthorization or concurrent review for continuing care.
See pages 10-12 for details.
Professional services including:
Individual and group therapy rendered by providers such as psychiatrists, psychologists, or clinical social workers

Medication management Note: We cover this under Section 5( a) pharmacological visits, no preauthorization required.
Diagnostic tests including psychological testing Out-of-Network Area: 20% of Plan allowance
Services provided by a hospital or other facility Out-of-Network Area Inpatient Facility: $200 copayment per person per confinement (No

deductible) 43
43 Page 44 45
2002 Foreign Service Benefit Plan 44 Section 5 (e)
Out-of-Network Area: IOP Intensive Outpatient Program and partial hospitalization
facility: 20% of Plan allowance and any difference between our allowance and the
billed amount

Out-of-Network Area Day Care Facility: 20% of Plan allowance and any difference between
our allowance and the billed amount for up to 20 days. After 20 days you pay all charges.

OUT-OF-NETWORK AREA BENEFITS Mental health and substance abuse benefits (continued) You pay
Services in approved outpatient care settings such as:
Intensive Outpatient Programs (IOP). These programs offer time-limited services that:

Are coordinated, structured, and intensively therapeutic;
Are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from psychiatric

or addictive disorders; and
Offer 3-4 hours of active treatment per day at least 2-3 days per week.

Partial Hospitalization. Partial hospitalization is a time limited, ambulatory, active treatment program that:

Offers therapeutically intensive, coordinated and structured clinical services within a stable therapeutic milieu; and
Provides at least 20 hours of scheduled programming extended over a minimum of 5 days per week in either a licensed or JCAHO
accredited facility.
Day Care in a day care facility (see definition, page 9)

Not covered: All charges.
Services we have not approved
Counseling or therapy for marital, educational, sexual, or behavioral problems

Treatment of mental retardation and learning disabilities
Telephone consultations

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.
Precertification/ Preauthorization We have the same precertification, preauthorization and concurrent review (which means review of continuing treatment) requirements for non-PPO (within Network
Area) services and Out-of-Network Area in the United States as we do for PPO (within Network Area). We waive these requirements for treatment you receive
outside of the United States. See pages 40-41 for details.
Out-of-Network Area Limitation We will limit your benefits if you do not follow all of our authorization processes and your treatment plan except for care received outside of the U. S.

See these sections of the brochure for more valuable information about these benefits:
Section 4, Your cost for covered services, for information about catastrophic protection for these benefits.
Section 7, Filing a claim for covered services, for information about submitting non-PPO and Out-of-Network claims 44
44 Page 45 46
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 page 47.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year deductible applies only to prescriptions purchased outside of the 50 United States in this
Section. We added "( No deductible)" to show when the calendar year deductible does not apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.

There are important things you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
When you have to purchase a prescription.
We will provide you with a combination Foreign Service Benefit Plan/ PAID Prescription Drug Identification Card. The PAID Prescription LOGO will appear on the front of the card. The Plan's RX Group Number of

FSBP000 and PAID PRESCRIPTIONS, L. L. C. appear with the logo as follows:

In most cases, you simply present the card together with the prescription to a network pharmacy. You do not file a PAID prescription card claim with the Plan.
Where you can obtain your prescription.
Network Pharmacies within the 50 United States You must fill your prescription at a network pharmacy participating in the PAID TelePAID system. You may

obtain the names of network pharmacies by calling 1-800/ 818-6717, on the internet at www. merckmedco. com, or as a link through our web page at www. afspa. org. You must present your combined Foreign Service
Benefit Plan/ PAID Prescription Drug Identification Card when filling your prescription in order to receive this benefit. Prescriptions you purchase at network pharmacies without the use of your card are not
covered.
Non-Network Pharmacies in the 50 United States Prescriptions you purchase at non-network pharmacies in the 50 United States are not covered.

Mail Order You will receive forms for refills and future prescription orders each time you receive drugs or supplies under
the Merck-Medco Mail Service Pharmacy (Home Delivery Pharmacy service). You may also order refills over the internet directly from Home Delivery Pharmacy service by visiting www. merckmedco. com. If you have any
questions about a particular drug or a prescription, or to request your order forms, you may call 1-800/ 818-6717 in the United States or 1-800/ 497-4641 (available in over 140 countries) from overseas. You can also call
Merck-Medco collect at 973/ 560-6100 if the overseas number does not work for you. Your doctor must be licensed in the United States. If you are posted, living or traveling overseas, you may request up to a 1 year
supply of most medications. Prescriptions you purchase by mail order from a source other than Merck-Medco Home Delivery Pharmacy service are not covered.

To order by mail: 1) Complete the initial mail order form; 2) Enclose your prescription and copayment; 3) Mail your order to Home Delivery Pharmacy service; and 4) Allow approximately two weeks for delivery.

Retail Pharmacies outside of the 50 United States Fill your prescription as you normally do. Use the Plan's claim form to claim benefits for prescription drugs and
supplies you purchased through a retail pharmacy outside of the 50 United States. Claims must include receipts that show the name of the patient, prescription number, name of drug( s), name of the prescribing
doctor, name of the pharmacy, date, and the charge. You may obtain claim forms by calling 202/ 833-4910 or from our website at www. afspa. org. Mail claims to the Plan's address shown on page 53.

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2002 Foreign Service Benefit Plan 45 Section 5 (f)
FSBP000 PAID PRESCRIPTIONS, LLC
Section 5 (f). Prescription drug benefits
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2002 Foreign Service Benefit Plan 46 Section 5 (f)
These are the dispensing limitations.
The Plan follows Food and Drug Administration (FDA) guidelines.
You may purchase up to a 30-day supply of medication at a network pharmacy. Refills cannot be obtained until 50% of the drug has been used. You may not obtain more than a 30-day supply through the network

pharmacy arrangement.
You may purchase long-term (up to a 90-day supply) prescription needs through the Home Delivery Pharmacy service to receive higher benefits. Home Delivery Pharmacy service will fill your prescription.

