Page Navigation Panel Document Outline

Document Outline

Pages 1--85 from Untitled


Page 1 2
For changes in benefits
see page 5.

A fee-for-service plan with a preferred provider organization

Sponsored and administered by: The Association
Who may enroll in this Plan: Members of the Association
Annuitants (retirees) who are members of the Association may enroll in this Plan

Enrollment codes for this Plan:
421 -Self Only
422 -Self and Family

A PLAN FOR THE FUTURE
Association Benefit Plan 2002

Mutual of Omaha Insurance Company, the underwriter for Association Benefit Plan, has received accreditation
from URAC (also known as the American Accreditation Healthcare Commission) for Health Utilization Man-agement
Standards. See the 2002 Guide for more infor-mation on accreditation. 1
1 Page 2 3
2002 Associate Benefit Plan 1 Table of Contents
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Section 1. Facts about this fee-for-service plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Identification card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Covered providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Covered facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What you must do to get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How to Get Approval for. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Your hospital stay (precertification) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Other services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Differences between our allowance and the bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
When government facilities bill us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
If we overpay you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
When you are age 65 or over and you do not have Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
When you have Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . 18
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . 30
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . 35
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
(e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Flexible benefits option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
24-hour nurse line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
High risk pregnancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2
2 Page 3 4
2002 Associate Benefit Plan 2 Table of Contents
Centers of excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Service overseas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
(h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Section 6. General exclusions things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
TRICARE/ Workers Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
When other Government agencies are responsible for your care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Your medical and claims records are confidential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Long Term Care is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 3
3 Page 4 5
2002 Association Benefit Plan 3
Introduction
Association Benefit Plan
PO Box 668587
Charlotte, NC 28266-8587

This brochure describes the benefits of the Association Benefit Plan under the Government Employees Health Association's
contract (CS 1065) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. The Plan is underwritten by Mutual of Omaha Insurance Company. 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 are sum-marized
on page 74. Rates are shown at the end of this brochure.

Plain Language

Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or
family member; "we" means Association 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 any comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also
write to OPM at the Office of Personnel Management, 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 infor-mation,
do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-634-0069
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.
Introduction/ Plain Language 4
4 Page 5 6
2002 Association Benefit Plan 4 Section 1
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 reside in the PPO network area and use our PPO
providers, you will receive covered services at reduced cost. If you reside in Washington, DC, or in one of the
states listed below, contact us at 1-800-634-0069 for information concerning your PPO. You can also go to the
Mutual of Omaha website, www. mutualofomaha. com, for PPO information. Do not call OPM for our provider
directory. Also, when you phone for an appointment, please verify that your physician is still a PPO provider.

The Out-of-network benefits are the standard benefits of this plan. PPO benefits apply only when you reside in the
PPO network area and use a PPO provider. You must present your PPO identification (ID) card confirming
your PPO participation to be eligible for PPO benefits. Provider networks may be more extensive in some areas
than others. We cannot guarantee the availability of every specialty in all areas. If no PPO provider is available, or
you do not use a PPO provider, the standard non-PPO benefits apply. When you use a PPO hospital, keep in mind
that the professionals who provide services to you in the hospital, such as radiologists, emergency room physi-cians,
anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid as
non-PPO providers.

The PPO Network Area consists of Washington, D. C. and selected counties and cities in the following states:

If you reside in the PPO network area and no PPO provider is available, or if you do not use a PPO provider, non-PPO
benefits apply.

How we pay providers
Our participating providers are generally reimbursed according to an agreed-upon fee schedule and are not offered addi-tional
financial incentives based on care provided or not provided to you. Our standard provider agreements do not con-tain
any contractual provisions that include incentives to restrict a providers ability to communicate with and advise
patients of any appropriate treatment options. In addition, the Plan has 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. If you want more information about us, call 1-800-634-0069, or write to Asso-ciation
Benefit Plan, PO Box 668587, Charlotte, NC 28266-8587.

Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware Florida Georgia Idaho Illinois
Indiana Iowa Maryland Massachusetts Michigan Missouri
Nevada New Jersey New Mexico New York North Carolina Ohio
Oregon Pennsylvania South Carolina Tennessee Texas Utah
Virginia Washington West Virginia 5
5 Page 6 7
2002 Association Benefit Plan 5 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 in 2002: Georgia, Montana, North
Dakota, and Texas. Louisana has been removed from the list of medically underserved states in 2002. See page 7.

Changes to this Plan
We now cover intestinal transplants. (Section 5( b)).
We changed speech therapy benefits by removing the requirement that services must be required to restore functional
speech. (Section 5( a)).

We clarified the brochure to better explain that the Out-of-network benefits are the standard benefits of this Plan, that
PPO benefits apply only when you reside in the PPO network area and use a PPO provider, and that when no PPO
provider is available, non-PPO benefits apply.

We expanded our optional hospital and physician Preferred Provider Organization (PPO) network area to include selected
counties and cities in the following states: Alabama, Arizona, Arkansas, Colorado, Connecticut, Florida (North), Georgia,
Illinois, Indiana, Iowa, Massachusetts, Michigan, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina,
Ohio, Oregon, South Carolina, Tennessee, Texas, Utah, Virginia (Roanoke) and West Virginia. (Section 4).

If you reside in the PPO network area and use PPO providers, annual routine preventative care services provided out-side
the physician's office will be paid at 100% of the Plan allowance, not subject to the deductible. (Section 5( a)).

A routine mammogram is now available annually for women 35 years and older. (Section 5( a)).
If you have an accidental injury, we will pay 100% of the Plan allowance, not subject to the deductible, of the first
$500 of your outpatient expenses. Your subsequent outpatient care will be paid under the appropriate benefit and at
your applicable copayment/ coinsurance amount. (Section 5( d)).

If you have an accidental dental injury while enrolled in the Plan, we will pay 80% of the Plan allowance, not subject
to the deductible, until the treatment is completed as long as you remain enrolled in the Plan. (Section 5( h)).

Smoking cessation benefits will be limited to $100 per 12 months and will be paid at your applicable copayment/
coinsurance amount, subject to the calendar year deductible. (Section 5( a)).

Physical, speech, and occupational therapy visits will be limited to total combined 90 visits. We removed speech ther-apy
limitations. (Section 5( a)).

Your calendar year deductible will increase to $300 per person or $600 per family. (Section 4)
Your inpatient hospital copayment will increase to $100 for PPO; and $200 for Non-PPO and Out-of-network facili-ties.
(Section 5( c)).

Your out-of-pocket maximum for PPO and Out-of-network providers will increase to $2,500 and to $3,500 for
Non-PPO providers. (Section 4).

Your share of the premiums will increase by 15.4% for Self Only or 13.2% for Self and Family. 6
6 Page 7 8
2002 Association Benefit Plan 6 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card and a Prescription Drug Card when you enroll. You should carry both cards with you at all times. You
must show your ID card whenever you receive services from a medical or
dental provider, or your Prescription Drug Card to fill a prescription at a
participating Plan pharmacy. Until you receive your ID card, use your copy
of the Health Benefits Election Form, SF-2809, or your health benefits
enrollment confirmation (for annuitants).

If you do not receive your cards within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-634-
0069.

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 reside in the PPO network area and use our pre-ferred
providers, you will pay less.

Covered providers We consider the following to be covered providers when they perform ser-vices within the scope of their license or certification:

Physician: Doctors of medicine or psychiatry (M. D.), osteopathy
(D. O.), dental surgery (D. D. S.), medical dentistry (D. M. D.), podiatric
medicine (D. P. M.), and optometry (O. D.) when acting within the scope
of their licenses or certification.

Qualified Clinical Psychologist: An individual who has earned either a
Doctoral or Masters Clinical Degree in psychology or an allied disci-pline
and who is licensed or certified in the state where services are per-formed.
This presumes a licensed individual has demonstrated to the
satisfaction of state licensing officials that he/ she, by virtue of academic
and clinical experience, is qualified to provide psychological services in
that state.

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 Master's or Doc-toral
degree in social work, 2) has at least two years of clinical social
work practice, and 3) in states requiring licensure, certification or regis-tration,
is licensed, certified, or registered as a social worker where the
services are rendered.

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

Licensed Professional Counselor or Master's Level Counselor: A
person who is licensed, registered, or certified in the state where ser-vices
are performed 7
7 Page 8 9
2002 Association Benefit Plan 7 Section 3
Section 3. How you get care (continued)
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 for by these clinics are considered outpatient
'office' services rather than facility charges

Christian Science Practitioner: If you choose to visit a Christian Sci-ence
practitioner instead of a physician, the charges are still considered
allowable expenses. To qualify for benefits, you must make this choice
annually. The benefits will then apply to all subsequent expenses
incurred during the year. You can change your mind only at the time of
your first claim each year. The practitioner you choose must be listed as
such in the Christian Science Journal that is current at the time the ser-vice
is provided. Your choice will not apply to, or prevent payment of, a
physician's maternity charges.

Medically underserved areas. 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.

Covered facilities Covered facilities include:
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-hours-a-day nursing
service, and that is primarily engaged in providing:

a) General patient 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.

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; 8
8 Page 9 10
2002 Association Benefit Plan 8 Section 3
Section 3. How you get care (continued)
2) furnishes primarily domiciliary or custodial care including
training in the routines of daily living; or

3) is operated as a school.
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.

Skilled nursing facility: An institution, or that part of an institution that
provides convalescent skilled nursing care 24 hours a day and is
classified as a skilled nursing facility under Medicare.

Birthing Center: A licensed facility that is equipped and operated
solely to provide prenatal care, to perform uncomplicated spontaneous
deliveries and to provide immediate post-partum care.

Hospice: A facility that meets all of the following:
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; and

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.

What you must do to
get covered care
It depends on the kind of care you want to receive. You can go to any
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 Benefits (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 until the end of your postpartum care, even if it is
beyond the 90 days. 9
9 Page 10 11
2002 Association Benefit Plan 9 Section 3
Section 3. How you get care (continued)
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
1-800-634-0069.

