Page Navigation Panel Document Outline

Document Outline

Pages 1--52 from Lovelace Health Systems


Page 1 2

A Health Maintenance Organization
Serving: The State of New Mexico
Enrollment in this Plan is limited. You must live or work in our Geographic service
area to enroll. See page 6 for requirements.

Lovelace
Health Systems, Inc. http: / / www. cigna. com

RI 73-079
2002
For changes
in benefits
see page 8.

This Plan has commendable accreditation from the NCQA.
See the 2002 Guide for more information on accreditation.

Enrollment codes for this Plan:
Q11 Self Only
Q12 Self and Family

HealthCare

Authorized for distribution by the:
United States Office of Personnel Management

Retirement and Insurance Service
http:// www. opm. gov/ insure

This Plan has been accredited with
commendation from the JCAHO. 1
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2002 Lovelace Health Plan 2 Table of Contents
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General Advisory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1. Facts about this HMO plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Who provides my healthcare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Your Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 2. How we change for 2002. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 3. How you get care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Where you get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What you must do to get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Services requiring our prior approval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Your out-of-pocket maximum for copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Section 5. Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . 14
( b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . 22
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2
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2002 Lovelace Health Plan 3 Table of Contents
( g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Flexible benefits option
24 hour nurse Line
Services for deaf and hearing impaired
High risk pregnancy
Centers of Excellence for transplants/ heart surgery/ etc.
Travel benefits/ services overseas
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
( i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Section 6. General exclusions things we don t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 8. The disputed claims process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 9. Coordinating benefits with other coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
When you have
Other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Original Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Medicare managed care plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

TRICARE/ Workers Compensation/ Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Other Government agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 10. Definitions of terms we use in this brochure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Section 11. FEHB facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Coverage information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Where you get information about enrolling in the FEHB Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Your medical and claims records are confidential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When you retire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When FEHB coverage ends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Getting a Certificate of Group Health Plan Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Long term care insurance is coming later in 2002. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Inde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover 3
3 Page 4 5

2002 Lovelace Health Plan 4 Introduction/ Plain Language
Introduction
Lovelace Health Plan is a business of Lovelace Health Systems, Inc.
Altura Office Complex
4101 Indian School Road, NE
Albuquerque, NM 87110

This brochure describes the benefits of Lovelace Health Systems, Inc. under our contract ( CS 1911) with the Office of
Personnel Management ( OPM) , as authorized by the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this
brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and
Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that
were available before January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes
are summarized on page 8. 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 Lovelace Health Plan. .

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

Our brochure and other FEHB plans brochures have the same format and similar descriptions to help you compare plans. .

If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM s
Rate Us feedback area at www. . opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. 4
4 Page 5 6
2002 Lovelace Health Plan 5 Introduction/ Plain Language
Inspector General Advisory
Fraud increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-CIGNA24
( 1-800-244-6224) 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

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.

Stop health care fraud!
Penalties for Fraud 5
5 Page 6 7
2002 Lovelace Health Plan 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

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

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. We
compensate our participating providers in ways that are intended to emphasize preventive care, promote quality of care,
and assure the most appropriate use of medical services. You can discuss with your provider how he is compensated by
us. The methods we use to compensate participating providers are:

Discounted fee for service payment for service is based on an agreed upon discounted amount for the services provided. .
Capitation Physicians, provider groups and physician/ hospital organizations are paid a fixed amount at regular intervals
for each Member assigned to the physician, provider group or physician/ hospital organization, whether or not services are
provided. This payment covers the physician and/ or, where applicable, hospital or other services covered under the
benefit plan. Medical groups and physician/ hospital organizations may in turn compensate providers using a variety of
methods.

Capitation offers health care providers a predictable income, encourages Physicians to keep people well through preven-
tive care, eliminates the financial incentive to provide services that will not benefit the patient, and reduces paperwork.

Providers paid on a capitated basis may participate with us in a risk sharing arrangement. . They agree upon a target
amount for the cost of certain health care services, and they share all or some of the amount by which actual costs are
over target. Provider services are monitored for appropriate utilization, accessibility, quality and Member satisfaction.

We may also work with third parties who administer payments to Participating Providers. Under these arrangements, we
pay the third party a fixed monthly amount for these services. Providers are compensated by the third party for services
provided to Healthplan participants from the fixed amount. The compensation varies based on overall utilization.

Salary Physicians and other providers who are employed to work in our medical facilities are paid a salary. . The
compensation is based on a dollar amount, decided in advance each year, that is guaranteed regardless of the services
provided. Physicians are eligible for any annual bonus based on quality of care, quality of service and appropriate use of
Medical Services.

Bonuses and Incentives Eligible Physicians may receive additional payments based on their performance. . To determine
who qualifies, we evaluate Physician performance using criteria that may include quality of care, quality of service,
accountability and appropriate use of Medical Services. 6
6 Page 7 8

2002 Lovelace Health Plan 7 Section 1
Per Diem A specific amount is paid to a hospital per day for all health care received. The payment may vary by type of
service and length of stay.

Case Rate A specific amount is paid for all the care received in the hospital for each standard service category as
specified in our contract with the provider ( e. g. , for a normal maternity delivery) .

Who provides my health care?
We contract with a group of doctors and hospitals to provide your health care. You will select a primary care physician
who supervises your total health care needs. You may see a Plan gynecologist for annual routine examination without a
referral.

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

Lovelace Health Plan is in compliance with all State and Federal licensing and certification requirements and has
received its 3 year commendable accreditation by the National Committee on Quality Assurance ( NCQA) in October,
1999.

Lovelace Health Plan is a Health Maintenance Organization licensed in the State of New Mexico since 1981.

If you want more information about us, call 1-800-CIGNA24 ( 1-800-244-6224) , or write to Lovelace Health Plan,
Altura Office Complex, 4101 Indian School Road, NE, Albuquerque, NM 87110. You may also visit our website at
www. cigna. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area
is: The State of New Mexico.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the area ( for example, if your child goes to college in another state) , you should consider enrolling in a fee-for-
service plan or an HMO that has agreements with affiliates in other areas. You and covered members of your family may
be eligible for medical benefits at participating CIGNA Healthplans throughout the United States; just call 1-800-CIGNA24
( 1-800-244-6224) statewide for more information regarding the CIGNA/ Lovelace Guest Privilege Program. If you or a
family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8 9
2002 Lovelace Health Plan 8 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 changes not shown here is a
clarification that does not change benefits.

Program-wide changes
We increased speech therapy benefits by removing the requirement that services must be required to restore functional
speech. ( Section 5( a) )

Changes to this Plan
Your share of the non-Postal premium will increase by 2.1% for Self Only and decrease by 18.9% for Self and
Family.