We cover all drugs and supplies listed except for those that require constant refrigeration, are too heavy to mail, or that must be administered by a physician.

Per Federal regulations, Home Delivery Pharmacy service can only mail to addresses in the United States, APO and FPO addresses.
You may not obtain hormone therapy treatment with your combined Foreign Service Benefit Plan/ PAID Prescription ID Card or through the Home Delivery Pharmacy service.

If a Federally-approved generic equivalent to the prescribed drug is available, the Home Delivery Pharmacy service will dispense the generic equivalent instead of the brand name unless your physician specifies that the
brand name is required. Your physician must note "Dispense as Written" (DAW) for you to receive the name brand.

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 brand name is the name under which the manufacturer advertises and sells a

drug. Under Federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and effectiveness.

You can save money by using generic drugs. However, you and your physician have the option to request a brand name drug if a generic is available. To do so, make sure your physician notes "Dispense as Written"
(DAW) for you to receive the brand name.

When you have to file a claim.
See the previous page for instructions when you purchase prescriptions from a pharmacy outside of the United States.

Contact us for instructions on how to receive reimbursement if you purchase a prescription and any of the following apply:
You recently enrolled in the Plan and you do not have your combined Foreign Service Benefit Plan/ PAID Prescription ID Card;
Your participating pharmacy does not accept your ID card (such as enrollment issues, compound prescription medication, etc); or
You are in a nursing home that requires unit dosing or purchase of medication from a non-network pharmacy.

Prescription drug benefits (continued)

Prescription drug benefits begin on next page. 46
46 Page 47 48
2002 Foreign Service Benefit Plan 47 Section 5 (f)
Network Retail (including Medicare Part B): $10 generic/$ 20 brand name (No
deductible) Non-Network Retail (in the 50 United
States, including Medicare Part B): 100% of cost
Non-Network Retail pharmacies (outside of the 50 United States, including
Medicare Part B): 20% of cost Network Mail Order the Home Delivery
Pharmacy service (including Medicare Part B): $15 generic/$ 25 brand (No
deductible)
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.
Note: When Medicare Part B is the primary payer, the Plan does not waive

the copayment applicable to covered drugs and supplies purchased at a network
pharmacy or through the Home Delivery Pharmacy service.

Benefit Description You pay
NOTE: The calendar year deductible applies only to prescriptions purchased outside of the 50 United States.
We say "( No deductible)" when it does not apply.

Covered medications and supplies
You must present your combined Foreign Service Benefit Plan/ PAID Prescription Drug Identification Card when filling your prescription at

a network pharmacy.
You may purchase the following medications and supplies prescribed by a physician from either a network pharmacy, retail pharmacy outside of the

50 United States, or by mail through the Home Delivery Pharmacy service:
Drugs that by Federal law of the United States require a doctor's prescription for their purchase except those listed as not covered

Insulin
FDA-approved drugs, prescriptions, and devices for birth control
Prescription drugs for smoking cessation

You may also purchase the following supplies that do not require a prescription by using your card:

Needles and syringes for the administration of covered medications
Diabetic, colostomy, and ostomy supplies
Prescription drugs you receive from a doctor or facility are covered only as specified under Section 5( a) and 5( c).

Not covered: All charges.
Drugs and supplies you purchase at a non-network pharmacy in the
United States except as covered under Section 5( a) and 5( c)

Drugs and supplies you purchase without using your combined Foreign
Service Benefit Plan/ PAID Prescription Drug ID Card at a network
pharmacy except as covered under Section 5( a) and 5( c)

Drugs and supplies you purchase by mail order from a source other than
the Plan's Merck-Medco Home Delivery Pharmacy service

Prescription Drug Card copays
Non-prescription medicines (over-the-counter medications)
Drugs and supplies for cosmetic purposes
Nutritional supplements and vitamins
Medication that under Federal law does not require a prescription, even if your doctor prescribes it or State law requires it or for which

there is a non-prescription equivalent available
Hormone therapy to diagnose or treat infertility except that limited to the
$5,000 lifetime maximum as part of the diagnosis and treatment of
infertility (see page 23). You may not obtain hormone therapy treatment with your combined Foreign Service Benefit Plan/ PAID Prescription

ID Card or through the Home Delivery Pharmacy service.
Drugs and supplies related to impotency, sex transformations, sexual
dysfunction, or sexual inadequacy 47
47 Page 48 49
Section 5 (g). Special features
Special features Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

24 hour nurse line Optum NurseLine:
You can reach a R. N. 24 hours every day by calling:
Toll-free 1-877/ 610-9809 (this number is also available in over 140 countries from overseas using the specific country's AT& T Access Number); or

A dedicated collect call number (from overseas) at 304/ 767-7374.
You can also access health and well-being information through Optum's Internet application at www. healthforums. com.

Optum NurseLine provides assistance with:
General health information
Deciding where to go for care
Choosing self-care measures
Guidance for difficult conditions
Medication questions
Communicating with your health care provider

We mail new members information on Optum NurseLine that contains more details on the services Optum offers.

Centers of excellence for Mutual of Omaha has special arrangements with facilities to provide services for tissue tissue and organ transplants and organ transplants its Medical Specialty Network. The network was designed to
give you an opportunity to access providers that demonstrate high quality medical care for transplant patients. Your physician can coordinate arrangements by calling a case
manager in Mutual of Omaha's Medical Management Department at 1-800/ 228-0286. For additional information regarding the transplant network, please call this number.