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

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the benefits of the hospitalized person.
How to Get Approval for
Your hospital stay Precertification is the process by which prior to your inpatient hospi-tal admission we evaluate the medical necessity of your proposed stay

and the number of days required to treat your condition. Unless we are
misled by the information given to us, we won't change our decision on
medical necessity.

In most cases, your physician or hospital will take care of precertifica-tion.
Because you are still responsible for ensuring that we are asked to
precertify your care, you should always ask your physician or hospital
whether they have contacted us.

Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one
contacts us for precertification. If the stay is not medically necessary, we
may not pay any benefits.

How to precertify an
admission:
You, your representative, your physician, or your hospital must call us at
1-800-634-0069 before admission.

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, the physician, or
the hospital must telephone us within two business days following the
day of the emergency admission, even if you have been discharged from
the hospital.

Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting physician; 10
10 Page 11 12
2002 Association Benefit Plan 10 Section 3
Section 3. How you get care (continued)
Name of hospital or facility; and
Number of planned days of confinement.

We will then tell the physician and/ or hospital the number of approved
inpatient days and we will send written confirmation of our decision to
you, your physician, and the hospital.

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 for precertification of
additional days for your baby.

If your hospital stay needs to
be extended:
If your hospital stay including for maternity care needs to be extended,
you, your representative, your physician or the hospital must ask us to
approve the additional days.

What happens when you
do not follow the
precertification rules

When we precertified the admission but you remained in the hospital
beyond the number of days we approved and did not get the additional
days 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 medical services and supplies otherwise payable on an
outpatient basis and will not pay inpatient benefits.

If no one contacted us, we will decide whether the hospital stay was
medically necessary.

If we determine that the stay was medically necessary, we will pay
the inpatient 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 only
pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis.

If no one contacted us for specified services such as Hospice Care,
Skilled Nursing Facility Care, Home Health Care, we will disqualify
higher paid benefits.

If we denied the precertification request, we will not pay inpatient hos-pital
benefits. We will only pay for any covered medical supplies and
services that are otherwise payable on an outpatient basis.

Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the United States. 11
11 Page 12 13
2002 Association Benefit Plan 11 Section 3
Section 3. How you get care (continued)
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, then we will become the primary payer
and you do need precertification.

Other services Some other services require precertification, or prior authorization, such as:
Home health care
Hospice care
Organ/ tissue transplants
Skilled nursing facilities
Psychiatric and substance abuse treatment
Surgery for morbid obesity 12
12 Page 13 14
2002 Association Benefit Plan 12 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. You will only be responsible for
one copayment per day to a provider or facility.
Example: When you see your PPO physician you pay a copayment of $10
per visit, and when you go in a PPO hospital, you pay a copayment of $100
per admission.

Deductible A deductible is a fixed amount of covered expenses you must incur for cer-tain covered services and supplies before we start paying benefits for them.

Copayments do not count toward any deductible.
The calendar year deductible is $300 per person. Under a family enroll-ment,
the deductible is satisfied for all family members when the com-bined
covered expenses applied to the calendar year deductible for
family members reach $600.

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. Coinsurance doesn't begin until you meet your deductible.

Example: You pay 10% of our allowance for an X-ray.
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 physician ordinarily charges $100 for a service but
routinely waives your 10% coinsurance, the actual charge is $90. We will
pay $81 (90% of the actual charge of $90).

Differences between our
allowance and the bill
Our "Plan allowance" is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in

different ways, so their 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.

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 or copayment. Here is
an example about coinsurance: 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 phy-sician
will not bill you for the $50 difference between our allowance and
his bill. 13
13 Page 14 15
2002 Association Benefit Plan 13 Section 4
Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. For instance,

When reside in the PPO network area and 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. Because you've met your deductible, you
are responsible for your coinsurance, so you pay 25% of our $100
allowance ($ 25). 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 reside outside the PPO network area, you will pay
your deductible and coinsurance plus any difference between our
allowance and charges on the bill. As in the example above, once
you have met your deductible, you are responsible for your coinsur-ance.
You will pay 15% of our allowance ($ 15) and the physician
can bill you for the $50 difference between our allowance and his
bill.

The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician
when you reside in the PPO network area. 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.

Your catastrophic protection
out-of-pocket maximum
for deductibles, coinsurance,
and copayments

If your out-of-pocket coinsurance expenses exceed your catastrophic limit
in a calendar year, we will pay 100% of the Plan allowance for the
remainder of the year. The calendar year limits are:

PPO providers: $2,500

Non-PPO providers: $3,500
Out-of-network providers: $2,500
Out-of-pocket expenses are:
Your $300/$ 600 calendar year deductible;

EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: 100 We set it at: 100
We pay 90% of our allowance: 90 75% of our allowance: 75
You owe:
Coinsurance
10% of our allowance: 10 25% of our allowance: 25

+Difference up to charge?
No: 0 Yes: 50

TOTAL YOU PAY $10 $75 14
14 Page 15 16
2002 Association Benefit Plan 14 Section 4
The percentage you pay for covered services after you have met your
deductible;

The percentage you pay for surgery, anesthesia and extended medical
care after an accidental injury; and

Your copayment for hospital admissions.
The following cannot be included in your out-of-pocket expenses:
Expenses in excess of the Plan allowance or maximum benefit
limitations;

Non-covered services and supplies;
Prescription drug copayments;
PPO copayments;
Expenses for dental care including the 20% you pay for dental care after
an accidental injury; or

Any amounts you pay if benefits have been reduced because of
noncompliance with our cost containment requirements.

When government facilities
bill us
Facilities of the Department of Veterans Affairs, the Department of
Defense, and the 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. If your claim has been paid in error for any reason, we
shall make a diligent effort to recover an overpayment to you from you or,
if to the provider, from the provider. We may reduce subsequent benefit
payments to the member or to a provider on behalf of the member to offset
overpayments.

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.) 15
15 Page 16 17
2002 Association Benefit Plan 15 Section 4
When you the have the Original
Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that
Medicare would pay under Medicare A (Hospital insurance) and Medicare
B (Medical 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 reim-bursed
by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket
costs for services 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.

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; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.
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
Medicare assignment for the claim and
is a member of our PPO network,

your deductibles, coinsurance, copayments; and
any balance up to the Medicare approved amount;

Participates with Medicare and is not in
our PPO network,
your deductibles, coinsurance, copayments, and
any balance up to the Medicare approved amount;

Does not participate with Medicare, your deductibles, coinsurance, copayments, and
any balance 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 the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the physician or hospital 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 Association Benefit Plan 16 Section 4
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) form
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 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
Private Contract
A physician may ask you to sign a private contract agreeing that you can be
billed directly for services Medicare ordinarily covers. 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 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 Association Benefit Plan 17 Section 5
Section 5. Benefits OVERVIEW (See page 5 for how our benefits changed this year and page 74 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
1-800-634-0069.

(a) Medical services and supplies provided by physicians and other health care professionals .................................. 18-29

(b) Surgical and anesthesia services provided by physicians and other health care professionals............................... 30-34
(c) Services provided by a hospital or other facility, and ambulance services ............................................................. 35-38

(d) Emergency services/ Accidents................................................................................................................................ 39-40
(e) Mental health and substance abuse benefits ............................................................................................................ 41-45
(f) Prescription drug benefits........................................................................................................................................ 46-48
(g) Special features ....................................................................................................................................................... 49

(h) Dental benefits......................................................................................................................................................... 50-51
(i) Non-FEHB benefits available to Plan members...................................................................................................... 52
SUMMARY OF BENEFITS.......................................................................................................................................... 74

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical, occupational, and speech therapies
Hearing services (testing, treatment, and
supplies)

Vision services (testing, treatment, and
supplies)

Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

Inpatient hospital
Outpatient hospital or ambulatory surgical
center

Skilled nursing care facility

Hospice care
Ambulance

Medical emergency
Accidental injury
Ambulance

Flexible benefits option
High risk pregnancies
Services Overseas

24-hour nurse line
Centers of excellence 18
18 Page 19 20
2002 Association Benefit Plan 18 Section 5 (a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I
M
P
O
R
T
A
N
T

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 -* -to show when
the calendar year deductible does not apply.

The Out-of-network benefits are the standard benefits of this Plan. PPO benefits apply
only when you reside in the PPO network area and use a PPO provider. When no PPO
provider is available, non-PPO 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.

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 added asterisks -* -to show
when the calendar year deductible does not apply.

Diagnostic and treatment services
Professional services of physicians
In physician's office
PPO: $10 copayment*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Professional services of physicians

In a hospital or urgent care center
In a skilled nursing facility
Second surgical opinion
At home

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Note: For physical therapy treatment, see Physical, occupational and
speech therapies. 19
19 Page 20 21
2002 Association Benefit Plan 19 Section 5 (a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Sonograms

PPO: Services in physician's office$ 10
copayment*

PPO: Services outside physician's office
10% of the Plan allowance

Note: If your PPO provider uses a non-PPO
lab or radiologist, we will pay non-PPO bene-fits
for any lab and X-ray charges.

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.

Not covered:
Preventative medical care and services (including periodic checkups
and immunizations such as polio, flu, mumps, and smallpox shots),
except as provided under Preventative care, adult and children,
page 20

Telephone consultations

All charges

Preventive care, adult
One annual routine physical examination per person to include a his-tory
and physical, chest X-ray, urinalysis, blood tests, and EKG (elec-trocardiogram).

One annual cervical cancer screening (pap smear) for women age 18
and older. Note: if you see another physician for your pap smear, the
office visit will be covered.

One annual Prostate Specific Antigen test (PSA prostate cancer
screening) for men age 40 and older.

One annual fecal occult blood test (colorectal cancer screening) for
members age 40 and older.

A sigmoidoscopy once every five years starting at age 50.
One annual routine mammogram (breast cancer screening) for women
age 35 and older:

NOTE: Your physician's bill must clearly state "Routine Physical
Exam". If a medical diagnosis is provided on the bill, those services
will be paid under the medical benefit.