We no longer limit total blood cholesterol tests to certain age groups. ( Section 5( a) )
We now cover certain intestinal transplants. ( Section 5( b) )
We now cover specialist office visit copay at $ 20 per visit.
The urgent care center copayment is now $ 25 per visit.
We limit durable medical equipment to a maximum of $ 3,500 per member per contract year. You pay nothing.
Infertility office visit copay is now $ 10 per office visit.
We now cover outpatient rehabilitation services up to 60 visits per year. You pay $ 20 per visit.
Under prescription drug benefits, you now pay $ 15 for Preferred Brand name drugs and $ 35 for non-Preferred Brand
name drugs.

Under prescription drug benefits, drugs to treat sexual dysfunction are now subject to the same copayment amounts
shown under Section 5( f) , Covered medications and supplies.

Under mail order prescription drugs, you now pay $ 40 for Preferred Brand name drugs and $ 100 for non-Preferred
Brand name drugs.

The out-of-pocket maximum is now $ 1,000 for Self Only enrollment and $ 2,000 for Self and Family enrollment. 8
8 Page 9 10
2002 Lovelace Health Plan 9 Section 3
Section 3. How you get care
We will send you an identification ( ID) card when you enroll. You should
carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy.
Until you receive your ID card, use your copy of the Health Benefits
Election Form, SF-2809, your health benefits enrollment confirmation ( for
annuitants) , or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-CIGNA24
( 1-800-244-6224) .

You get care from Plan providers and Plan facilities. You will only pay
copayments and coinsurance, and you will not have to file claims unless you
receive emergency services from a provider who does not have a contract
with us.

Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our members.
We credential Plan providers according to national standards.

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

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

It depends on the type of care you need. First, you and each family member
must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care.
When you enroll, you choose a Primary Care Physician ( PCP) . Each family
member also chooses a PCP. Your PCP is your personal doctor and serves as
your health care manager. If you do not select a PCP, we will assign one for
you. If your PCP leaves our network, you will be able to choose a new PCP.
You may voluntarily change your PCP for other reasons but not more than
once in any calendar month. We reserve the right to determine the number
of times during a year that you will be allowed to change your PCP. If you
select a new PCP before the fifteenth day of the month, the designation will
be effective on the first day of the month following your selection. If you
select a new PCP on or after the fifteenth day of the month, the designation
will be effective on the first day of the month following the next full month.
For example, if you notify us on June 10, the change will be effect on July 1.
If you notify us on June 15, the change will be effective on August 1.

Some Primary Care Physicians belong to provider organizations which usually
refer to a network of Specialty Care Physicians and Hospitals that are in the
provider organization. Your choice of Primary Care Physician may affect the
Hospital( s) and Specialty Care Physicians to which you may be referred.
Therefore, you may not have access to every specialist or Participating
Provider in your Service Area. Before you select a PCP, you should check to
see if that PCP is associated with the specialist or facility you prefer to use.

Identification cards
Where you get covered care
Plan providers

Plan facilities
What you must do
to get covered care 9
9 Page 10 11
2002 Lovelace Health Plan 10 Section 3
Your primary care physician can be a general practitioner, family practitioner,
internist or pediatrician. Your primary care physician will provide most of
your health care, or give you a referral to see a specialist.

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

Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without addi-
tional referrals. The primary care physician must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see an
OB/ GYN for well-woman care or go to a hospital for emergency care
without a referral.

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

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

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

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

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

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

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

Your Plan primary care physician or specialist will make necessary hospital
arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.

Primary care
Specialty care

Hospital care 10
10 Page 11 12
2002 Lovelace Health Plan 11 Section 3
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800-CIGNA24 ( 1-800-244-6224) .
If you are new to the FEHB Program, we will arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever
happens first.

These provisions apply only to the benefit of the hospitalized person.

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

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

A referral or Prior Authorization must be obtained prior to receiving services
performed by any health care provider EXCEPT:

For services provided by
Your Primary Care Physician;
OB/ GYN Services; and
Emergency Services or Urgently Needed Care.

A Referral must be obtained directly from your Primary Care Physician.
Your Primary Care Physician must provide a referral if you receive services
and benefits such as Specialty Care Physician services. If you receive
services which require a referral without a referral from your Primary
Care Physician, you will be obligated to pay for the unauthorized Services.
We will not pay for unauthorized services.

Certain benefits and services require Prior Authorization from us. Prior
Authorization must always be obtained through your Plan Provider. If Prior
Authorization is required from us, your Primary Care Physician or Specialty
Care Physician will make arrangements with our Medical Director. Prior
Authorization is required for the following types of benefits and services
such as: Inpatient and Outpatient Hospital Services, Rehabilitative Therapy,
Skilled Nursing Facility Services, Home Health Services, Second Surgical
Opinions, Services provided by a Non-Plan Provider, Durable Medical
Equipment and Prosthetic Devices.

If your coverage is terminated prior to the date of service, the service will
not be covered, regardless of any Prior Authorization given by us or your
Primary or Specialty Care Physician.

Circumstances beyond
our control

Services requiring our
prior approval 11
11 Page 12 13
2002 Lovelace Health Plan 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

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

Example: When you see your primary care physician you pay a
copayment of $ 10 per office visit.

A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for them. We do not have a
deductible.

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 is the percentage of our negotiated fee that you must pay for
your care. Example: In our Plan, you pay 50% of our allowance for infertility
services.

After your copayments total $ 1, 000 per person or $ 2, 000 per family enrollment
in any calendar year, you do not have to pay any more for covered services.
However, copayments for the following services do not count toward your
out-of-pocket maximum, and you must continue to pay copayments for these
services:

Prescription drugs
Dental services
Mental Health/ Substance Abuse
External prosthetic appliances
Infertility services

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum.

Copayments
Deductible

Coinsurance
Your out-of-pocket maximum
for copayments and coinsurance 12
12 Page 13 14

2002 Lovelace Health Plan 13 Section 5
Section 5. Benefits OVERVIEW
( See page 8 for how our benefits changed this year and page 51 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. Please read the important things you should keep in mind at the beginning of each subsection. To obtain claims
forms, claims filing advice, or more information about our benefits, contact us at 1-800-CIGNA24 ( 1-800-244-6224) or
at our website at www. cigna. com/ healthcare.

Medical emergency
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29

Inpatient hospital
Outpatient hospital or ambulatory
surgical center

( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-27

Surgical procedures
Reconstructive surgery

( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . 22-24

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies
Speech therapy

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . 14-21
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

Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

Extended care benefits/ skilled
nursing care facility benefits

Hospice care
Ambulance

( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-31
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-33
( g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Flexible benefits option
24 hour nurse line
Services for deaf and hearing impaired
High risk pregnancies
Centers of Excellence for transplants/ heart surgery/ etc.
Travel benefit/ services overseas

( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Ambulance 13
13 Page 14 15
2002 Lovelace Health Plan 14 Section 5( a)
Diagnostic and treatment services
Professional services of physicians
In physician s office
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

At home Nothing

Lab, X-ray and other diagnostic tests
Tests, such as: Nothing
Blood tests
Urinalysis
Pap tests
Pathology
X-rays
Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Note: You pay nothing for Lab, X-rays and other diagnostic tests,
however a provider or facility copayment may apply. Refer to the
provider/ facility charges identified in this Section 5( c) .