Disease management programs Healthydirections sm , a disease management program for members and covered dependents with asthma, diabetes, or congestive heart failure (CHF).
Healthydirections sm is provided at no additional cost to participants. The program provides:
Nurse support;
Education about the disease and how it affects the body; and
Proper medical management that can help lead to a healthier lifestyle.

We will contact candidates and ask them to participate voluntarily. The participant and his/ her physician remain in charge of the participant's treatment plan.

If you would like to contact Mutual of Omaha for more information about this program, please call 1-800/ 228-0286.

2002 Foreign Service Benefit Plan 48 Section 5 (g) 48
48 Page 49 50
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.

The calendar year deductible is: $300 per person ($ 600 per family). The calendar year deductible does not apply to most benefits in this Section. We added "( calendar year
deductible applies)" to show when the calendar year deductible does apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also

read Section 9 about coordinating benefits with other coverage, including with Medicare.
NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the health of the patient, even

though we may not pay benefits for services of dentists or doctors in connection with the dental treatment.

2002 Foreign Service Benefit Plan 49 Section 5 (h)
PPO: 20% of Plan allowance (calendar year deductible applies)
Non-PPO and Out-of-Network Area: 20% of Plan allowance and any difference between
our allowance and the billed amount (calendar year deductible applies)

Dental benefits continued on next page

Accidental injury benefit You pay
We cover dental work (including dental X-rays) to repair or initially replace sound natural teeth under the following conditions:

You must receive these services as a result of an accidental injury (see page 37) to the jaw or sound natural teeth.
You must be covered by this Plan when the accident occurred.
You must receive these services within 24 months of the accident.

Note: We define a sound natural tooth as a tooth which
is whole or properly restored;
is without impairment, periodontal or other conditions; and
does not need treatment for any reason other than an accidental injury.

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Section 5 (h). Dental benefits 49
49 Page 50 51
2002 Foreign Service Benefit Plan 50 Section 5 (h)
Dental benefits (continued) (Only those services listed below are covered)
Service We pay You pay (scheduled allowance)
Preventive care, limited to two services per person per calendar year
Oral exam $13 per exam
Prophylaxis (cleaning), adult $23 per cleaning
Prophylaxis, child (thru age 14) $16 per cleaning
Prophylaxis with fluoride, child (thru age 14) $26 per cleaning All charges in excess of the

Surgery scheduled amounts listed to the left
Apicoectomy (tooth root amputation) $50 per root
Alveolectomy (excision of alveolar bone) $40 for 4 through 12 teeth $60 for 13 through 20 teeth

$80 for 21 or more teeth
Alveolar abscess, incision and drainage $10 per abscess
Gingivectomy (excision of gum tissue) $50 per quadrant

Note: Excision of impacted teeth and non-dental oral surgical procedures are covered under
Surgery Section 5( b), page 30.

Orthodontic Services We pay You pay
We define orthodontics as the realignment of 50% of Plan allowance up to a 50% of Plan allowance until natural teeth or correction of malocclusion. lifetime maximum of $1,000 per benefits stop at $1,000. All charges

person after $1,000. 50
50 Page 51 52
2002 Foreign Service Benefit Plan 51 Section 5 (i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles, copayments or out-of-pocket

maximums.
The importance of Long Term care insurance has never been clearer. The government will present its own offering in October of this year and you can read about it on page 67 of this
brochure. AFSPA members are eligible for our plans NOW. We offer two excellent policies with group rates and deep discounts. Both plans provide benefits for all levels of nursing home care
(skilled, intermediate, custodial), assisted living facility, home health care, adult day care and respite care. The underwriters, Mutual of Omaha and John Hancock, are highly respected pillars
of the insurance industry.
Mutual of Omaha John Hancock $100 daily benefit $50 to $300 daily benefit

5% simple inflation 5% simple or compound inflation Benefit Increase Option 100% of benefit for home health care
International coverage 2-year to lifetime benefit period Return-of-premium feature Some International coverage

You may purchase non-covered (off-plan) prescription drugs at a discount directly from Merck-Medco Rx (MMRx) Services such as:
Dermatologicals (Retin-A) Anorexiants Rx Vitamins
Erectile dysfunction agents (Viagra) Drugs labeled for cosmetic indications (Propecia)
You pay 100% of the discounted price. You cannot file a claim with us for off-plan prescriptions.

Call MMRx Services first at 1-800/ 818-6717 to find out the price of off-plan prescriptions. Obtain the prescription from your doctor.
Complete the mail order envelope and enclose your prescription along with your check or credit card number. You must include full payment with your order for prescriptions.

Up to $200,000 of coverage Includes acts of terrorism or war
Simple, inexpensive, straightforward protection
Two Plans offered: CONSUMER DENTAL CARE (Available DC/ MD/ VA Only)

No claim forms, deductibles, or waiting period for pre-existing conditions DENTAL INDEMNITY PLAN (CIGNA International)
International and domestic coverage; Based on coinsurance at 100%, 80% and 50%; Overseas dental referrals; Claims processed in any language and most currencies

Long Distance Calling Card and, for those overseas, Callback Service Telephone No sign-up fees, no monthly fees, excellCould not acquire words on page 52 ent domestic and international rates, and no hidden
Services costs
Senior Living At no cost to our members, we offer information on senior living facilities throughout the U. S. Services

Legal Services Three firms located in the Washington Metropolitan area serve our members at special rates
Travel Emergency medical evacuation; On-the-spot medical payments; Worldwide medical referrals Assistance and medical monitoring; Prescription replacement assistance; Repatriation of remains benefit

Services

For information and written material on any of the above programs, please contact us at:
American Foreign Service Protective Association 202/ 833-4910 1716 N Street, NW 202/ 833-4918 (fax)

Washington, D. C. 20036-2902 E-mail: afspa@ afspa. org Web site: www. afspa. org

Term Life Insurance
Expanded Dental Benefits

Discount on Non-Covered
Prescription Drugs

Long Term Care 51
51 Page 52 53

52 Page 53 54
2002 Foreign Service Benefit Plan 53 Section 7
Section 7. Filing a claim for covered services
How to claim benefits To obtain claim forms or other claims filing advice or answers about our benefits, contact us by mail at Foreign Service Benefit Plan, 1716 N Street, NW, Washington,
DC 20036-2902, by phone at 202/ 833-4910, by fax at 202/ 833-4918, by e-mail at afspa@ afspa. org or at our website at www. afspa. org.