PPO: Services in physician's office$ 10
copayment*

PPO: Services outside physician's office
Nothing*

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-Network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount.* 20
20 Page 21 22
2002 Association Benefit Plan 20 Section 5 (a)
Preventative care, adult -Continued You Pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

Pneumococcal vaccine, annually, age 65 and over
Influenza vaccine, annually, regardless of age

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Preventive care, children
Childhood immunizations recommended by the American
Academy of Pediatrics (to age 22)
PPO: Nothing*

Non-PPO: Only the difference between the
Plan allowance and the billed amount*

Out-of-network: Only the difference between
the Plan allowance and the billed amount*

For well-child care charges for routine examinations and care (to
age 2)
PPO: 10% of the Plan allowance.

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount.

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Maternity care
Complete maternity (obstetrical) care such as:
Prenatal care
Amniocentesis
Inpatient delivery
Initial, routine examination of your newborn infant covered under
your family enrollment

Circumcision of your newborn infant
Postnatal care

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount*

Note: Here are some things to keep in mind
You do not have to precertify your normal delivery; see page 9 for
other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will cover an
extended stay, if medically necessary, but you, your representative,
your physician or your hospital must precertify. 21
21 Page 22 23
2002 Association Benefit Plan 21 Section 5 (a)
Maternity care-Continued You Pay
We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment if we cover the
infant under a Self and Family enrollment.

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

If your baby stays in the hospital after your discharge and is
covered under yourself and Family enrollment, you must pay a
separate hospital admission. See Section 5( c), Hospital benefits.

Bassinet or nursery charges on which you and your baby are
confined are considered your maternity expenses, not your baby's.

Sonograms and other related tests that are not included in your
routine prenatal or postnatal care are covered in Lab, X-ray, and
other diagnostic tests, page 19.

Outpatient maternity (obstetrical care) for covered hospital and
physician services at the time of delivery, including the initial, routine
examination of your newborn infant covered under your family
enrollment, when:

Delivery is on an outpatient basis;
Delivery is at a licensed birthing center; or
Inpatient delivery results in a hospital confinement of one day
(overnight) or less and no more than one day's room and board
charge applies

PPO: Nothing*
Non-PPO: Only the difference between the
Plan allowance and the billed amount*

Out-of-network: Only the difference between
the Plan allowance and the billed amount*

Note: If you or your newborn child is transferred from a birthing
center to a hospital due to medical complications, the birth center
expenses will be paid as inpatient care.

If you and your child leave the hospital against medical advice, this
outpatient benefit is not payable.

Not covered:

Routine sonograms to determine fetal age, size or sex; or 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 or rape or incest

All charges 22
22 Page 23 24
2002 Association Benefit Plan 22 Section 5 (a)
Family planning You Pay
A broad range of voluntary family planning services, limited to:
Voluntary sterilization (such as Norplant)
Surgically implanted contraceptives
Intrauterine devices (IUDs)

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount*

Injection of contraceptive drugs (such as Depo-Provera)

Note: We cover oral contraceptive drugs in Section 5( f), Prescrip-tion
drug benefits.

Note: We cover contraceptive drugs in Section 5( f).

PPO: $10 copay*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility including prescription drugs, up
to $5,000 per person per lifetime, except as shown in Not covered.
PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount 23
23 Page 24 25
2002 Association Benefit Plan 23 Section 5 (a)
Infertility services-Continued You Pay
Not covered:
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination

in vitro fertilization
embryo transfer and 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

All charges

Allergy care
Allergy testing, injections and treatment

Note: We cover allergy serum in Section 5( f), Prescription drug
benefits

PPO services in physician's office: $10
copayment*

PPO services outside physician's office: 10%
of the Plan allowance

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered: Provocative food testing, end point titration techniques,
hair analysis, and sublingual allergy desensitization
All charges 24
24 Page 25 26
2002 Association Benefit Plan 24 Section 5 (a)
Treatment therapies You Pay
Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed in Section 5( b),
Organ/ tissue transplants.

Note: We cover chemotherapy drugs in Section 5( f).
Dialysis Hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy Home IV and antibiotic
therapy

Respiratory and inhalation therapies
Growth hormone therapy (GHT)
Note: We only cover GHT when you obtain prior approval. Call
1-800-634-0069 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See services
requiring our prior approval in Section 3.

Note: Growth hormone is covered under the prescription drug benefit.

PPO services in physician's office: $10
copayment*

PPO services outside physician's office:
10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Physical, occupational, and speech therapies
90 total combined visits per calendar year for the following:
Visits for the services of each of the following:

physicians;
qualified physical therapists;
speech therapists; and
occupational therapists

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: We only cover therapy when a physician:
1) orders the care;

2) identifies the specific professional skills you require and the
medical necessity for skilled services; and

3) indicates the length of time you need the services. 25
25 Page 26 27
2002 Association Benefit Plan 25 Section 5 (a)
Physical, occupational, and speech therapies (continued) You Pay
Not covered:
Exercise programs
All charges

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental
injury or intra-aural surgery.

Note: Expenses must be incurred within one year of the date of the
accident or surgery.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:
Hearing aids, testing and examinations for them, except for
accidental injury or intra-aural surgery.

All charges.

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses per lifetime to correct an
impairment directly caused by accidental ocular injury or intraocu-lar
surgery (such as for cataracts)

Note: Services must be received within one year of the date of accident
or surgery.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:
Eyeglasses or contact lenses and examinations for them, except for
accidental injury and intraocular surgery

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye refractions

All charges. 26
26 Page 27 28
2002 Association Benefit Plan 26 Section 5 (a)
Foot care You pay
No routine benefits All charges

Orthopedic and prosthetic devices
Orthopedic braces, canes, casts, cervical collars, cervical traction
kits, crutches splints and trusses

Artificial limbs and eyes to replace natural limbs and eyes; stump
hose

Two externally worn breast prostheses and two surgical bras per cal-endar
year, including necessary replacements following a mastec-tomy

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

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Two wigs per lifetime, up to a maximum of $150 each, when
required due to hair loss in connection with chemotherapy or radia-tion
treatment

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount*

Not covered:
Orthopedic and corrective shoes and other supportive devices for
the feet

Arch supports
Foot orthotics
Heel pads and heel cups
Corsets, trusses, elastic stockings, support hose, and other
supportive devices

All charges 27
27 Page 28 29
2002 Association Benefit Plan 27 Section 5 (a)
Durable medical equipment (DME) You Pay
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician
who is treating your illness or injury);

2. Are medically necessary;
3. Are primarily and customarily used only for a medical pur-pose;

4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an ill-ness
or injury.

We cover purchase or rental up to the purchase price, at our option,
including repair and adjustment, of durable medical equipment, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;

Respirators;
Wheelchairs;
Crutches; and
Walkers.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered: Sun or heat lamps, whirlpool baths, heating pads, air
purifiers, humidifiers, air conditioners, and exercise devices
All charges

Home health services You pay
For services provided on a part-time basis (less than an 8-hour shift):
If precertified, 90 visits per calendar year up to a maximum Plan pay-ment
of $80 per visit when:

A registered nurse (R. N.) or licensed practical nurse (L. P. N.) pro-vides
the services;

A licensed therapist provides physical, occupational or speech
therapy;

The attending physician orders the care;
The physician identifies the specific professional skills required by
the patient and the medical necessity for skilled services; and

The physician indicates the length of time the services are needed.

PPO: Charges in excess of $80 per visit*
(90 visit maximum)

Non-PPO: Charges in excess of $80 per visit
and any difference between the Plan allow-ance
and the billed amount* (90 visit
maximum)

Out-of-network: Charges in excess of $80 per
visit and any difference between the Plan
allowance and the billed amount* (90 visit
maximum) 28
28 Page 29 30
2002 Association Benefit Plan 28 Section 5 (a)
Home health services (continued) You pay
If not precertified, 40 visits per calendar year up to a maximum plan
payment of $40, subject to the above provisions.
PPO: Charges in excess of $40 per visit.*
(40 visit maximum)

Non-PPO: Charges in excess of $40 per visit
and any difference between the Plan allow-ance
and the billed amount*
(40 visit maximum)

Out-of-network: Charges in excess of $40 per
visit and any difference between the Plan
allowance and the billed amount* (40 visit
maximum)

For private duty nursing provided on a full-time basis (more than an
8-hour shift) by a Registered Nurse (R. N.) or Licensed Practical Nurse
(L. P. N.) when:

the care is ordered by the attending physician, and

your physician identifies the specific professional nursing skills that
you require, as well as the length of time needed.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

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

Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabitili-tative;

Custodial care as defined in Section 10, Definitions.

All charges.

Chiropractic
No benefits. All charges

Alternative treatments You Pay
Acupuncture when used as an anesthetic agent for covered surgery PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount* 29
29 Page 30 31
2002 Association Benefit Plan 29 Section 5 (a)
Alternative treatments (continued) You Pay
Not covered:
Chiropractic services

Chelation therapy except for acute arsenic, gold, mercury, or lead
poisoning

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

All charges

Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $100 maximum for one program per 12
months to include

1. Individual/ Group counseling and over-the-counter (OTC)
drugs and

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

2. Office visits for Smoking Cessation PPO: $10 copayment*
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: Prescription drugs are covered under Section 5( f), Prescription
drug benefits.

Healthydirections sm a disease management program for members
and covered dependents with asthma, diabetes, or congestive heart
failure (CHF). Your health is important to us! If you or your covered
dependent have asthma, diabetes or congestive heart failure (CHF),
you will be contacted to voluntarily participate. If you would like to
contact us for more information about this program, please call
1-800-228-0286.

Nothing 30
30 Page 31 32
2002 Association Benefit Plan 30 Section 5 (b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I
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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 exclu-sions
in this brochure and are payable only when we determine they are medically
necessary.

The calendar year deductible does not apply for these benefits; however, we added
asterisks -*-to show that the calendar year deductible does not apply.

The Out-of-network benefits are the standard benefits of this Plan. PPO benefits apply
only when you reside in the PPO network area and use a PPO provider. When no PPO
provider is available, non-PPO 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.).

YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCE-DURES.
Please refer to the precertification information shown in Section 3 to be
sure which services require precertification.