Benefit Description You pay
I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T

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

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

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

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist 14
14 Page 15 16
2002 Lovelace Health Plan 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as: Nothing
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Note: You pay nothing for routine screenings, however a provider
or facility copayment may apply. Refer to the provider/ facility
charges identified in this Section 5( c) .

Prostate Specific Antigen ( PSA test) one annually for men age 40
and older

Routine pap test
Note: The office visit is covered if pap test is received on the
same day; see Diagnostic and treatment services , above.

Note: You pay nothing for routine tests, however a provider
or facility copayment may apply. Refer to the provider/ facility
charges identified in this Section 5( c) .

Routine mammogram covered for women age 35 and older,
as follows:

From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Note: You pay nothing for routine mammograms, however a provider
or facility copayment may apply. Refer to the provider/ facility
charges identified in this Section 5( c) .

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

Routine immunizations, limited to: Nothing
Tetanus-diphtheria ( Td) booster once every 10 years, , ages 19
and over ( except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Preventive care, children
Childhood immunizations and injections recommended by the Nothing
American Academy of Pediatrics

Note: You pay nothing for childhood immunizations, however a
provider or facility copayment may apply. Refer to the provider/
facility charges identified in this Section 5( c) .

Well-child care charges for routine examinations, immunizations $ 10 per visit
and care ( under age 22)

Examinations, such as:
Eye exams through age 17 to determine the need for vision
correction

Ear exams through age 17 to determine the need for hearing
correction

Examinations done on the day of immunizations ( under
age 22) 15
15 Page 16 17
2002 Lovelace Health Plan 16 Section 5( a)
$ 10 for the first office visit to
confirm pregnancy; no copay
for all pre-/ post-delivery visits
thereafter.

50% per treatment/
surgical procedure

Infertility services benefits continued on the next page.

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist

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

Note: Here are some things to keep in mind:
You do not need to obtain prior authorization for your normal
delivery; see page 11 for other circumstances, such as extended
stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.

We cover routine nursery care of the newborn child during the covered
portion of the mother s maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.

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

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

Family planning
Voluntary sterilization Nothing
Note: You pay nothing for Voluntary sterilization, however a provider
or facility copayment may apply. Refer to the provider/ facility charges
identified in this Section 5( c) .

Surgically implanted contraceptives ( such as Norplant)
Injectable contraceptive drugs ( such as Depo provera)

Intrauterine devices ( IUDs)

Note: We cover oral contraceptives under the prescription
drug benefit.

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

Infertility services
Diagnosis of infertility

Treatment of infertility, such as:
Artificial insemination:
intravaginal insemination ( IVI)
intracervical insemination ( ICI)
intrauterine insemination ( IUI)
Oral Fertility drugs

Note: We do not cover injectable fertility drugs and oral fertility drugs
are covered under the prescription drug benefit. 16
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2002 Lovelace Health Plan 17 Section 5( a)
Infertility services ( continued) You pay
Not covered: All charges
Assisted reproductive technology ( ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies r lated to excluded ART procedures
Cost of donor sperm
Cost of donor eggs

Allergy care
Testing and treatment
Allergy injection

Allergy serum Nothing
Not covered: Self-administered allergy injections All charges

Treatment therapies
Chemotherapy and radiation therapy Nothing
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 21.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)

Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when your PCP has received our prior
authorization Prior approval must be received before you begin
treatment; otherwise, we will only cover GHT services from the date
your PCP receives prior authorization. If prior authorization is not
received or if we determine GHT is not medically necessary, we will
not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

Physical and occupational therapies
60 visits total per year for the services of:
qualified physical therapists;
occupational therapists;
chiropractors; and
cardiac and pulmonary rehabilitation programs.

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

Not covered: All charges
long-term rehabilitative therapy

exercise programs

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist 17
17 Page 18 19
2002 Lovelace Health Plan 18 Section 5( a)
All charges above the maximum
amount shown for lenses and
frames.

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist

$ 10 per visit to your primary
care physician
$ 20 per visit to a specialist

Speech therapy You pay
60 visits per condition $ 20 per visit

Hearing services ( testing, treatment, and supplies
Hearing testing for children through age 17 ( see Preventive care,
childr n )

Not covered: All charges
all hearing testing

hearing aids, testing and examinations for them

Vision services ( testing, treatment, and supplies)
One pair of eyeglasses or contact lenses for treatment of keratoconus
or post-cataract surgery

One pair of eyeglass or one set of contact lenses is covered every two
years limited to the maximum Plan payment shown:

Note: You pay all charges ABOVE the Maximum Plan Payment shown.

Single lenses -$ 20
Bifocal lenses -$ 30
Trifocal lenses $ 40
Contact lenses -$ 75
Frames -$ 30

One complete eye exam is covered every two years through
participating providers.

Annual eye refractions ( to determine the need for vision correction)

Note: See Preventive care, children for eye exams for children.

Not covered: All charges
Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for medical
conditions such as diabetes; fungal infection of the nail beds, circulatory
impairment; immunocomprimised patients.

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

Not covered: All charges
Cutting, trimming or removal of corns, calluses, or the free edge
of toenails, and similar routine treatment of conditions of the foot,
except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and
of any instability, imbalance or subluxation of the foot ( unless the
treatment is by open cutting surgery) 18
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2002 Lovelace Health Plan 19 Section 5( a)
You pay the first $ 200 per
calendar year.

Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; hands or hooks.
The Maximum Plan allowance is $ 1,000 per calendar year.

Externally worn breast prostheses and surgical bras, including Nothing
necessary replacements, following a mastectomy.

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

Not covered: All charges
orthopedic and corrective shoes

arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive
devices

prosthetic replacements due to wear and tear, loss, theft or destruction.
corrective orthopedic appliances for non-dental treatment of
temporomandibular joint ( TMJ) pain dysfunction syndrome

biomechanical devices
penile prosthetics

Durable medical equipment ( DME)
Rental or purchase, at our option, including repair and adjustment, of We limit coverage to $ 3,500
durable medical equipment prescribed by your Plan physician and per member per year.
received from a vendor approved by the Plan, such as oxygen tents and You pay nothing.
dialysis equipment. Under this benefit, we also cover:

We limit coverage to $ 3,500 per member per year.
hospital beds;
wheelchairs ( limited to the lowest cost alternative to satisfy
medical necessity) ;

crutches;
walkers;
blood glucose monitors and blood glucose monitors for the
legally blind;

insulin pumps and infusion devices;
respirators; and
oxygen tents.

Note: Your PCP will prescribe and arrange for a participating health
care provider to rent or sell you the durable medical equipment.
We will not cover equipment received from a non-participating health
care provider unless your PCP has received our prior authorization.