In most cases, providers and facilities file claims for you. Your physician must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the
UB-92 form.
When you must file a claim such as for non-PPO or out-of-network providers, overseas claims or when another group health plan is primary submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Name of patient and relationship to enrollee;
Plan identification number of the enrollee;
Name and address of person or firm providing the service or supply;
Dates that services or supplies were furnished;
Diagnosis;
Type of each service or supply; and
The charge for each service or supply.
Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. The Plan cannot accept a claim as an e-mail

attachment.
In addition:
Generally, you need to fill out only one claim form per year. You should fill out a claim form if you submit a claim due to accidental injury or you have changed

your address, or if the member's other insurance/ Medicare status has changed.
You must send a copy of the explanation of benefits (EOB) from any primary payer (such as the Medicare Summary Notice (MSN)) with your claim. See page

59 for Medicare claims.
Bills for private duty nursing care must show that the nurse is a registered (R. N.) or licensed practical nurse (L. P. N.). You should also include the initial history and

physical, treatment plan indicating expected duration and frequency from your attending physician and the nursing notes from the nurse.

Claims for rental or purchase of durable medical equipment must include the purchase price, a prescription and a statement of medical necessity including the
diagnosis and estimated length of time needed.
Claims for physical, occupational, and speech therapy must include an initial evaluation and treatment plan indicating length of time needed for therapy and

progress (therapy) notes for each date of service from the therapist.
Claims for dental services must include a copy of the dentist's itemized bill (including the information required above) and the dentist's Federal Tax I. D.

number. We do not have separate dental claim forms. 53
53 Page 54 55
2002 Foreign Service Benefit Plan 54 Section 7
Overseas (foreign) claims If you are posted overseas and both the Medical and Health Program of the Department of State -Office of Medical Services (OMS) and we cover you,
submit claims to us as described on the previous page or as directed by OMS, through your Administrative Office.

If the Medical and Health Program of the Department of State does not cover you, you should submit claims directly to us as described on the previous page.
You may include an English translation (not required) and a currency exchange rate (recommended). We will translate claims and will convert to U. S. Currency
using the exchange rate applicable at the time the expense was incurred if you do not supply us with a translation or conversion.

We have direct billing arrangements with hospitals in several countries, including Brazil, Germany, Korea and Panama. We also have a fast track
payment process if you are posted in Korea. Please contact us for more information on these arrangements if you are in these locations.

After you complete a claim form and attach proper documentation, send your claims to:
Foreign Service Benefit Plan 1716 N Street, NW
Washington, DC 20036-2902
If you are overseas and have access to the Department of State pouch mail, you may send your claims in care of Department of State, Washington, DC 20520. Note: Do not
use this address if you are in the United States. It will delay your claim.
Plan telephone number: 202/ 833-4910

Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of
all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim.

We will provide you with a record of expenses you submit and benefits we paid for each claim that you file (explanation of benefits (EOB)). You are responsible for
keeping these. We will not provide duplicate or year-end statements.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim within 90 days after you incur the expense, but in no event later than 2 years
from the date you incur the expense. We can extend this deadline if you were prevented from filing your claim timely by administrative operations of Government or
legal incapacity, provided you file the claim as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

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. 54
54 Page 55 56
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/ prior approval:

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: Foreign Service Benefit Plan, 1716 N Street NW, Washington, DC 20036-2902; 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: Office of Personnel Management, Office of Insurance Programs, Contracts Division 2, 1900 E Street, NW, Washington, D. C. 20415-3620

The Disputed Claims process
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.

2002 Foreign Service Benefit Plan 55 Section 8 55
55 Page 56 57
2002 Foreign Service Benefit Plan 56 Section 8
The Disputed Claims process (continued)
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 based on the terms of the contract. OPM will send you a final decision within 60 days. There are
no other administrative appeals.

6 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 202/ 833-4910 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 Benefits Contracts Division II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 56
56 Page 57 58
2002 Foreign Service Benefit Plan 57 Section 9
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 most 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. You must send us your primary plan's explanations of benefits (EOBs) if we ask for them. After the

primary plan pays, we will pay what is left of our allowance, up to the lesser of:
Our benefits in full, or
A reduced amount that, when added to the benefits payable by the primary plan, does not exceed 100% of covered expenses.

We will not pay more than our allowance. The combined payments from both plans might not equal the entire amount billed by the provider.

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+ Choice plan
you have.
The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in the United (Part A or Part B) 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 Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. We do not require precertification
of inpatient hospital confinements when Medicare Part A is primary. We do not require preauthorization and concurrent review of Mental Health Substance Abuse treatment
when Medicare Part B is primary. However, when Medicare stops paying benefits for any reason, you must follow our precertification, preauthorization and concurrent
review procedures. 57
57 Page 58 59
2002 Foreign Service Benefit Plan 58 Section 9
Claims process when you have the Original Medicare Plan -Send us a copy of your Medicare Card when we are secondary to Medicare. We need this information
in order to start electronic crossover of your claims. Electronic crossover is a process that assures, in most cases, you do not have to file a claim when Medicare is primary.
Call us at 202/ 833-4910 or contact us at afspa@ afspa. org to find out if your claims are being electronically filed or you have questions about the process described below.