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Benefit Description You pay
NOTE: We added asterisks -* -to show when the calendar year deductible does not apply

Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an
individual (1) is the greater of 100 pounds or 100% over his or her
normal weight (in accordance with the Plan's underwriting
standards) with complicating conditions; and (2) has been so for at
least five years with documented unsuccessful attempts to reduce
under a doctor-monitored diet and exercise program

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

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount* 31
31 Page 32 33
2002 Association Benefit Plan 31 Section 5 (b)
Surgical procedures Continued You Pay
Voluntary sterilization, Norplant (a surgically implanted
contraceptive), and intrauterine devices (IUDs)

Treatment of burns
Surgical treatment of bunions or spurs
Assistant surgeons -we cover up to 20% of our allowance for the
surgeon's charge

Note: For related services, see applicable benefits section (i. e., for
inpatient hospital benefits, see Section 5( c).

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount (No deductible)*

When multiple or bilateral surgical procedures performed during the
same operative session add time or complexity to patient care, our
benefits are:

For the primary procedure:

PPO: 90% of the Plan allowance or*
Non-PPO: 75% of the Plan allowance or*
Out-of-network: 85% of the Plan allowance*
For the secondary procedure( s):
PPO: 90% of one-half of the Plan allowance or*
Non-PPO: 75% of one-half of the Plan allowance*
Out-of-network: 85% of one-half of the Plan allowance*
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.

PPO: 10% of the Plan allowance for the
primary procedure and 10% of one-half of
the Plan allowance for the secondary
procedure( s)*

Non-PPO: 25% of the Plan allowance for the
primary procedure and 25% of one-half of
the Plan allowance for the secondary
procedure( s); and any difference between our
payment and the billed amount*

Out-of-network: 15% of the Plan allowance
for the primary procedure and 15% of
one-half of the Plan allowance for the
secondary procedure( s); and any difference
between our payment and the billed amount*

Not covered:
Reversal of voluntary sterilization

Services of a standby surgeon, except during angioplasty or other
high risk procedures when we determine standbys are medically
necessary

Routine treatment of conditions of the foot
Radial keratotomy, or other refractive surgery
Removal of corns or calluses, or the trimming of toenails
Telephone consultations

All charges. 32
32 Page 33 34
2002 Association Benefit Plan 32 Section 5 (b)
Reconstructive surgery You Pay
Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's
appearance and

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

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

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

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

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount*

Note: Internal breast prostheses are covered under Section 5( c).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

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

Surgeries related to sex transformation or sexual dysfunction

All charges 33
33 Page 34 35
2002 Association Benefit Plan 33 Section 5 (b)
Oral and maxillofacial surgery You Pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion

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

Surgical correction of temporomandibular joint (TMJ) dysfunction
Surgical removal of impacted teeth, including anesthesia charges
Other surgical procedures that do not involve the teeth or their
supporting structures

20% of the Plan allowance and any difference
between the Plan allowance and the billed
amount*

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

Pre-and post-operative examinations in preparation for surgical
removal of impacted teeth

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Lung
Kidney
Kidney/ Pancreas
Liver
Pancreas
Intestinal transplant
Allogeneic bone marrow transplants
Autologous bone marrow transplants only for patients with acute
lymphocytic or nonlymphocytic leukemia, advanced Hodgkin's
lymphoma, advanced nonHodgkin's lymphoma, advanced
neuroblastoma, breast cancer, multiple myeloma, epithelial ovarian
cancer, and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

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

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount* 34
34 Page 35 36
2002 Association Benefit Plan 34 Section 5 (b)
Organ/ tissue transplants Continued You Pay
Not covered:
Donor screening tests and donor search expenses, except those per-formed
for the actual donor

Transplants not listed as covered
Implants of artificial organs

All charges

Anesthesia
Professional services provided in
Hospital (inpatient)

Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

PPO: 10% of the Plan allowance*
Non-PPO: 25% of the Plan allowance and
any difference between our allowance and the
billed amount*

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount* 35
35 Page 36 37
2002 Association Benefit Plan 35 Section 5 (c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I
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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 applies to only a few benefits. We added asterisks -*-to
show when the calendar year does not apply.

The Out-of-network benefits are the standard benefits of this Plan. PPO benefits apply
only when you reside in the PPO network area and use a PPO provider. When no PPO
provider is available, non-PPO 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 Section 5( a) or (b).

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO
DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precerti-fication
information shown in Section 3 to be sure which services require precertification.

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Benefit Description You pay
NOTE: We added asterisks -* -to show when the calendar year deductible does not apply

Inpatient hospital
Room and board, such as
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 pre-vent
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 com-parable
hospital in the area.

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics
Internal breast prostheses not related to cosmetic surgery

PPO: $100 per admission*
Non-PPO: $200 per admission and 25% of
the covered charges*

Out-of-network: $200 per admission* 36
36 Page 37 38
2002 Association Benefit Plan 36 Section 5 (c)
Inpatient hospital-Continued You Pay
Take-home drugs are covered under Section 5( f), Prescription drug
benefits

Take-home medical supplies, appliances, medical equipment, and
any covered items billed by a hospital are covered under Section
5( a), Durable Medical Equipment.

Pre-admission testing when testing is:
performed within 7 days before your scheduled hospital admission;

related to your covered hospital confinement;
accepted by the hospital instead of tests performed during your con-finement;
and

repeated only if your medical record shows the pre-admission test
results and the need for repeated tests when you are admitted.

NOTE: Charges for professional services of a physician when billed by
the hospital are paid separately. For example, when the hospital bills for
your surgeon's charges, we pay under Surgical services, Section 5( b);
and for your physical therapist's charges, we pay under Physical, occu-pational,
and speech therapies, Section 5( a).

PPO: Nothing*
Non-PPO: Nothing*
Out-of-network: Nothing*

Hospitalization for dental procedures
We cover hospital services related to dental procedures (even though
the dental procedure itself may not be covered) only when a
nondental physical impairment exists that makes hospitalization
necessary to safeguard your health.

PPO: Nothing*
Non-PPO: Nothing*
Out-of-network: Nothing*

Not covered:
A hospital admission that is not medically necessary, i. e., the medi-cal
services did not require the acute hospital inpatient (overnight)
setting but could have been provided in a doctor's office, the outpa-tient
department of a hospital, or some other setting without
adversely affecting your condition or quality of medical care ren-dered.

Inpatient hospital services and supplies for surgery that we do not
cover

Custodial care (see definition) even when provided by a hospital.
Non-covered facilities, such as nursing homes, rest homes, places for
the aged, convalescent homes or any place that is not a hospital,
skilled nursing facility, or hospice

Personal comfort items, such as radio, television, telephone, beauty
and barber services

Private nursing care

All charges. 37
37 Page 38 39
2002 Association Benefit Plan 37 Section 5 (c)
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
Internal breast prostheses not related to cosmetic surgery
Note: We cover directly related services and supplies rendered at the
time of the surgery at 100% of the Plan allowance.

We cover hospital services related to dental procedures (even though
the dental procedure itself may not be covered) only when a nondental
physical impairment exists that makes hospitalization necessary to safe-guard
your health.

PPO: 10% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount

Skilled nursing care facility benefits
If precertified, we cover semiprivate room, board, services and sup-plies
in a Skilled Nursing Facility (SNF) for up to 60 days when:

1) confinement is medically necessary and
2) when the confinement is under the supervision of a physician

PPO: Charges in excess of 60-day maximum*
Non-PPO: Charges in excess of 60-day maxi-mum
and the difference between the Plan
allowance and the billed amount*

Out-of-network: Charges in excess of 60-day
maximum and the difference between the
Plan allowance and the billed amount*

If not precertified, we cover semiprivate room, board, services and
supplies for up to 30 days subject to the above conditions

Note: SNF benefits will be restored for each new period of confinement.
There is a new period of confinement when at least 60 days have
elapsed since you were last confined in an SNF.

PPO: 20% and charges in excess of the
30-day maximum*

Non-PPO: 20% of the Plan allowance
and any difference between our allow-ance
and the billed amount for 30 days,
then all additional charges*

Out-of-network: 20% of the Plan
allowance and any difference between
our allowance and the billed amount
for 30 days, then all additional
charges*

Not covered: Custodial care All charges. 38
38 Page 39 40
2002 Association Benefit Plan 38 Section 5 (c)
Hospice care You Pay
Hospice is a coordinated inpatient and outpatient program of
maintenance and supportive care for the terminally ill provided by a
medically supervised team under the direction of a
Plan-approved independent hospice administration.

If precertified, we pay $7500 for inpatient or outpatient hospice care

PPO: Charges in excess of $7500
maximum*

Non-PPO: Charges in excess of $7500
maximum and the difference between the
Plan allowance and the billed amount*

Out-of-network: Charges in excess of $7500
maximum and the difference between the
Plan allowance and the billed amount*

If not precertified, we pay $4500 for inpatient or outpatient hospice
care
PPO: Charges in excess of $4500 maximum*

Non-PPO: Charges in excess of $4500
maximum and the difference between the
Plan allowance and the billed amount*

Note: One hospice program is covered per lifetime. This benefit does
not apply to services covered under any other provisions of the Plan.
Out-of-network: Charges in excess of $4500
maximum and the difference between the
Plan allowance and the billed amount*

Ambulance
We pay the first $50 for:
Local professional ambulance service when medically appropriate

Transportation by professional ambulance, railroad or commercial
airline on a regularly scheduled flight to the nearest hospital
equipped to furnish special and unique treatment

PPO: 10% of Plan allowance after $50 benefit
Non-PPO: 25% of Plan allowance and any
difference between our allowance and the
billed amount after $50 benefit

Out-of-network: 15% of Plan allowance and
any difference between our allowance and the
billed amount after $50 benefit 39
39 Page 40 41
2002 Association Benefit Plan 39 Section 5 (d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.

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 asterisks -*-to show
when the calendar year deductible does not apply.

The Out-of-network benefits are the standard benefits of this Plan. PPO benefits apply
only when you reside in the PPO network area and use a PPO provider. When no PPO
provider is available, non-PPO 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 that requires immediate medical attention and is sustained solely through violent,
external, and accidental means, such as broken bones, animal bites, insect bites and stings, and poisonings. Accidental
dental injury is under Section 5( h), Dental benefits.