Durable medical equipment ( DME ) continued on next page. 19
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2002 Lovelace Health Plan 20 Section 5( a)
Durable medical equipment ( DME) ( continued) You pay
Not covered: All charges
Hygienic or self-help items or equipment, or item or equipment that
are primarily for comfort or convenience, such as bathtub chairs,
safety grab bars, stair gliders or elevators, over-the-bed tables,
saunas or exercise equipment;

Environmental control equipment, such as air purifiers,
humidifiers, and electrostatic machines;

Institutional equipment such as air fluidized beds and diathermy
machines;

Consumable medical supplies including, but not limited to, bandages
and other disposable supplies, skin preparations, test strips, ostomy
supplies, surgical leggings, elastic stockings and wigs.

Home health services
Home health care ordered by a Plan physician and provided by a Nothing
registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Not covered: All charges
nursing care requested by, or for the convenience of, the patient or
the patient s family;

home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative;

services primarily for rest, domiciliary or convalescent care.

Chiropractic
See Physical and occupational therapies under this Section, Chiropractic Same as Physical and
is part of Physical and occupational therapies. occupational therapies.

Alternative treatments
Acupuncture limited to authorized referrals for the treatment of $ $ 10 per visit to your primary
chronic musculoskeletal or neurogenic pain. The maximum benefit of care physician
two months of treatment per condition per lifetime is contingent on $ 20 per visit to a specialist
documented process.

Not covered: All charges
naturopathic services

hypnotherapy
biofeedback
massage services 20
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2002 Lovelace Health Plan 21 Section 5( a)
Educational classes and programs You pay
Coverage such as: Nothing
Diabetes self-management, with a referral from your primary
care provider

Nutrition
Care giving: Families coping with chronic illness
Parenting Children with ADHD
It s up to You to Bring it Down: A class for people managing
hypertension

Breast Health Program 21
21 Page 22 23
2002 Lovelace Health Plan 22 Section 5( b)
Surgical procedures
A comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( see reconstructive surgery)
Insertion of internal prosthetic devices. See 5( a) Orthopedic
and prosthetic devices for device coverage information

Treatment of burns

Note: Generally, we pay for internal prostheses ( devices) according
to where the procedure is done. For example, we pay Hospital
benefits for a pacemaker and Surgery benefits for insertion of the
pacemaker.

Surgical treatment of morbid obesity a condition in which an 50% % of charges
individual weighs 200% of his or her normal weight according to
the 1983 Metropolitan Life Insurance Company height-weight
chart with a history of morbid obesity for at least 5 years and has
complied with more conservative methods of weight loss

Not covered: All charges
Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care.

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Section 5( b) . Surgical and anesthesia services provided by physicians
and other health care professionals

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

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

The amounts listed below are for the charges billed by 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. ) .

YOUR PLAN PROVIDER MUST GET PRIOR AUTHORIZATION OF SOME
SURGICAL PROCEDURES. Please refer to the prior authorization information
shown in Section 3 to be sure which services require prior authorization and
identify which surgeries require prior authorization.

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2002 Lovelace Health Plan 23 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect Nothing
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member s
appearance and

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

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

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

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

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

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

Surgeries r lated to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, with the prior approval of Plan Medical Nothing
Director, such as:

Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;

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

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

Not covered: All charges
Oral implants and transplants

Procedures that involve the teeth or their supporting structures
( such as the periodontal membrane, gingiva, and alveolar bone) 23
23 Page 24 25
2002 Lovelace Health Plan 24 Section 5( b)
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Pancreas
Liver
Allogenetic ( donor) bone marrow transplants
Autologous bone marrow transplants ( autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin s
lymphoma; advanced non-Hodgkin s lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial
ovarian cancer; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors

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

National Transplant Program ( NTP) please see Section 5( g) ,
Special Features

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

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

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

Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in Nothing
Hospital ( inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 24
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2002 Lovelace Health Plan 25 Section 5( c)
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Section 5( c) . Services provided by a hospital or other
facility, and ambulance services

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

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

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

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

YOUR PRIMARY CARE PHYSICIAN MUST OBTAIN OUR PRIOR
AUTHORIZATION FOR HOSPITAL STAYS, EXCEPT FOR
EMERGENCIES. Please refer to Section 3 to be sure which services
require Prior Authorization.

Benefit Description You pay
Inpatient hospital
Room and board, such as: Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

Note: If you request a private room and it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood, blood products and other biologicals
Blood or blood plasma
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics and anesthesia services

Not covered: All charges
Custodial car

Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber
services, guest meals and beds

Private nursing car 25
25 Page 26 27
2002 Lovelace Health Plan 26 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood products and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia services

Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

Not covered: blood and blood derivatives not replaced by the member All charges

Extended care benefits/ skilled nursing care facility benefits
Covered for up to 60 days per calendar year when full-time skilled Nothing
nursing care is necessary, and confinement in a skilled nursing facility
is medically appropriate as determined by a Plan doctor and approved
by the Plan.

Skilled and general nursing services
Physicians visits
Physiotherapy
X-rays
Administration of drugs, medications and fluids

Not covered: All charges
Personal comfort items, such as television and telephone

Custodial care, rest cures, domiciliary or convalescent car 26
26 Page 27 28
2002 Lovelace Health Plan 27 Section 5( c)
Hospice care You pay
Hospice care for a patient who as certified by a Plan doctor is in the Nothing
terminal stages of illness and who has a life expectancy of six months
or less.

Hospice care services include:
inpatient care

outpatient care
physician services
psychologist, social worker or family counselor services for
individual or family counseling

Not covered: All charges
Independent nursing

homemaker services, including services and supplies that ar
primarily to aid you or your dependent in daily living

services of a person who is a member of your family who normally
r sides in your house

services or supplies not listed in the Hospice Care Program
services for curative or life-prolonging procedures
bereavement counseling
services for respite car
nutritional supplements, non-prescription drugs or substances,
medical supplies, vitamins or minerals

Ambulance
Local professional ambulance service when medically appropriate Nothing 27
27 Page 28 29
2002 Lovelace Health Plan 28 Section 5( d)
Section 5( d) . Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.

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

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

What to do in case of emergency:
Emergency Services Both In and Out of our Service Area: In the event of an emergency, get help immediately.
Go the nearest emergency room, the nearest hospital or call or ask someone to call 911 or your local emergency
service, police or fire department for help. You do not need a referral from your PCP for emergency services, but
you do need to call your PCP as soon as possible for further assistance and advice on follow-up care. If you require
specialty care or a hospital admission, your PCP will coordinate it and handle the necessary authorizations for care
or hospitalization. Participating providers are on call twenty-four ( 24) hours a day, seven ( 7) day a week, to assist
you when you need Emergency Services.

If you receive emergency services outside the service area, you must notify us as soon as reasonably possible. We
may arrange to have you transferred to a participating provider for continuing or follow-up care if it is determined
to be medically safe to do so.

Emergency services are defined as the medical, psychiatric, surgical, hospital and related health care services and
testing, including ambulance service, which are required to treat a sudden unexpected onset of a bodily injury or a
serious illness which could reasonably be expected by a prudent layperson to result in serious medical complications,
loss of life or permanent impairment to bodily functions in the absence of immediate medical attention. Examples
of emergency situations include uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest
pains or severe squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis
or slurred speech, burns, cuts, and broken bones. The symptoms that led you to believe you needed emergency
care, as coded by the provider and recorded by the hospital on the UB92 claim form or its successor, or the final
diagnosis, whichever reasonably indicated an emergency medical condition, will be the basis for the determination
of coverage, provided such symptoms reasonably indicate an emergency.