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, we will coordinate your claims automatically and we will pay the

balance of covered charges. There are exceptions:
If you have not sent us a copy of your Medicare card as stated above, you will need to send us your claims and Medicare Summary Notices (MSN) until you

have sent us your Medicare Card and we have had time to set up electronic crossover.

If Medicare rejects your claim completely, send us your claim and your MSN. You must send them in order for us to begin processing your claim.
If Medicare rejects a part of your claim or pays a reduced amount, you may need to send us your claim and MSN. In that case, we will ask you for a copy of
them. You must send them to us in order for us to continue processing your claim.

We waive some costs when you have the Original Medicare Plan When Original Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:
Medical services and supplies provided by physicians and other health care professionals in Section 5( a).
If you are enrolled in Medicare Part B, we will waive your calendar year deductible and coinsurance.

Surgical and anesthesia services provided by physicians and other health care professionals in Section 5( b).
If you are enrolled in Medicare Part B, we will waive your coinsurance.
Services provided by a hospital or other facility, and ambulance services in Section 5( c).

If you are enrolled in Medicare Part A, we will waive your inpatient hospital copayment and coinsurance for inpatient confinement.
If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance for outpatient hospital, ambulatory surgical center and ambulance.

Services provided by facilities and providers covered under Emergency services/ Accidents in Section 5( d).
If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance.

Services provided by Mental health and substance abuse facilities and providers in Section 5( e).
If you are enrolled in Medicare Part A, we will waive the inpatient hospital copayment and coinsurance for inpatient confinement.
If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance.

Services provided under Prescription benefits Section 5( f). We do not waive the prescription copay.
Services provided under Dental benefits in Section 5( h). We do not waive the coinsurance under Dental benefits. 58
58 Page 59 60
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
A. When either you or your covered spouse are age 65 Then the primary payer is or over and
Original Medicare This Plan

1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely 3
because of a disability),
2) Are an annuitant, 3
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or 3
b) The position is not excluded from FEHB 3
(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 3

your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, 3 3 (for Part B (for other

services) services)
6) Are a former Federal employee receiving Workers' Compensation 3 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 or a covered family member 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 because of ESRD, 3
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD, 3
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, 3
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 3
b) Are an active employee 3
c) Are a former spouse of an annuitant 3
d) Are a former spouse of an active employee 3

2002 Foreign Service Benefit Plan 59 Section 9
Also, this Plan is primary if you receive services or incur charges:
At a VA Medical Center;
Overseas; or
On board a ship not in a U. S. port or more than six hours before arrival at, or after departure from a U. S. port, even if the ship is of U. S. registry.

Note: Medicare remains primary in certain bordering areas of Canada and Mexico. 59
59 Page 60 61
2002 Foreign Service Benefit Plan 60 Section 9
Medicare managed care 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 a Medicare managed care plan.
These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide all the benefits that original Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed plan, contact Medicare at 1-800-MEDICARE (1-800/ 633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB
plan. We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area, but we will not
waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care 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 the Medicare managed care plan's service area.

Private Contract with your physician A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an
agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after
Original Medicare's payment.

If you do not enroll in Medicare If you do not have one or both Parts of Medicare, you can still be covered under the Part A or Part B 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 TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. If both
TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

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 a similar agency pays its maximum benefits for your treatment, we will cover your care. 60
60 Page 61 62
2002 Foreign Service Benefit Plan 61 Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, or Federal Government are responsible for your care agency directly or indirectly pays for them.

When others are responsible We have the right to recover payment we have made to you from any recovery you for injuries receive because of illness or injury caused by the act or omission of a third party
(another person or organization).
If you do not seek damages you must agree to let us try. This is called subrogation. We are also subrogated to your present and future claims against the third party.

If you suffer an injury or illness through the act or omission of a third party, you agree:
to reimburse us for benefits paid up to the recovery amount; and
that we are subrogated to your rights to the extent of benefits paid, including the right to bring suit.

All recoveries must be used to reimburse us for benefits paid. Unless we agree in writing to a reduction, you cannot reduce our share of the recovery because you do not
receive the full amount of damages claimed.
If we invoke this provision:
We will pay benefits for the injury or illness as long as you:
take no action to prejudice our ability to recover benefits; and
reasonably assist us in recovery.

Our reimbursement right extends only to the amount we paid or would pay because of the injury or illness.

We may insist on a proceeds assignment and may withhold payment of benefits otherwise due until the assignment is provided. Failure to request or obtain
assignment prior to us paying benefits will in no way diminish our rights of reimbursement and subrogation.

We will have a lien on the proceeds of your claim to the third party to reimburse ourselves the full amount of benefits we have paid or may pay. Our lien will apply to
any and all recoveries for the claim and will be satisfied in full out of the proceeds before the satisfaction of any individual's claim.

You are required to notify us promptly of any claim that you may have for damages as a result of the act or omission of a third party, for which we have paid or may pay
benefits. In addition, you are required to notify us of any recovery that you obtain, and you are required to reimburse us in full for the benefits paid or to be paid. Any
reduction of our lien for payment of associated costs must be approved by us prior to payment. 61
61 Page 62 63
2002 Foreign Service Benefit Plan 62 Section 10
Section 10. Definitions of terms we use in this brochure
Admission The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, we count the date of entry and the date
of discharge as the same day.

Assignment You authorize us to issue payment of benefits directly to the provider of services. The Plan reserves the right to pay the member directly for all covered services.

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 The percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 13.