Benefit Description You pay After the calendar year deductible
NOTE: We added asterisks -* -to show when the calendar year deductible does not apply
Accidental injury
We pay the first $500 for your accidental injury outpatient care for:
Outpatient facility charges

Physician services and supplies
Related x-ray, laboratory expenses, or durable medical equipment
Note: Charges in excess of the $500 benefit will be paid under the appli-cable
benefit (i. e., follow-up physician visits, see Section 5( a))..

PPO: Nothing up to the $500 maximum
benefit*

Non-PPO: Only the difference between our
allowance and the billed amount up to the
$500 maximum benefit*

Out-of-network: Only the difference between
our allowance and the billed amount up to the
$500 maximum benefit* 40
40 Page 41 42
2002 Association Benefit Plan 40 Section 5 (d)
Medical emergency
Outpatient medical or surgical services and supplies PPO: 10% of Plan allowance
Non-PPO: 25% of Plan allowance and any
difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount.

Ambulance
We pay $50 for:
Local professional ambulance service when medically appropriate

Transportation by professional ambulance, railroad or commercial
airline on a regularly scheduled flight to the nearest hospital
equipped to furnish special and unique treatment

PPO: 10% of Plan allowance after the $50
benefit

Non-PPO: 25% of Plan allowance and any
difference between our allowance and the
billed amount after the $50 benefit

Out-of-network: 15% of Plan allowance and
any difference between our allowance and the
billed amount after the $50 benefit 41
41 Page 42 43
2002 Association Benefit Plan 41 Section 5 (e)
Section 5 (e). Mental health and substance abuse benefits
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If you reside in the PPO Network Area, you may choose to get PPO or Non-PPO care. If
you reside outside the network area, you will receive out-of-network care. PPO members
who choose PPO care must get our approval for services and follow a treatment plan we
approve. Cost-sharing and limitations for PPO or out-of-network 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.

The calendar year deductible is $300 per person ($ 600 per family) and applies to
almost all benefits in this Section. We added asterisks -*-to show when the calendar
year deductible does not apply.

The Out-of-network benefits are the standard benefits of this Plan. PPO benefits apply
only when you reside in the PPO network area and use a PPO provider. When no PPO
provider is available, non-PPO benefits apply.

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

PPO MEMBERS WHO CHOOSE PPO CARE MUST GET PREAUTHORIZA-TION
OF THESE SERVICES. See the instructions after the benefits descriptions
below.

PPO mental health and substance abuse benefits are listed below, then Non-PPO and
Out-of-network benefits begin on page 44.

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Benefit Description You Pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We added asterisks -* -to show
when the calendar year deductible does not apply

PPO Network benefits
All diagnostic and treatment services contained in a treatment plan that
we approve. The treatment plan may include services, drugs, and sup-plies
described elsewhere in this brochure.

Note: PPO benefits are payable only when we determine the care is clin-ically
appropriate to treat your condition and only when you receive the
care as part of a treatment plan we approve.

Your cost sharing responsibilities are no
greater than for other illness or conditions. 42
42 Page 43 44
2002 Association Benefit Plan 42 Section 5 (e)
PPO Network benefits-Continued You Pay
Professional services provided by a physician PPO: 10% of the Plan allowance*
Other professional services (i. e., psychologists, clinical social work-ers,
licensed counselors), inpatient professional services, and outpa-tient
hospital services

Services in approved alternative care settings, such as partial hospi-talization
or facility-based intensive outpatient treatment

Diagnostic tests
Psychological testing

PPO: 10% of the Plan allowance

Medication management PPO: $10 copayment*
Inpatient hospital charges PPO: $100 per admission*
Not covered:
Services we have not approved.

All charges for chemical aversion therapy, conditioned reflex
treatments, narcotherapy or any similar aversion treatments and all
related charges (including room and board)

Any provider not specifically listed as covered
Counseling or therapy for marital, educational or behavioral
problems, or related to mental retardation or learning disabilities

Community-based programs such as self-help groups or 12 step
program

Treatments for learning disabilities and mental retardation
Services by pastoral, marital, or drug/ alcohol counselors
Biofeedback, conjoint therapy, hypnotherapy, interpretation/ prepara-tion
of reports

Telephone consultations

All charges

Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor of
another. 43
43 Page 44 45
2002 Association Benefit Plan 43 Section 5 (e)
PPO Network benefits-Continued
Preauthorization and To be eligible to receive these enhanced mental health and substance Precertification abuse benefits you must obtain a treatment plan and follow all of our net-work
authorization processes. These include:
Outpatient mental health and substance abuse benefits will be reduced
by 50% if services are not preauthorized within two business days of
the initial visit.

Preauthorization and concurrent review are required for all levels of
care whether in-or out-of-network.

The medical necessity of your inpatient services must be precertified
for you to receive full Plan benefits. Otherwise, the benefits payable
will be reduced by $500. Emergency admissions must be reported
within two business days following the day of admission even if you
have been discharged.

You, your representative, your physician, or your hospital must call
Mutual of Omaha's Care Review Unit prior to admission. The toll-free
number is 1-800-634-0069.

You must provide the following information: enrollee's name and Plan
identification number; patient's name, birth date and phone number; rea-son
for hospitalization, proposed treatment; name of hospital or facility;
name and number of admitting physician; and number of planned days of
confinement. 44
44 Page 45 46
2002 Association Benefit Plan 44 Section 5 (e)
Non-PPO and Out-of-network benefits You Pay
Mental Health
Professional services by physicians, psychologists, clinical social
workers or licensed counselors, and inpatient professional services

Non-PPO: 50% of the Plan allowance and
any difference between our allowance and
the billed amount ($ 50 visit maximum)

Out-of-network: 15% of the Plan allowance
and the difference between our allowance
and the billed amount

Psychological testing

Medical management
Non-PPO: 25% of the Plan allowance and
the difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and the difference between our Plan and the
billed amount

Outpatient hospital charges Non-PPO: 50% of the Plan allowance and
the difference between our allowance and the
billed amount

Out-of-network: 15% of the Plan allowance
and the difference between our Plan and the
billed amount

Inpatient hospital charges Non-PPO: $200 per admission and 25% of
the covered charges*

Out-of-network: $200 per admission*

Services in approved alternative care settings, such as partial
hospitalization or facility-based intensive outpatient treatment
Non-PPO: All charges

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount

Substance Abuse

Inpatient care includes room and board and ancillary charges for con-finements
in a treatment facility for rehabilitative treatment of alco-holism
or substance abuse

Non-PPO: $200 per admission and 25% of
the covered charges up to $10,500 per
28-day program*

Out-of-network: $200 per admission*

Outpatient benefits (including aftercare) Non-PPO: 25% of the Plan allowance and
the difference between our allowance and the
billed amount up to the maximum $4,000
benefit

Out-of-network: 15% of the Plan allowance
and the difference between our allowance
and the billed amount

Services in approved alternative care settings, such as partial
hospitalization or facility-based intensive outpatient treatment
Non-PPO: All charges

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount 45
45 Page 46 47
2002 Association Benefit Plan 45 Section 5 (e)
Non-PPO and Out-of-network benefits-Continued You Pay
Not covered:
Services we have not approved.

All charges for chemical aversion therapy, conditioned reflex treat-ments,
narcotherapy or any similar aversion treatments and all
related charges (including room and board)

Any provider not specifically listed as covered
Counseling or therapy for marital, educational or behavioral prob-lems,
or related to mental retardation or learning disabilities

Community-based programs such as self-help groups or 12 step pro-gram

Treatments for learning disabilities and mental retardation
Services by pastoral (except in medically underserved areas), mari-tal,
or drug/ alcohol counselors

Biofeedback, conjoint therapy, hypnotherapy, interpretation/ prepara-tion
of reports

Telephone consultations

All charges.

Lifetime maximum Non-PPO inpatient or outpatient care for the treatment of alcoholism and drug abuse is limited to three treatment programs per lifetime. With-drawal
from a treatment program prior to completion constitutes use of
one program.

Preauthorization and Preauthorization of treatment programs is not required. The medical Precertification necessity of your admission to a hospital or other covered facility must be

precertified for you to receive these benefits. Emergency admissions must
be reported within two business days following the day of admission even
if you have been discharged. Otherwise, the benefits payable will be
reduced by $500. See Section 3 for details. Precertification is not required
for overseas care.

See these sections of the brochure for more valuable information about these benefits:
Section 3, How you get care, 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 46
46 Page 47 48
2002 Association Benefit Plan 46 Section 5 (f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described below.

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

Certain drugs require prior authorization or may be subject to quantity limits. If your
prescription is for a drug requiring prior authorization, additional information from
your physician will be needed before the medication is dispensed. Your physician
may call 1-800-634-0069 to begin the review process.

The calendar year deductible does not apply to almost all benefits in this Section. We
added asterisks -* -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.

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

Where you can obtain them. You may fill the prescription at a network pharmacy or by mail. To locate a network
pharmacy in your area, call 1-800-752-0598 or you may also visit Mutual of Omaha's website at www. mutualofo-maha.
com. We will send you information on the mail order drug program. To use the program: 1) complete the ini-tial
mail order form; 2) enclose your prescription and copayment; 3) mail your order to Express Scripts, Inc., PO
Box 27226, Albuquerque, NM 87125-9908; 4) allow two to three weeks for delivery. You will receive forms for
refills and future prescription orders each time you receive drugs or supplies under this program. If you have ques-tions
about the mail order program, call 1-800-417-8173.

We use a formulary. A formulary is a list of selected FDA-approved commonly prescribed medications from
which your physician or dentist may choose to prescribe. The formulary is designed to inform you and your physi-cian
about quality medications that, when prescribed in place of other nonformulary medications, can help contain
the increasing cost of prescription drug coverage without sacrificing quality. To find out if your medication is on the
formulary call Express Scripts, Inc., at 1-800-752-0598 or visit Mutual of Omaha's website at www. mutualofomaha. com. If you
are prescribed a drug not on the formulary, you will pay a higher copayment. If due to medical reasons unique to you for which a
nonformulary is mandatory, you may request an exception in writing through the Disputed Claims Process as described on page 57.
If the exception is approved, you will pay the formularly copayment.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expen-sive
brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dos-age
to the original brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food
and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards
of quality and strength as brand-name drugs.