Continuing or follow-up treatment, whether in or out of the service area, is not covered unless it is provided or
arranged for by your PCP or upon Prior Authorization of our Medical Director.

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2002 Lovelace Health Plan 29 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a Plan doctor s office $ 10 per office visit
Emergency care at an urgent care center $ 25 per office visit. Copayment
waived if admitted to hospital

Emergency care as an outpatient or inpatient at a hospital, $ 50 per office visit. Copayment
including doctors services waived if admitted to hospital

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

Emergency outside our service area
Emergency care at a doctor s office $ 10 per office visit
Emergency care at an urgent care center $ 25 per office visit. Copayment
waived if admitted to hospital

Emergency care as an outpatient or inpatient at a hospital, $ 50 per office visit. Copayment
including doctors services waived if admitted to hospital

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

Emergency care provided outside the service area if the need for
care could have been for seen before leaving the service area

Ambulance
Professional ambulance service when medically appropriate. Nothing
See 5( c) for non-emergency service. 29
29 Page 30 31
2002 Lovelace Health Plan 30 Section 5( e)
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider Your cost sharing
and contained in a treatment plan that we approve. The treatment responsibilities are no
plan may include services, drugs, and supplies described elsewhere greater than for other
in this brochure. illness or conditions.

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

Professional services, including individual or group therapy by $ 10 per office visit
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial Nothing, however a provider
hospitalization, facility based intensive outpatient treatment copayment may apply.

Not covered: Services we have not approved. All charges
Note: OPM will base its review of disputes about treatment plans on
the treatment plan s clinical appropriateness. OPM will generally
not order us to pay or provide one clinically appropriate treatment
plan in favor of another.

Mental health and substance abuse benefits continued on next page.

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Section 5( e) . Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve,
cost-sharing and limitations for Plan mental health and substance abuse benefits will
be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this
brochure.

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

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

Benefit Description You pay 30
30 Page 31 32
2002 Lovelace Health Plan 31 Section 5( e)
Preauthorization
Mental health and substance abuse benefits ( continued)
To be eligible to receive these benefits you must follow your treatment plan
and all the following authorization processes:

Mental Health and Substance Abuse Services are provided by CIGNA
Behavioral Health, Inc. You do not need a referral to receive these services.
However, to obtain these services, you must call CIGNA Behavioral Health
directly, their phone number can be found on your ID Card, to get more
information or speak with someone about a specific problem. A representa-
tive is available to assist you twenty-four ( 24) hours a day, seven ( 7) days a
week. The representative will provide you with a choice of providers in your
area and will authorize an appropriate number of visits. 31
31 Page 32 33
2002 Lovelace Health Plan 32 Section 5( f)
Section 5( f) . Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning
on the next page.

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

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

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a plan retail pharmacy, or by plan mail-order
pharmacy. You must fill the prescription at a plan retail pharmacy. You may fill your maintenance medications
by mail through a plan mail-order pharmacy.

We use a formulary. A formulary is a listing of approved drug products. The drugs and medications included
have been approved in accordance with parameters established by us. This list is subject to periodic review and
is amended as required. Only those medications included on the formulary are covered.

These are the dispensing limitations.
Your copayment for generic retail prescription drugs that are on the formulary is $ 5. Your copayment for name
brand retail prescription drugs that are on the formulary but do not have a generic equivalent is $ 15. Your
copayment for name brand drugs that are on the formulary but do do have a generic equivalent OR for drugs that
are not on the formulary is $ 35. Each prescription order or refill is limited to a consecutive thirty ( 30) day supply
or one hundred ( 100) units, whichever is less, at a retail participating pharmacy, unless limited by the drug
manufacturer s packaging.

Maintenance medications prescribed by Plan doctors may also be obtained through our mail order program.
Your copayment for generic mail order prescription drugs that are on the formulary is $ 10. Your copayment for
name brand mail order prescription drugs that are on the formulary but do not have a generic equivalent is $ 40.
Your copayment for name brand drugs that are on the formulary but do have a generic equivalent OR for drugs
that are not on the formulary is $ 100. Each prescription order or refill is limited to a consecutive ninety ( 90) day
supply at a mail order participating pharmacy, unless limited by the manufacturer s packaging.

Each prescription order or refill is further limited to:
generic drugs unless a generic alternative does not exist or substitution is not permitted by state law. .
Coverage for prescription drugs are subject to a Copayment. In no event will the Copayment exceed the cost
of the drug.

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

When you have to file a claim. Please refer to Section 7 Filing a claim for covered services .
Prescription drug benefits begin on the next page.

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2002 Lovelace Health Plan 33 Section 5( f)
We cover the following medications and supplies prescribed by a
Plan physician and obtained from a Plan pharmacy or through our mail
order program:

Drugs and medicine that by Federal law of the United States require
a physician s prescription for their purchase, except those listed as
Not covered.

Oral and injectable contraceptive drugs and contraceptive devices;
contraceptive diaphragms

Insulin, glucose test strips, and other prescription diabetic supplies
Disposable needles and syringes needed to inject covered prescribed
medications

Oral fertility medications.
Intravenous fluids and medication for home use, implantable drugs, and
some injectable drugs are covered under Medical and Surgical Benefits.

Drugs to treat sexual dysfunction are limited. Contact the Plan for
dose limits.

Implanted time-release medications, such as Norplant. There is no $ 100 one-time copay per
charge when the device is implanted during a covered hospitalization. prescription
There will be no refund of any portion of this copay if the implanted
time-release medication is removed before the end of its expected life.

Oral agent for controlling blood sugar Nothing
Not covered: All charges
Drugs and supplies for cosmetic purposes

Vitamins ( except for prenatal vitamins) , nutrients and food
supplements even if a physician prescribes or administers them

Non-prescription medicines, over the counter drugs
Drugs obtained from a non-Plan pharmacy except for out-of-ar a
emergencies

Medical supplies such as dr ssings and antiseptics
Drugs to enhance athletic performance
Smoking cessation drugs and medications, including nicotine patches
Diet pills or appetite suppressants ( except when used in the
treatment of morbid obesity)

Replacement of drugs due to loss or theft
Prescriptions more than one year from the original date of issue
Injectable fertility drugs ( see Infertility benefit under Medical and
Surgical Benefits for limited coverage)

Benefit Description You pay
Covered medications and supplies
Retail Pharmacy
$ 5 per generic formulary drug
$ 15 per name brand formulary
drug with no generic equivalent.