Confinement An admission (or series of admissions separated by less than 60 days) to a hospital as an inpatient for any one illness or injury. You start a new confinement when an
admission is: (1) for a cause entirely unrelated to the cause for the previous admission; (2) for an enrolled employee who returns to work for at least one day before the next
admission; or (3) for a dependent or annuitant when confinements are separated by at least 60 days.

Copayment A fixed amount of money you pay to the provider when you receive covered services. See page 13.
Covered services Services we provide benefits for, as described in this Brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could render safely and reasonably, or
that help you mainly with daily living activities. These activities include but are not limited to:

1) Personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;
2) Homemaking, such as preparing meals or special diets;
3) Moving you;
4) Acting as companion or sitter;
5) Supervising medication that you can usually take yourself; or
6) Treatment or services that you may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, respirations, or

administration and monitoring of feeding systems.
We determine which services are custodial care.

Deductible 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 13.

Effective date The date the benefits described in this brochure become effective:
1) January 1 for all continuing enrollments;
2) The first day of the first full pay period of the new year if you change plans or options or elect FEHB coverage during the Open Season for the first time; or

3) The date determined by your employing or retirement system if you enroll during the calendar year, but not during the Open Season. 62
62 Page 63 64
2002 Foreign Service Benefit Plan 63 Section 10
Expense The cost incurred for a covered service or supply ordered or prescribed by a doctor. You incur an expense on the date the service or supply is received. Expense does not
include any charge:
1) for a service or supply that is not medically necessary; or
2) that is in excess of the Plan's allowance for the service or supply.

Experimental or A drug, device or biological product is experimental or investigational if the drug, Investigational Services device, or biological product cannot be lawfully marketed without approval of the U. S.
Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of
ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the
standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product
or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its
efficacy as compared with the standard means of treatment or diagnosis.
Reliable evidence means only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or
the protocol( s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating
facility or by another facility studying substantially the same drug, device or medical treatment or procedure.

If you need additional information regarding the determination of experimental and investigational, please contact us.

Group health coverage Health care coverage that you are eligible for because of employment, membership in, or connection with, a particular organization or group that provides payment for any
health care services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of
any of these benefits through COBRA.

Medical emergency 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 that you receive within 72 hours after the onset. Medical emergencies include deep cuts, broken bones, heart attacks, cardiovascular
accidents, poisonings, loss of consciousness or respiration, convulsions, and such other acute conditions that we determine to be medical emergencies.

Medically necessary Services, drugs, supplies or equipment provided by a hospital or covered provider of the health care services that we determine:
1) Are appropriate to diagnose or treat your condition, illness or injury;
2) Are consistent with standards of good medical practice in the United States;
3) Are not primarily for your, a family member's or a provider's personal comfort or convenience;

4) Are not a part of or associated with your scholastic education or vocational training; and
5) In the case of inpatient care, cannot be provided safely on an outpatient basis.
The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary. 63
63 Page 64 65
2002 Foreign Service Benefit Plan 64 Section 10
Mental Conditions/ Conditions and diseases listed in the most recent edition of the International Substance Abuse Classification of Diseases (ICD) as psychoses, neurotic disorders, or personality
disorders; other nonpsychotic mental disorders listed in the ICD, to be determined by us; or disorders listed in the ICD requiring treatment for abuse of or dependence upon
substances such as alcohol, narcotics, or hallucinogens.

Plan allowance The amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We
determine our allowance as follows:
PPO Providers -Our Plan allowance is a negotiated amount between us and the provider. Neither you nor the provider can unilaterally change the negotiated amount.
We base our coinsurance on this negotiated amount. This applies to all benefits in Section 5 of this Brochure.

Non-PPO and Out-of-Network Providers -We base our Plan allowance on reasonable and customary charges (R& C). We define R& C as charges that are:
Comparable to those made by other providers for similar services and supplies under comparable circumstances in the same geographic area;
Developed from actual claims we receive from each Zip Code area throughout the United States, as compiled by the Health Insurance Association of America;
Updated twice a year; and
Are within the 90th percentile of the charges. We chose the 90th percentile to assure that as broad a range of charges are considered to be within R& C as possible under

the FEHB Program.
We use this method for determining our allowance for all benefits in Section 5 of this Brochure. For certain specific services in Section 5, exceptions to this general
method for determining the Plan's allowances may exist.
We generally do not reduce overseas claims to a Plan allowance. However, we reserve the right to request information that will enable us to determine an
allowance on charges that we deem to be excessive.
We determine what is a reasonable and customary charge and what is within our Plan allowance.

For more information, see Differences between our allowance and the bill in Section 4.
Us/ We Us and we refer to the Foreign Service Benefit Plan.
You You refers to the enrollee and each covered family member. 64
64 Page 65 66
2002 Foreign Service Benefit Plan 65 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office can answer your about enrolling in the questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures
FEHB Program for other plans, and other materials you need to make an informed decision about: 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.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, for you and your family 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.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan during premiums start Open Season, your coverage begins on the first day of your first pay period that starts
on or after January 1. 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.
Your medical and claims We will keep your medical and claims information confidential. Only the following records are confidential will have access to it:

OPM, this Plan, and subcontractors when they administer this contract; This Plan and appropriate third parties, such as other insurance plans and the Office
of Workers' Compensation Programs (OWCP), when coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits; Individuals involved in bona fide medical research or education that does not
disclose your identity; As part of its administration of the Prescription Drug Benefits, the Plan may
disclose information about a member's prescription drug utilization, including the names of prescribers to any treating prescribers or dispensing pharmacies; or
OPM, when reviewing a disputed claim or defending litigation about a claim. 65
65 Page 66 67
2002 Foreign Service Benefit Plan 66 Section 11
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 TCC.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not continue to get coverage 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.
Temporary Continuation If you leave Federal service, or if you lose coverage because you no longer qualify as a of Coverage (TCC) family member, you may be eligible for TCC. For example, you can receive TCC if

you are not able to continue your FEHB enrollment after you retire, if you lose your Federal 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.