Some drugs require prior authorization. Prior Authorization Requirements (PAR) are applied to encourage
appropriate use of medications that are most likely to have certain risk factors. These requirements apply to drugs
that may be used in amounts that exceed dosage or length of treatment recommendations or that may be more costly
than medications that are proven to be clinically and therapeutically similar. If your prescription is identified as a
drug requiring PAR, your physician should call Customer Service at 1-800-634-0069.

These are the dispensing limitations. When you obtain prescription drugs from a pharmacy using your Prescrip-tion
Drug Card, you may obtain up to a 30-day supply of covered drugs. If purchasing more than a 30-day supply on
the same day, any expense exceeding that supply limit will not be covered through the pharmacy arrangement. You
may purchase your covered prescription drugs and supplies by presenting your prescription drug card and your pre-scription
to a participating provider. Prescription refills will be covered when no more than 50% of the 30-day sup-ply
remains based on your physician's prescription. 47
47 Page 48 49
2002 Association Benefit Plan 47 Section 5 (f)
Section 5 (f). Prescription drug benefits (continued)
If your physician or dentist prescribes a medication that will be taken over an extended period of time, you should
request two prescriptions one for immediate use with a participating retail pharmacy and the other for up to a 90-day
supply from the Mail Order Program. Express Scripts, Inc., will fill your prescription. All drugs and supplies covered
by the Plan are available under this program except fertility drugs. If you have questions about a particular drug or a
prescription, and to request your first order forms, call 1-800-417-8173. If a generic equivalent to the prescribed drug is
available, Express Scripts will dispense the generic equivalent instead of the brand name unless you or your physician
specifies that the brand name is required.

Benefit Description You Pay
NOTE: The calendar year deductible applies to almost all benefits in this Section. We added asterisks -* -to show
when the calendar year deductible does not apply

Covered medications and supplies
Each new enrollee will receive a prescription drug card (two cards if
enrolled in a Family plan), a mail order form/ patient profile and a pread-dressed
reply envelope. If you need additional cards, call 1-800-634-
0069.

You may purchase the following medications and supplies prescribed by
a physician from either a pharmacy or by mail:

Drugs, vitamins and minerals that by Federal law of the United States
require a doctor's prescription for their purchase

Insulin
FDA-approved drugs and devices requiring a doctor's prescription
for the purpose of birth control

Needles and syringes for the administration of covered medications
Diabetic, colostomy, and ostomy supplies
Here are some things to keep in mind about our prescription drug pro-gram:

A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. Your physician must
specify "dispense as written" if a brand name drug is required.

When purchasing drugs at a pharmacy, you must use your Prescrip-tion
Drug Card. Please call us to request additional prescription drug
cards for family members.

We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your physician
may prescribe a name brand drug from a formulary list. To order a pre-scription
drug brochure, call Customer Service at 1-800-752-0598.

Network Retail:
$10 generic*
$20 formulary brand name*
$30 nonformulary brand name*

Network Retail Medicare:
$5 generic*
$15 formulary brand name*
$25 nonformulary brand name*

Network Mail Order:
$15 generic*
$30 formulary brand name*
$45 nonformulary brand name*

Network Mail Order Medicare:
$8 generic*
$23 formulary brand name*
$38 nonformulary brand name*

Note: If there is no generic equivalent avail-able,
you will still have to pay the brand
name copay. 48
48 Page 49 50
2002 Association Benefit Plan 48 Section 5 (f)
Covered medications and supplies-Continued You Pay
If you are overseas and do not order prescription drugs through the Mail
Order Prescription Drug Program:

If you are provided drugs directly by a physician or covered facility (not
a pharmacy):

If you do not use your prescription drug card to purchase needles and
syringes for the administration of covered medications or diabetic,
colostomy or ostomy supplies:

20%

Not covered:
Drugs and supplies for cosmetic purposes
Nutritional supplements and vitamins (including prenatal) that do
not require a prescription

Medication that does not require a prescription under Federal law
even if your physician prescribes it or a prescription is required
under your State law

Medical supplies such as dressings and antiseptics
Medication for which there is a non-prescription equivalent avail-able

Prescriptions received from non-participating pharmacies unless
overseas or through a covered physician or facility. Call 1-800-752-
0598 to locate a participating pharmacy.

Drug copayments
Fertility drugs are covered only under "Infertility services"

All Charges 49
49 Page 50 51
2002 Association Benefit Plan 49 Section 5 (g)
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 For any of your health concerns, 24 hours a day, 7 days a week, you may call the Optum NurseLine at toll free 1-877-861-3861 and talk with a

registered nurse who will discuss treatment options and answer your
health questions. A PIN number is needed to access the nurse line. If you
needed assistance, please call 1-800-634-0069.

High risk pregnancies You have access to Mutual of Omaha's Health Maternity Program, which provides educational material and support to pregnant women. Contact

Customer Service at 1-800-634-0069 for more information.
Centers of excellence Mutual of Omaha has special arrangements with facilities to provide ser-vices 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. For
additional information regarding our transplant network, please call
1-800-228-0286.

Services overseas Our overseas customers receive the same out-of-network benefits and prompt customer service as their stateside counterparts. There is no

additional claims processing time for foreign claims. 50
50 Page 51 52
2002 Association Benefit Plan 50 Section 5 (h)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

The calendar year deductible does not apply to almost all benefits in this Sec-tion.
We added asterisks -* -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.

Note: Even when the dental procedure itself may not be covered, we cover
hospitalization for dental procedures when a non-dental physical impairment
exists which makes hospitalization necessary to safeguard the health of the
patient.

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Accidental injury benefit You Pay
We cover outpatient restorative services necessary to promptly
repair (but not replace) sound natural teeth until treatment is completed.

The need for these services must result from an accidental injury from
an external force such as a blow or fall that requires immediate attention
(not from biting or chewing). You must be enrolled in the Plan at the
time of injury and must remain in the Plan until treatment is completed.

20% of the Plan allowance and any difference
between our allowance and the billed
amount*

Dental benefits
Service We pay (scheduled allowance) You pay
Routine oral examinations
including X-rays, cleaning,
diagnosis, and preparation of a
treatment plan

Dental fillings:

$39 twice per year All charges in excess of the
scheduled amounts listed to the
left*

One surface $12
Two surfaces $19
Three or more surfaces $24 51
51 Page 52 53
2002 Association Benefit Plan 51 Section 5 (h)
Section 5 (h). Dental benefits (continued)
Not covered:
Charges for tooth extractions, dental implants, preparation for orthodontic treatment or dentures, or other dental
work or surgery that involves any tooth structure, alveolar process, abscess, periodontal disease or disease of the
gingival tissue

Dental appliances, study models, splints, and other devices or dental services associated with the treatment of tem-poromandibular
joint (TMJ) dysfunction

Crowns and root canals
Other dental services not listed as covered
Note: Surgical removal of impacted teeth is covered in Section 5( b), Surgical and Anesthesia Services. 52
52 Page 53 54
2002 Association Benefit Plan 52 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 or out-of-pocket maximums.

Supplemental Dental
Consumer Dental Care offers a reduced fee dental program to individuals located in Maryland and Washington, DC,
through Consumer Dental Corp.; and to individuals located in Virginia through Consumer Dental Care of Virginia, Inc.

Through the Consumer Dental Care Select you can enjoy reduced savings on all areas of dentistry to include:

Additional features include:
Retired persons are eligible
Over 1,500 Participating General Dentists and Specialists
Extremely attractive rates!

Vision Care
Outlook Vision Services offers you and your dependents the opportunity to purchase eye wear at special discount
prices. Enrollment in Outlook Vision Services provides the following benefits:

Substantial savings on eye wear purchases with over 8,000 optical providers located nationwide (not
available in CA).

Discounts on eye exams at select locations where approved (not available in CA or WA)
Optical providers consist of but are not limited to: Sears, J. C. Penney Optical, Vision Works, D. O. C.
Optics, Shopko Optical, LensCrafters, Pearle, and many others

Save up to 50% of retail prices on eye wear: lenses, frames, contact lenses, prescription and
nonprescription sunglasses and accessories.

Save up to 50% off on contact lenses when ordering though Outlook's unique mail order contact lens
replacement program.

Unlimited selection on eye wear with no limit on quantities
NO waiting periods, NO pre-existing conditions, NO paperwork
Benefits cover the entire household at extremely attractive rates!

HearPO
HearPO is a nationwide network of credentialed audiology professionals who provide quality hearing care services and
hearing instruments throughout the United States.

HearPO provides substantial savings off the manufacturer's suggested retail price of all HearPO brand hearing
devices, including the latest programmable and digital technology.

Diagnostic/ Preventative, Restorative Dentures
Crowns and Bridges Endodontics
Periodontics Oral Surgery
Orthodontics

No deductibles No claim forms
No pre-existing conditions
(except orthodontics in progress)
No maximum level of benefits 53
53 Page 54 55
2002 Association Benefit Plan 53 Section 5 (i)
HearPO provides discounts on repairs and hearing aid batteries.
There is a 60-day trial period with a money back guarantee.
HearPO professionals conduct comprehensive follow-up services at no charge for one year.
You can reach HearPO on 1-888-HEARING (432-7464) or on the Internet at www. hearpo. com. You must identify
yourself as a member of Diversified Federal Groups, the name on your prescription drug card. Or you may call
1-703-613-7215 or 1-800-769-6953.

Glucose Monitors
Plan members diagnosed with diabetes may receive a free glucose monitor from Roche Diagnostics who provides the
Accu-Check Advantage monitor; or from Bayer Diagnostics who provides the Elite, Elite XL, and Dex monitors.

The monitor is a small device that diabetics used to check and monitor their blood sugar. Monitoring and controlling
blood sugars is essential for managing diabetes and preventing unnecessary complications. To obtain a glucose monitor,
call one of the manufacturers listed below:

You must identify yourself as a Mutual of Omaha Member. If you have difficulty obtaining a free glucose monitor,
please call the Plan at 1-800-634-0069.