$ 35 per name brand formulary
drug with generic equivalent OR
per non-formulary drug

Mail Order ( Maintenance
medications only)

$ 10 per generic formulary drug
$ 40 per name brand formulary
drug with no generic equivalent

$ 100 per name brand formulary
drug with generic equivalent OR
per non-formulary drug

Note: If there is no generic
equivalent available, you will
still have to pay the brand name
copay 33
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2002 Lovelace Health Plan 34 Section 5( g)
Section 5( g) . Special features
Feature Description

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.

For any of your health concerns, 24 hours a day, 7 days a week, you may call
1-800-CIGNA24 ( 1-800-244-6224) and talk with a registered nurse who will
discuss treatment options and answer your health questions.

Certified Languages International is a company that is contracted by
Lovelace Health Plan to supply interpreters for patients and providers in any
language including sign language, either by phone or in person if certified
employee interpreters are not available.

Deaf/ Hearing impaired individuals may access the member services
department by calling their state relay line.

Healthy Babies is a program that provides guidance and support to women
from pre-pregnancy through post-partum care. This program is designed to
promote better maternity care, reduce the number of premature births and
educate expectant parents.

CIGNA HealthCare members have access to the CIGNA Lifesource Organ
Transplant Network which is an organization of participating hospitals
which provides organ transplant services. As part of the rigorous
credentialing program, each hospital s transplant program is evaluated for
patient outcome, as well as waiting period, housing arrangements, patient
friendly environment and the availability of transportation, , before it is
included in the CIGNA Lifesource Organ Transplant Network .

We cover you for emergency services anywhere in the world.

Flexible benefits option
24 hour nurse line
Services for deaf and
hearing impaired

Centers of Excellence
for transplants/ heart
surgery/ etc.

Travel benefit/
services overseas

High risk pregnancies 34
34 Page 35 36
2002 Lovelace Health Plan 35 Section 5( h)
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Section 5 ( h) . Dental Benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when prior authorized by
our Medical Director and a non-dental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient; we do not cover
the dental procedure unless it is described below.

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

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly $ 10 per office visit
repair ( but not replace) sound natural teeth. The need for these
services must result from an accidental injury.

Dental benefits
We have no other dental benefits. 35
35 Page 36 37

2002 Lovelace Health Plan 36 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.

DENTAL SOURCE DENTAL PLAN
URGENT NOTE TO MEMBERS CONSIDERING ENROLLING IN THIS DENTAL PLAN:
Before you choose this non-FEHB Dental Benefit, please read our list of participating dentists. To
obtain a copy of the list of participating dentists, call the Dental Member Services Department at
( 505) 237-1505. Our dental network has a limited number of dentists. Our dental provider list shows
the number of dental providers we have and the county their office is located in. The following is
the list of the counties the majority of our dentists are located in, including the percentage of our
participating dentists in each county.

Percentage of
our participating
County dentists in each County

Bernalillo County 62%
El Paso County 17%
Sandoval County 5%
Santa Fe County 13%
San Juan County 3%

Dental Source Dental Plan is a discount referral dental plan available to Lovelace Health Plan members enrolled through
the FEHB Program. Members select a personal dentist from a list of participating dentists throughout the state of New
Mexico.

Dental Source Dental Plan has no deductibles, no claim forms, no waiting periods, no maximums, and no pre-existing
exclusions. The plan includes:

Preventive & diagnostic services
Restoratives/ endontics/ orthodontia
Save as much as 20% to 60% off many dental procedures
Simply pay the member fees listed on your schedule directly to the dental office
Select your dentist from a list of participating dentists

It is easy to enroll. Complete your enrollment/ authorization form with the correct payment to Dental Source in the self
addressed return envelope. You may pay the entire annual premium by check, money order, Master Card, Discover or
Visa. Member $ 48.88, Member plus one dependent $ 97.60, or Family $ 148.88.

Or you may select the monthly bank draft. Monthly premiums would be: Member $ 4.75; Member plus one $ 8.68; Family
$ 13.25.

There are no limits on the number of visits or amount of dental care you receive per year. For any requested dental office
changes, or questions you may have, you may call the Dental Member Services Department at ( 505) 237-1501. If
received before the 23 rd of the month, the transfer will take effect the 1 st of the following month. You can also change your
provider office, address telephone number or request additional ID cards on the internet by visiting their web page at
www. Dentalsource. com.

Benefits on this page are not part of the FEHB contract. 36
36 Page 37 38
2002 Lovelace Health Plan 37 Section 6
Section 6. General exclusions things we don t cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition and we agree, as discussed under Services Requiring Our Prior Approval on page 11.

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 37
37 Page 38 39
2002 Lovelace Health Plan 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

In most cases, providers and facilities file claims for you. Physicians must
file on the form HCFA-1500, Health Insurance Claim Form. Facilities will
file on the UB-92 form. For claims questions and assistance, call us at
1-800-CIGNA24 ( 1-800-244-6224) .

When you must file a claim such as for out--of-area care submit it on the
HCFA-1500 or a claim form that includes the information shown below.
Bills and receipts should be itemized and show:

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

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

Receipts, if you paid for your services.

Submit your claims to: Please refer to your ID card for the address to
mail any claims.

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

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

Medical, hospital and
drug benefits

Deadline for filing
your claim

When we need more
information 38
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2002 Lovelace Health Plan 39 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: :

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: Lovelace Health Plan, Altura Office Complex, 4101 Indian School Road, NE,
Albuquerque, NM 87110; and

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

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

We have 30 days from the date we receive your request to:
( a) Pay the claim ( or, if applicable, arrange for the health care provider to give you the care) ; or

( b) Write to you and maintain our denial go to step 4; ; or
( c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request go to step 3. .

You or your provider must send the information so that we receive it within 60 days of our request. We will then
decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information
was due. We will base our decision on the information we already have.

We will write to you with our decision.

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 3,
1900 E Street, NW, Washington, D. C. 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

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

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

1
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2002 Lovelace Health Plan 40 Section 8
The disputed claims process ( continued)
Note: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, 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.

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 adminis-
trative appeals.

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

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

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

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

( a) We haven t responded yet to your initial request for care or preauthorization/ prior approval, then call us at
1-800-CIGNA24 ( 1-800-244-6224) 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 3 at 202-606-0737 between 8 a. m. and 5 p. m. eastern time.

5
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2002 Lovelace Health Plan 41 Section 9
Section 9. Coordinating benefits with other coverage
You must tell us if you are covered or a family member is covered under
another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called double coverage.

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance Commissioners
guidelines.

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

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

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

Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not have to pay for
Part A. If you or your spouse worked for at least 10 years in Medicare-
covered employment, you should be able to qualify for premium-free
Part A insurance. ( Someone who was a Federal employee on January 1,
1983 or since automatically qualifies. ) Otherwise, if you are age 65 or
older, you may be able to buy it. Contact 1-800-MEDICARE for more
information.

Part B ( Medical Insurance) . Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.

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

The Original Medicare Plan ( Original Medicare) is a Medicare+ Choice plan
that 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. Your care
must continue to be authorized by your Plan PCP, or recertified as required.

We will not waive any of our copayments or coinsurance.
( Primary payer chart begins on next page. )

When you have other health
coverage

What is Medicare?