Converting to You may convert to a non-FEHB individual policy if:
individual coverage 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.
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.
Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coverage 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); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 66
66 Page 67 68
2002 Foreign Service Benefit Plan 67 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance?
It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or injury, or an age-related disease such as Alzheimer's.

LTC insurance can provide broad, flexible benefits for care in a nursing home, in an assisted living facility, in your home, adult day care, hospice care, and more. Long term care insurance can supplement care provided by family members, reducing the
burden you place on them.

I'm healthy. I won't need long term care. Or, will I?
76% of Americans believe they will never need long term care, but the facts are that about half them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a serious

accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but you should have a plan just in case. LTC insurance may be vital to your financial and retirement planning.

Is long term care expensive?
Yes. A year in a nursing home can exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a year, that's before inflation!

LTC can easily exhaust your savings but LTC insurance can protect it.

But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of your FEHB brochure. Custodial care, assisted living, or continuing home health care for activities of daily living are not covered. Limited stays in skilled nursing facilities can be

covered in some circumstances.
Medicare only covers skilled nursing home care after a hospitalization with a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but restricts covered services and where they can be received. LTC insurance can provide choices of care and preserve your independence.

When will I get more information?
Employees will get more information from their agencies during the late summer/ early fall of 2002.
Retirees will receive information at home.

How can I find out more about the program NOW?
A toll-free telephone number will begin in mid-2002. You can learn more about the program now at www. opm. gov/ insure/ ltc.

Many FEHB enrollees think that their health plan and/ or Medicare covers long-term care. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need? Consider buying long-term
care insurance. 67
67 Page 68 69
2002 Foreign Service Benefit Plan 68 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear. This Index references both
covered and non-covered services and supplies.

Accidental injury ..................... 37-38, 49 Acupuncture ............................... 7, 8, 27
Allergy care ......................................... 23 Ambulance ..................................... 36, 38
Anesthesia ....................................... 30-31 Authorization (Mental Health
Services) .............................. 12, 39-44

Birthing centers ............................... 9, 22 Bone marrow transplant ...................... 31
Breast prosthesis ........................... 25, 30

Cancer screening ................................. 20 Catastrophic (out-of-pocket)
protection ......................................... 15 Changes for 2002 .................................. 7
Chemotherapy...................................... 24 Chiropractic ................................ 7, 8, 27
Claiming benefits ........ 46, 53-54, 57-58 Coinsurance ................ 13-14, 52, 58, 62
Contact lenses ..................................... 25 Contraceptive devices and
drugs .......................................... 22, 47 Coordination of benefits ......... 57-60, 65
Copayment ............ 13, 15, 32, 42-43, 62 Cosmetic services .. 29-30, 33-34, 47, 52
Covered facilities .................................. 9 Covered providers ................................. 8
Custodial care ........ 9, 24, 27, 33, 35, 62

Day care ...................... 9, 15, 40, 42, 44 Deductible ............ 13, 15-16, 19, 45, 49,
58, 62 Dental benefits ........................ 30, 49-50
Diagnostic and treatment services ....................................... 19-20
Disputed claims process. ............... 55-56 Drug card ............................. 8, 13, 45-47

Effective date of enrollment .......... 8, 10, 13, 62
Emergency ...... 11, 17, 37-38, 40, 58, 63 Equipment, medical ..... 26, 33-34 53, 63
Experimental or investigational .... 52, 63 Eyeglasses ............................................ 25

Family planning .................................. 22 Flexible benefits option ...................... 48
Foot care .............................................. 25

Group therapy ........................ 39, 41, 43

Hearing services .................................. 25 Home Delivery Pharmacy
service ......................................... 45-47 Home health services .. 10-12, 26-27, 32
Hospice ......................... 9-12, 15, 32, 35 Hospital........ 9-13, 15-16, 19-22, 31-34,
36-44, 49
Identification cards ........ 5, 8, 14, 45-47 Impacted teeth, removal of ........... 19, 30
Impotency ............ 19, 22, 29, 34, 47, 52 Individual therapy .................. 39, 41, 43
Infertility services .................. 15, 23, 47 Insulin .................................................. 47
Investigative or experimental ....... 52, 63
Lab, X-rays and other diagnostic tests ............................................. 19-20
Lifetime maximums .. 15, 23, 35, 47, 50
Mail order prescription drugs (Home Delivery Pharmacy service) ....... 45-47
Maternity care ................... 11, 21-22, 33 Medically necessary ......... 10-12, 19, 26,
28, 32, 36-37, 39-40, 45, 49 Medicare .......... 9, 12, 16-17, 26, 41, 47,
52-53, 57-60 Mental Health/ Substance
Abuse ................ 12, 15, 39-44, 57, 64 Merck-Medco Rx Services ............ 45-47

Newborn care ................................. 21-22 No-fault insurance ............................... 61
Non-FEHB benefits............................. 51 NurseLine (Optum) ............................. 48
Nursery charges .............................. 21-22
Obesity, morbid ............................ 28, 52 Obstetrical care ....................... 11, 21-22
Occupational therapy ............... 7, 24, 26 Office visits ......................................... 19
Organ/ issue transplants ....................... 31 Orthodontics .................................. 15, 50
Orthopedic devices ............ 25, 28, 33-34 Out-of-pocket expenses .................. 13-15
Overseas (outside of U. S.) claims ................ 12, 14, 33, 43-46, 48
Oxygen .............................. 24, 26, 33-34
Pharmacy drug card ............ 8, 13, 45-47 Physical therapy ................. 7, 24, 26, 53
Physician......... 4, 5, 8-11, 13-14, 16-17, 19, 24, 26, 32-33, 37-38,
45-47, 53-58