Lifestyle Prescription Medications
Many lifestyle prescription drugs are available at a discounted rate through participating pharmacies and the Plan's mail
order program. You are responsible for the entire cost of the drugs; however, they are available to you at Mutual of
Omaha's preferred contracted rate. The following lifestyle prescription drugs are covered under this benefit:

Cosmetic: Renova, Vaniqua, Propecia
Infertility: A. P. L., Chorex-5, Chorex-10, Chronon 10, Clomid, Clomiphene, Crinone gel, Fertinex, Follistem, Gonal-F,
Gonic, HCG, Humegon, Pergonal, Pregnyl, Profasi, Repronex, Serophone

Obesity: Adipost, Didrex, Ionamin, Merida, Phendimetrazine, Phentermine, Sanorex, Tenuate, Xenical
Sexual Dysfunction: Caverject, Edex, Muse, Viagra
This list is subject to change and may be subject to medical necessity review if they are covered under another benefit
provision (i. e., Infertility). If you have a question on drug coverage, call 1-800-634-0069.

American WholeHealth Networks
American WholeHealth is a national leader in offering discounted alternative medicine services.
Over 24,000 credentialed practitioners in chiropractic care, massage therapy, acupuncture, nutritional counseling,
and relaxing techniques

Alternative health information offering the most diverse and complete set of solutions for those seeking alternative medCould not acquire words on page 55 -icine
services

Discounts on vitamins and supplements on-line or by catalog

Long Term Care
When you or a family member require help with normal daily activities due to aging or a disabling accident or illness,
you may need long term care assistance. Long term care situations can quickly deplete a family's lifetime of savings.
Long Term Care guards against this circumstance. Long Term Care insurance underwritten by Mutual of Omaha
Insurance Company is available to you, your spouse, parents and parents-in-law under the age of 80.

For additional information or enrollment in any of these programs, please call 1-800-769-6953.

NON-FEHB Benefits are not part of the FEHB contract

Roche Diagnostic Bayer Diagnostic
Accu-Check Advantage monitor Elite, Elite XL, or Dex monitors
1-800-207-2312 1-877-229-3777 54
54 Page 55 56

55 Page 56 57
2002 Association Benefit Plan 55 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 at 1-800-634-0069.
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. For claims questions and assistance,
call us at 1-800-634-0069.

When you must file a claim such as for 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. Itemized bills and receipts
should be sent to Association Benefit Plan, PO Box 668587, Charlotte, NC
28266-8587.

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.
You should use the Plan's standard claim form to file dental claims. Attach
the dentist's itemized bill. The bill must include the name of the patient,
dates of service, itemized charges and the dentist's tax ID number.

Note: Canceled checks, cash register receipts, or balance due statements
are not acceptable substitutes for itemized bills.

In addition:
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.

Bills for home nursing care must show that the nurse is a registered or
licensed practical nurse and must include nursing notes.

Claims for rental or purchase of durable medical equipment; private
duty nursing; and physical, occupational, and speech therapy may
require a written statement from the physician specifying the medical
necessity for the service or supply and the length of time needed.

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 not provide duplicate or year-end statements. 56
56 Page 57 58
2002 Association Benefit Plan 56 Section 7
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim within two years of the date you received the service,
unless timely filing was prevented by administrative operations of Govern-ment
or legal incapacity and provided the claim was submitted as soon as
reasonably possible. Once we pay benefits, there is a three-year limitation
on the reissuance of uncashed checks.

Overseas claims For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States, you
must send a completed claim form and the itemized bills.
Overseas (foreign) claims for prescription drugs and supplies that are
not ordered through the Mail Order Prescription Drug Program must
include receipts that include the prescription number, name of drug or
supply, prescribing physician's name, date, and charge.

Claims for overseas (foreign) services should include an English trans-lation.

Charges should be converted to U. S. dollars using the exchange rate
applicable at the time the expense was incurred.

When we need more information Annually you may be asked to verify other health care coverage. We may delay processing or deny your claim if you do not respond. 57
57 Page 58 59
2002 Association Benefit Plan 57 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization/ 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: Association Benefit Plan, PO Box 668587, Charlotte, NC 28266-
8587; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific ben-efit
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 arrange for the health care provider to give you the care); or

(b) Write to you and, if applicable, 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 informa-tion
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 II,
1900 E Street, NW, Washington, D. C. 20415-3620. 58
58 Page 59 60
2002 Association Benefit Plan 58 Section 8
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 1-800-634-
0069 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.

The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

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

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

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

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

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

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 deCould not acquire words on page 61 nied 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 its disputed claim deci-sion.
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. 59
59 Page 60 61
2002 Association Benefit Plan 59 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health
coverage
You must tell us if you or a family member is covered under another group
health plan or has 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 sec-ondary
payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners' guide-lines.

When we are the primary payer, we will pay the benefits described in this
brochure.

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

What is Medicare Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requir-ing
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 infor-mation.

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

When you are enrolled in Original Medicare, along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. 60
60 Page 61 62

61 Page 62 63
2002 Association Benefit Plan 61 Section 9
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 or over and Then the primary payer is
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
because of a disability), 

2) Are an annuitant, 
3) Are a reemployed annuitant with the Federal government when

a) The position is excluded from FEHB,
or



b) The position is not excluded from
FEHB

(Ask your employing office which of these applies to you.)



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



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

(for other
services)

3) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,


(except for claims
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,


2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD,


3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,


C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and

a) Are an annuitant, or


b) Are an active employee 
c) Are a former spouse of an annuitant 
d) Are a former spouse of an active employee  62
62 Page 63 64
2002 Association Benefit Plan 62 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 Medi-care
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. Medi-care
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 care 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 man-aged
care plan, tell us. We will need to know whether you are in the Origi-nal
Medicare Plan or in a Medicare Managed care Plan so we can correctly
coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a 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 man-aged
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 man-aged
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 service 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 Part A or Part B
If you do not have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A. we will not ask you to
enroll in it.

TRICARE 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 63
63 Page 64 65
2002 Association Benefit Plan 63 Section 9
OWCP or a similar agency pays for through a third party injury settle-ment
or other similar proceeding that is based on a claim you filed under
OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treat-ment,
we will cover your care.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government
agencies are responsible for
your care

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

When others are responsible
for injuries
When you receive money to compensate you for medical or hospital care
for injuries or illness caused by another person, you must reimburse us for
any expenses we paid. However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called sub-rogation.
If you need more information, contact us for our subrogation pro-cedures. 64
64 Page 65 66
2002 Association Benefit Plan 64 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, the date of entry and the
date of discharge are counted as the same day.

Assignment Your authorization for the Plan to issue payment of benefits directly to the provider. We reserve 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 Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 12.

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. There is 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.

Congenital anomalies A condition existing at or from birth that is a significant deviation from the common form or anomaly norm. For purposes of this Plan, congenital
includes protruding ear deformities, cleft lips, cleft palates, webbed fingers
or toes, and other conditions that we may determine to be congenital anom-alies.
In no event will the term congenital anomaly include conditions relat-ing
to teeth or intra-oral structures supporting the teeth.

Copayment A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive covered services. See page 12.

Cosmetic surgery Any operative procedure or any portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through a
change in bodily form.

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 could be provided safely and reasonably by a person who
is not medically skilled, or are designed mainly to help the patient with
daily living activities. These activities include but are not limited to: 65
65 Page 66 67
2002 Association Benefit Plan 65 Section 10
1) personal care such as help in: walking; getting in or out of bed;
bathing; eating by spoon, tube or gastrostomy; exercising;
dressing;

2) homemaking, such as preparing meals or special diets;
3) moving the patient;
4) acting as a companion or sitter;
5) supervising medication that can usually be self administered; or
6) treatment services such as recording temperature, pulse, and
respirations, or administration and monitoring of feeding systems.

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

Effective date The date the benefits described in this brochure are effective:
1) January 1 for continuing enrollments and for all annuitant enroll-ments;

2) the first day of the first full pay period of the new year for enroll-ees
who change plans or options or elect FEHB coverage during
Open Season for the first time; or

3) for new enrollees during the calendar year, but not during Open
Season, the effective date of enrollment as determined by your
employing office or retirement system.

Experimental or
investigational services
A drug, device, or biological product is experimental or investigational if it
cannot lawfully be marketed without approval of the U. S. Food and Drug
Administration (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 deter-mine
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 is
that further studies or clinical trials are necessary to determine its maxi-mum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as
compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the
authoritative medical and scientific literature; the written protocol or proto-cols
used by the treating facility or the protocol( s) of another facility study-ing
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.

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 hospital, medical or other health care service or sup-plies,
or that pays a specific amount for each day or period hospitalization. 66
66 Page 67 68
2002 Association Benefit Plan 66 Section 10
Home health care agency A public agency or private organization under Medicare that is licensed as a home health care agency by the State and is certified as such.
Home health care plan A plan of continued care and treatment when you are under the care of a physician, and when certified by the physician that, without the home
health care, confinement in a hospital or skilled nursing facility would be
required.

Hospice care program A coordinated program of home and inpatient pain control and supportive care for the terminally-ill patient and the patient's family. Care is provided
by a medically supervised team under the direction of an independent
hospice administration that we approve.

Intensive outpatient Program
(IOP)
IOPs offer time-limited services that are coordinated, structured, and
intensively therapeutic. Such programs 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. At a minimum,
IOPs offer three to four hours of active treatment per day at least two to
three days per week.

Medical necessity Services, drugs, supplies, or equipment provided by a hospital or covered provider of 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 the personal comfort of the patient, the
family, or the provider;

4) are not a part of or associated with the scholastic education or
vocational training of the patient; 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.

Mental conditions/
substance abuse
Conditions and diseases listed in the most recent edition of the Interna-tional
Classification of Diseases (ICD) as psychoses, neurotic disorders, or
personality disorders; other nonpsychotic mental disorders listed in the
ICD to be determined by the Plan; or disorders listed in the ICD requiring
treatment for abuse of or dependence upon substances such as alcohol,
narcotics, or hallucinogens.

Plan allowance Our Plan allowance is 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:
Twice a year the Health Insurance Association of America (HIAA) com-piles
actual claims received in each Zip Code area throughout the United
States. HIAA guides are applied at the 90 th percentile to surgery, physician
services, therapy, X-ray and lab expenses. 67
67 Page 68 69
2002 Association Benefit Plan 67 Section 10
PPO providers accept the plan allowance as payment in full.
For more information, see Section 4, Differences between our allowance
and the bill.