The Original Medicare Plan
( Part A or Part B) 41
41 Page 42 43
2002 Lovelace Health Plan 42 Section 9
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 eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee, or
c) Are a former spouse of an annuitant, or

d) Are a former spouse of an active employee

1) Are an active employee with the Federal government ( including when you
or a family member are eligible for Medicare solely because of a disability) ,

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

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

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

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

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

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,

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

C. When you or a covered family member have FEHB and 42
42 Page 43 44

2002 Lovelace Health Plan 43 Section 9
Claims process when you have the Original Medicare Plan
You probably will never have to file a claim form when you have both
our Plan and the Original Medicare Plan. Please note, if your Plan
physician does not participate in Medicare, you will have to file a claim
with Medicare.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your
claim first. In most cases, your claims will be coordinated automatically
and we will pay the balance of covered charges. You will not need to
do anything. To find out if you need to do something about filing your
claims, call us at 1-800-CIGNA24 ( 1-800-244-6224) , or write to
Lovelace Health Plan, Altura Office Complex, 4101 Indian School Road,
NE, Albuquerque, NM 87110. You may also visit our website at
www . com. In this case we do not waive any out-of-pocket costs.

If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from another type of Medicare+ Choice plan a Medicare
managed care plan. These are health care choices ( like HMOs) in some areas
of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed
care plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescription drugs. To learn more about enrolling in a
Medicare managed 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 our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments, coinsurance, or deductibles
for your coverage.

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 ( if you use our Plan providers) , but we will not waive any
of our copayments, coinsurance, or deductibles. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your FEHB
premium. ( OPM does not contribute to your Medicare managed care plan
premium. ) For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you involun-
tarily lose coverage or move out of the Medicare managed care plan s
service area.

If you do not have one or both Parts of Medicare, you can still be covered

Medicare managed
care plan 43
43 Page 44 45
2002 Lovelace Health Plan 44 Section 9
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 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.

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

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

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

When you have this Plan and Medicaid, we pay first.
We do not cover services and supplies when a local, State, or Federal
Government agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures.

Medicaid
When other Government
agencies are responsible
for your care

When others are
responsible for injuries

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

TRICARE 44
44 Page 45 46
2002 Lovelace Health Plan 45 Section 10
Section 10. Definitions of terms we use in this brochure
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 is the percentage of our allowance that you must pay for your
care. See page 12.

A copayment is a fixed amount of money you pay when you receive covered
services. See page 12.

Care we provide benefits for, as described in this brochure.
A deductible is a fixed amount of covered expenses you must incur for
certain covered services and supplies before we start paying benefits for
those services. We have no deductible.

Experimental, investigational and unproven services are medical, surgical,
diagnostic, psychiatric, substance abuse or other health care technologies,
supplies, treatments, procedures, drug therapies or devices that are deter-
mined by the Medical Director to be:

not approved by the U. S. Food and Drug Administration ( FDA) to be
lawfully marketed for the proposed use and not recognized for the
treatment of the particular indication in one of the standard reference
compendia ( The United States Pharmacopoeia Drug Information,
The American Medical Association Drug Evaluations; or the American
Hospital Formulary Service Drug Information) or in medical literature.
Medical literature means scientific studies published in a peer-reviewed
national professional medical journal;

the subject of review or approval by an Institutional Review Board for the
proposed use;

the subject of an ongoing clinical trial that meets the definition of a phase
I, II or III Clinical Trial as set forth in the FDA regulations, regardless of
whether the trial is subject to FDA oversight; or

not demonstrated, through existing peer-reviewed literature to be safe and
effective for treating or diagnosing the condition or illness for which its
use is proposed.

Medically necessary covered Services and Supplies are those covered
Services and Supplies that are determined by our Medical Director to be:

No more than required to meet your basic health needs; and
consistent with the diagnosis of the condition for which they are
required; and

consistent in type, frequency and duration of treatment with scientifically
based guidelines as determined by medical research; and

required for purposes other than the comfort and convenience of the
patient or his Physician; and

rendered in the least intensive setting that is appropriate for the delivery
of health care; and

of demonstrated medical value.
Us and we refer to Lovelace Health Plan.

You refers to the enrollee and each covered family member.

Calendar year
Coinsurance
Copayment
Covered services
Deductible

Experimental or
investigational services

Medical necessity
Us/ We
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2002 Lovelace Health Plan 46 Section 11
Section 11. FEHB facts
We will not refuse to cover the treatment of a condition that you had before
you enrolled in this Plan solely because you had the condition before you
enrolled.

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

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

When your enrollment ends; and
When the next open season for enrollment begins.

We don t determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.

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

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to
Self and Family because you marry, the change is effective on the first day of
the pay period that begins after your employing office receives your enroll-
ment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age 22
marries or turns 22.

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

The benefits in this brochure are effective on January 1. If you joined this
Plan during Open Season, your coverage begins on the first day of your first
pay period that starts on or after January 1. 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.

No pre-existing condition
limitation

Where you can get
information about enrolling
in the FEHB Program

Types of coverage available
for you and your family

When benefits and
premiums start 46
46 Page 47 48

2002 Lovelace Health Plan 47 Section 11
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 coordi-
nating 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, 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) .

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.

If you are divorced from a Federal employee or annuitant, you may not
continue to get benefits under your former spouse s enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity law.
If you are recently divorced or are anticipating a divorce, contact your ex-
spouse s employing or retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees , or other information about your coverage
choices.

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

You may not elect TCC if you are fired from your Federal job due to gross
misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-
5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees , from your employ-
ing or retirement office or from www. opm. gov/ insure. It explains what you
have to do to enroll.

Your medical and claims
records are confidential

When you retire
When you lose benefits
When FEHB coverage ends

Spouse equity coverage

TCC 47
47 Page 48 49

2002 Lovelace Health Plan 48 Section 11
You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends ( If you
canceled your coverage or did not pay your premium, you cannot
convert) ;

You decided not to receive coverage under TCC or the spouse equity
law; or

You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You must
apply in writing to us within 31 days after you are no longer eligible for
coverage.

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

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

For more information, get OPM pamphlet RI 79-27, Temporary Continuation
of Coverage ( TCC) under the FEHB Program. See also the FEHB web site
( www. opm. gov/ insure/ health) ; refer to the TCC and HIPAA frequently
asked questions. These highlight HIPAA rules, such as the requirement that
Federal employees must exhaust any TCC eligibility as one condition for
guaranteed access to individual health coverage under HIPAA, and have
information about Federal and State agencies you can contact for more
information.

Converting to individual
coverage

Getting a Certificate of Group
Health Plan Coverage 48
48 Page 49 50

2002 Lovelace Health Plan 49 Long T rm Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG !

How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

The Office of Personnel Management ( OPM) will sponsor a high-quality long term care insurance program effective in
October 2002. As part of its educational effort, OPM asks you to consider these questions:

It s insurance to help pay for long term care services you may need if you
can t take care of yourself because of an extended illness or injury, or an
age-related disease such as Alzheimer s.