Plan allowance ...... 13-15, 19-44, 49-50, 52, 64
Preauthorization (Mental health services) ......................... 12, 15, 39-44
Precertification ..... 10-12, 15, 26-27, 32, 35, 39-44
Preferred Provider Organization (PPO) ................ 5-7, 13-16, 19-44, 64
Prescription drugs ......... 7-8, 13, 15, 22, 45-47, 51-53, 58, 65
Prescription drug card ......... 8, 13, 45-47 Preventive care ........................ 20-21, 50
Private duty nursing. ..................... 27, 33 Prosthetic devices ....... 25, 28, 30, 33-34

Radiation therapy ................................ 24 Reasonable and customary (R& C) ..... 64
Renal dialysis ...................................... 24 Routine physical examination and
services .................................. 7, 20-21

Second opinion .............................. 19, 28 Skilled nursing facility (SNF) ........ 9-12,
31-33, 35 Smoking cessation ......................... 27, 47
Speech therapy ................... 7, 24, 26, 53 Sterilization procedures ........... 22, 28-29
Subrogation provision ......................... 61 Substance abuse ... 12, 15, 39-44, 57, 64
Surgery ................. 15, 20-23, 25, 28-31, 33-34, 37-38, 50, 52
Surgical center ............................... 31, 58

Take-home items ............................ 33-34 Temporary continuation of coverage
(TCC) ............................................... 66 Temporomandibular joint (TMJ)
dysfunction ................................ 30, 52 Tests -X-ray, laboratory and other
diagnostic .................................... 19-20 Third party liability ............................. 61
Transplants ...................................... 7, 31 Treatment Therapies ........................... 24

Vision services .................................... 25
Weight control .............................. 28, 52 Well child care .................................... 21
Workers' compensation ................ 60, 65

X-rays, laboratory and other diagnostic tests ............................................. 19-20 68
68 Page 69 70
2002 Foreign Service Benefit Plan 69 Notes
Notes 69
69 Page 70 71
2002 Foreign Service Benefit Plan 70 Summary
Summary of benefits for the Foreign Service Benefit Plan 2002
Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the $300 calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO AND Out-of-Network Area physician or
other health care professional.
Benefits You Pay Page

Medical services provided by physicians: PPO: 10% of our allowance*

Diagnostic and treatment services provided in the Non-PPO: 30% of our allowance and any 19-27 hospital and office . . . . . . . . . . . . . . . . . . . . . . . . . . . difference between our allowance and the
billed amount*
Out-of-Network Area: 20% of our allowance and any difference between our allowance and
the billed amount*
Services provided by a hospital: Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PPO: Nothing 32-33

Non-PPO: $200 per confinement and 20% of charges
Out-of-Network Area: $200 per confinement
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical: 34

PPO: 10% of our allowance
Non-PPO: 30% of our allowance and any difference between our allowance and the
billed amount
Out-of-Network Area: 10% of our allowance and any difference between our allowance and
the billed amount
Medical: 34
PPO: 10% of our allowance*
Non-PPO: 30% of our allowance and any difference between our allowance and
the billed amount*
Out-of-Network Area: 20% of our allowance and any difference between our allowance
and the billed amount* 70
70 Page 71 72
2002 Foreign Service Benefit Plan 71 Summary
Benefits You Pay Page
Emergency benefits:

Accidental injury (for outpatient care received within PPO: Nothing 37-38 72 hours) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-PPO and Out-of-Network Area: Only the difference between our allowance and the
billed amount
Medical emergency . . . . . . . . . . . . . . . . . . . . . . . . . . Regular benefits* 38
Mental health and substance abuse treatment . . . . . . . . . . PPO and Out-of-Network Area: Regular cost 39-44 sharing*

Non-PPO: Benefits are limited*
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Network Pharmacies in the 50 United States: 45-47 Note You must show your Plan ID card:

Generic: $10 for up to a 30-day supply Brand name: $20 for up to a 30-day supply

Non-Network Pharmacies in the 50 United States: You pay 100% and cannot claim
reimbursement from the Plan (no coverage)
Retail Pharmacies outside of the 50 United States: 20%* (claim reimbursement from the
Plan)
Mail Order (Home Delivery Pharmacy service): Generic: $15 for up to a 90-day supply
Brand name: $25 for up to a 90-day supply
Dental Care 49-50 Routine preventive care and surgical procedures . . . . . . The difference between our scheduled
allowances and the actual billed amounts
Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50% of our allowance up to our maximum payment of $1,000; 100% after our maximum
payment of $1,000
Special features: Flexible benefits option Centers of excellence for tissue and organ transplants 48
24 hour nurse line Disease management
Protection against catastrophic costs PPO: Nothing after $3,000/ Self Only or (your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . $3,500/ Family enrollment per year 15

Non-PPO and Out-of-Network Area: Nothing after $4,000/ Self Only or $4,500/ Family
enrollment per year
Note: Benefit maximums still apply and some costs do not count toward this protection. 71
71 Page 72
Premium
Biweekly Monthly
Type of Gov't Your Gov't Your Enrollment Code Share Share Share Share

Self Only 401 $ 97.86 $ 37.44 $212.03 $ 81.12
Self & Family 402 $223.41 $105.19 $484.06 $227.91

2002 Foreign Service Benefit Plan

2002 Rate Information for
Foreign Service Benefit Plan

2002 rates for this Plan follow. If you are in a special enrollment category, refer to an FEHB Guide for that category or contact the agency that maintains your health benefits enrollment. 72

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