Partial hospitalization A time-limited, ambulatory, active treatment program that offers therapeu-tically intensive, coordinated, and structured clinical services with a stable
therapeutic environment. At a minimum, 20 hours of scheduled program-ming
extended over a minimum of five days per week will be provided by a
partial hospitalization program that is either licensed or JCAHO accredited.

Routine physical examination A complete evaluation, including a comprehensive history and physical examination, without symptoms or illness.

Sound natural tooth A tooth that is whole or properly restored and is without impairment, peri-odontal, or other conditions and is not in need of the treatment provided for
any other reason other than an accidental injury.

Us/ We Us and we refer to the Association Benefit Plan
You You refers to the enrollee and each covered family member. 68
68 Page 69 70
2002 Association Benefit Plan 68 Section 11
Section 11. FEHB facts
No pre-existing condition
limitation
We will not refuse to cover the treatment of a condition that you had before
you enrolled in this Plan solely because you had the condition before you
enrolled.

Where you can get information
about enrolling in the
FEHB Program

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

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
for you and your family
Self Only coverage is for you alone. Self and Family coverage is for you,
your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement
office authorizes coverage for. Under certain circumstances, you may also
continue coverage for a disabled child 22 years of age or older who is
incapable of self-support. In order to determine qualification, a medical
certificate must state your child is incapable of self support. The medical
certificate must be submitted to your employing office at least 60 days prior
to your child reaching age 22.

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. 69
69 Page 70 71
2002 Association Benefit Plan 69 Section 11
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
premiums start
The benefits in this brochure are effective on January 1. If you joined this Plan
during Open Season, your coverage begins on the first day of your first 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
records are confidential
We will keep your medical and claims information confidential. Only the
following 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; or

OPM, when reviewing a disputed claim or defending litigation about a
claim.

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not con-tinue to get benefits under your former spouse's enrollment. But, you may be

eligible for your own FEHB coverage under the spouse equity law. If you are
recently divorced or are anticipating a divorce, contact your former 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 of
Coverage (TCC)
If you leave Federal service, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for Temporary Continuation
of Coverage (TCC). For example, you can receive TCC if you are not able to
continue your FEHB enrollment after you retire, if you lose your Federal job,
if you are a covered dependent child and you turn 22 or marry, etc. 70
70 Page 71 72
2002 Association Benefit Plan 70 Section 11
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
individual coverage
You may convert to a non-FEHB individual policy if:

Your coverage under TCC or the spouse equity law ends. If you can-celed
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 cov-erage,
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
Group Health Plan Coverage
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
is a Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If
you leave the FEHB Program, your employing or retirement office will
give you a Certificate of Group Health PlanCould not acquire words on page 72 Coverage that indicates how
long you have been enrolled with us. You can use this certificate when get-ting
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 previ-ously
enrolled in other FEHB plans, you may also request a certificate from
those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continua-tion
of Coverage (TCC) under the FEHB Program. See also the FEHB web
site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" fre-quently
asked questions. These highlight HIPAA rules, such as the require-ment
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. 71
71 Page 72 73

72 Page 73 74
2002 Association Benefit Plan 72 Long Term Care Insurance
Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can
be received. Long term care insurance can provide choices of care and
preserve your independence.

When will I get more
information on how to apply for
this new insurance coverage?

Employees will get more information from their agencies during the
LTC open enrollment period in the late summer/ early fall of 2002.

Retirees will receive information at home.

How can I find out more about
the program NOW?
Our toll-free teleservice center will begin in mid-2002. In the mean-
time, You can learn more about the program on our web site at
www. opm. gov/ insure/ ltc. 73
73 Page 74 75
2001 Association Benefit Plan 73 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 39
Allergy tests 23
Alternative treatment 28
Ambulance 38,40
Anesthesia 34
Autologous bone marrow
transplant 33
Biopsies 30
Birthing centers 8
Blood and blood plasma 35
Breast cancer screening 19
Casts 26
Catastrophic protection 13
Changes for 2002 5
Chemotherapy 24
Childbirth 20
Chiropractic 28
Cholesterol tests 19
Circumcision 20
Claims 55
Coinsurance 12
Colorectal cancer screening 19
Congenital anomalies 30
Contraceptive devices and drugs 47
Coordination of benefits 59
Copayments 12
Covered charges 7
Covered providers 6
Crutches 27
Deductible 12
Definitions 64
Dental care 50
Diagnostic services 19
Disputed claims review 57
Donor expenses (transplants) 33
Dressings 37
Durable medical equipment 27
Educational classes and programs 29
Effective date of enrollment 65
Emergency 39
Experimental or investigational 65
Eyeglasses 25
Family planning 22
Fecal occult blood test 19
Flexible benefits option 49
Foot care 26
Freestanding ambulatory
facilities 37
General Exclusions 54

Hearing services 25
Home health services 27
Hospice care 38
Home nursing care 28
Hospital 7
Immunizations 20
Independent laboratories 19
Infertility 22
Inhospital physician care 18
Inpatient Hospital Benefits 35
Insulin 47
Laboratory and pathological
services 19
Machine diagnostic tests 19
Magnetic Resonance Imagings
(MRIs) 19
Mail Order Prescription Drugs 47
Mammograms 19
Maternity Benefits 20
Medicaid 63
Medically necessary 66
Medically underserved areas 7
Medicare 59
Members 67
Mental Conditions/ Substance Abuse
Benefits 41
Neurological testing 19
Newborn care 20
Non-FEHB Benefits 52
Nurse 6
Licensed Practical Nurse 6
Nurse Anesthetist 6
Nurse Midwife 6
Nurse Practitioner 6
Psychiatric Nurse 6
Registered Nurse 6
Nursery charges 21
Nursing School Administered
Clinic 8
Obstetrical care 20
Occupational therapy 24
Ocular injury 25
Office visits 18
Oral and maxillofacial surgery 33
Orthopedic devices 26
Ostomy and catheter supplies 47
Out-of-pocket expenses 13
Outpatient facility care 37
Overseas claims 56

Oxygen 27
Pap test 19
Physical examination 19
Physical therapy 24
Physician 6
Pre-admission testing 36
Precertification 9
Preferred Provider Organization
(PPO) 4
Prescription drugs 46
Preventive care, adult 19
Preventive care, children 19
Prior approval 9
Prostate cancer screening 19
Prosthetic devices 26
Psychologist 6
Psychotherapy 44
Radiation therapy 24
Rehabilitative therapies 24
Renal dialysis 24
Room and board 35
Second surgical opinion 18
Skilled nursing facility care 37
Smoking cessation 29
Social Worker 6
Speech therapy 24
Splints 27
Sterilization procedures 22
Subrogation 63
Substance abuse 41
Surgery 30
Anesthesia 34
Assistant surgeon 31
Multiple procedures 31
Oral 33
Outpatient 30
Reconstructive 32
Syringes 47
Temporary continuation of
coverage 69
Transplants 33
Treatment therapies 24
Vision services 25
Well child care 20
Wheelchairs 27
Workers' compensation 62
X-rays 19 74
74 Page 75 76
2002 Association Benefit Plan 74 Summary of Benefits
Summary of Benefits for the Association Benefit Plan -2002
Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this bro-chure.
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 not subject to the $300 calendar year deductible. And, after we pay, you gen-erally
pay any difference between our allowance and the billed amount.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the
office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PPO: $10 copayment*
Non-PPO: 25% of our allowance
Out-of-network: 15% of our allowance

18

Services provided by a hospital:
Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PPO: $100 admission
Non-PPO: $200 admission; 25% of
charges*

Out-of-network: $200 admission*

35

Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PPO: 10% of our allowance
Non-PPO: 25% of our allowance
Out-of-network: 15% of our allowance

37

Emergency benefits:
Accidental injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing for your outpatient care up to
$500*
39

Medical emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular benefits 40
Mental health and substance abuse treatment PPO: Regular cost sharing
Non-PPO: Benefits are limited
Out-of-network: Regular cost sharing

41
44
44

Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Retail copay: $10 generic, $20 formulary,
$30 brand name*

Mail order: $15 generic, $30 formulary,
$45 brand name*

Medicare retail and mail order copays*
Overseas retail: 20%

46

Dental care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Routine exams and fillings; fee schedule 50
Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flexible benefits option
24-hour nurseline
High risk pregnancies
Center of excellence
Services overseas

49
49
49
49
49 75
75 Page 76 77
2002 Association Benefit Plan 75 Summary of Benefits
Protection against Catastrophic costs . . . . . . . . . . . . . . . . . . . .
(your out-of-pocket maximum)
PPO: Nothing after $2,500/ Self Only or
Family enrollment per year
Non-PPO: Nothing after $3,500/ Self
Only or Family enrollment per year
Out-of-network: Nothing after $2,500/
Self Only or Family enrollment per year
Some costs do not count toward this
protection

13 76
76 Page 77 78
2002 Association Benefit Plan 76 Rates 2002
2002 Rate Information for Association Benefit Plan
FEHB benefits of this Plan are described in the Association Benefit Plan brochure
Premium Premium
Biweekly Monthly
Type of
Enrollment
Code Gov't
Share
Your
Share
Gov't
Share
Your
Share

Self 421 $97.86 $47.27 $212.03 $102.42
Self and Family 422 $223.41 $110.92 $484.06 $240.32 77
77 Page 78 79
2002 Association Benefit Plan 77 Notes
NOTES 78
78 Page 79 80
2002 Association Benefit Plan 78 Notes
NOTES 79
79 Page 80 81
2002 Association Benefit Plan 79 Notes
NOTES 80
80 Page 81 82
2002 Association Benefit Plan 80 Notes
NOTES 81
81 Page 82 83
2002 Association Benefit Plan 81 Notes
NOTES 82
82 Page 83 84
2002 Association Benefit Plan 82 Notes
NOTES 83
83 Page 84 85
2002 Association Benefit Plan 83 Notes
NOTES 84
84 Page 85
2002 Association Benefit Plan 84 Notes
NOTES 85

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