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

Welcome to the club!
76% of Americans believe they will never need long term care, but the
facts are that about half them will. And it s not just the old folks. About
40% of people needing long term care are under age 65. They may need
chronic care due to a serious accident, a stroke, or developing multiple
sclerosis, etc.

We hope you will never need long term care, but everyone should have a
plan just in case. Many people now consider long term care insurance to
be vital to their financial and retirement planning.

Yes, it can be very expensive. A year in a nursing home can exceed
$ 50,000. Home care for only three 8-hour shifts a week can exceed
$ 20,000 a year. And that s before inflation!

Long term care can easily exhaust your savings. Long term care insur-
ance can protect your savings.

Not FEHB. Look at the Not covered blocks in sections 5( ( a) and 5( c)
of your FEHB brochure. Health plans don t cover custodial care or a
stay in an assisted living facility or a continuing need for a home health
aide to help you get in and out of bed and with other activities of daily
living. Limited stays in skilled nursing facilities can be covered in some
circumstances.

Medicare only covers skilled nursing home care ( the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.

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.

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.

Our toll-free teleservice center will begin in mid-2002. In the meantime,
you can learn more about the program on our web site at www. opm. gov/
insure/ ltc.

What is long term care
( LTC) insurance?

I m healthy. I won t need
long term care. Or, will I?

Is long term care expensive?
But won t my FEHB plan,
Medicare or Medicaid cover
my long term care?

When will I get more informa-
tion on how to apply for this
new insurance coverage?

How can I find out more
about the program NOW? 49
49 Page 50 51
2002 Lovelace Health Plan 50 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
A ccidental injury . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Allergy tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Alternative treatment . . . . . . . . . . . . . . . . . . . . . 20
Allogenetic ( donor) bone marrow
transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Autologous bone marrow
transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

B iopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Blood and blood plasma . . . . . . . . . . . . . . . . 25
Breast cancer screening . . . . . . . . . . . . . . . . . 15
Casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Catastrophic protection . . . . . . . . . . . . . . . . . . 12
Changes for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chemotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Cholesterol tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Colorectal cancer screening . . . . . . . . . . . 15
Congenital anomalies. . . . . . . . . . . . . . . . . . . . 22
Contraceptive devices and drugs . . . 16
Coordination of benefits. . . . . . . . . . . . . . . . 41
Covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Covered providers. . . . . . . . . . . . . . . . . . . . . . . . . 45
Crutches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
D eductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Dental care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Diagnostic services . . . . . . . . . . . . . . . . . . . . . . . . 14
Disputed claims review . . . . . . . . . . . . . . . . . 39
Donor expenses ( transplants) . . . . . . . . 24
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Durable medical equipment
( DME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

E ducational classes and programs . . 21
Effective date of enrollment . . . . . . . . . . 46
Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Experimental or investigational . . . . . 45
Eyeglasses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

F amily planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Fecal occult blood test . . . . . . . . . . . . . . . . . . . 15
G eneral Exclusions . . . . . . . . . . . . . . . . . . . . . . . . 37
H earing services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Home health services . . . . . . . . . . . . . . . . . . . . . 20
Hospice care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Home nursing care . . . . . . . . . . . . . . . . . . . . . . . . . 20
Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
I mmunizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Inhospital physician care . . . . . . . . . . . . . . . 14
Inpatient Hospital Benefits . . . . . . . . . . . . 25
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
L aboratory and pathological
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Magnetic Resonance Imagings
( MRIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Mail Order Prescription Drugs . . . . . . 33
Mammograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Maternity Benefits. . . . . . . . . . . . . . . . . . . . . . . . . 16
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Medically necessary . . . . . . . . . . . . . . . . . . . . . . 45
Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Mental Conditions/ Substance
Abuse Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Newborn care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Non-FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . 36
Nurse
Licensed Practical Nurse . . . . . . . . . . . . 20
Registered Nurse . . . . . . . . . . . . . . . . . . . . . . . . 34
Nursery charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
O bstetrical care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Occupational therapy . . . . . . . . . . . . . . . . . . . . . 17
Office visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Oral and maxillofacial surgery . . . . . . 23
Orthopedic devices. . . . . . . . . . . . . . . . . . . . . . . . 19
Ostomy and catheter supplies . . . . . . . . 20
Out-of-pocket expenses . . . . . . . . . . . . . . . . . 12
Outpatient facility care . . . . . . . . . . . . . . . . . . 26
Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

P ap test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Physical examination . . . . . . . . . . . . . . . . . . . . . 15
Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Pre-admission testing . . . . . . . . . . . . . . . . . . . . . 23
Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . 11
Preventive care, adult . . . . . . . . . . . . . . . . . . . . 15
Preventive care, children . . . . . . . . . . . . . . . 15
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Preventive services . . . . . . . . . . . . . . . . . . . . . . . . 15
Prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Prostate cancer screening . . . . . . . . . . . . . . 15
Prosthetic devices . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Psychologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
R adiation therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Renal dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Room and board . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
S econd surgical opinion . . . . . . . . . . . . . . . . . 14
Skilled nursing facility care . . . . . . . . . . . 26
Smoking cessation . . . . . . . . . . . . . . . . . . . . . . . . . 33
Speech therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Splints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Sterilization procedures . . . . . . . . . . . . . . . . . 16
Subrogation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Oral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Reconstructive . . . . . . . . . . . . . . . . . . . . . . . . 23
Syringes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
T emporary continuation of
coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Treatment therapies . . . . . . . . . . . . . . . . . . . . . . . 17
V ision services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
W ell child care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Wheelchairs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Workers compensation . . . . . . . . . . . . . . . . . 44
X -rays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 50
50 Page 51 52
2002 Lovelace Health Plan 51 Summary
Eye exam every two years; annual
retractions; You pay $ 10 copay.

One pair of eyeglasses or one set of contact
lenses every two years, subject to the
following maximum Plan payment every
two years:

Single lenses $ 20; Bifocal lenses $ 30;
Trifocal lenses $ 40; Contact lenses $ 75;
Frames $ 30. You pay the difference above
amount shown for lenses and more costly
frames.

Summary of benefits for Lovelace Health Systems, Inc. 2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page

Office visit: $ 10 primary care;
$ 20 specialist

Medical services provided by physicians:
Diagnostic and treatment services provided in
the office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Services provided by a hospital:
Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing per admission

Emergency benefits:
In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . .
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Protection against catastrophic costs
( your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Special features: Flexible benefits option; 24 hour nurse line; Services for deaf and hearing impaired; High
risk pregnancies; Centers of Excellence for transplants/ heart surgery/ etc. ; Travel benefit/ services overseas

Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental Care ( Accidental dental injury only) . . . . . . . . . . . . . . . . . . . .

Nothing after $ 1,000/ Self Only or $ 2,000/
Family enrollment per year. This copay
maximum does not include Prescription
drugs, Dental services, Mental Health/
Substance Abuse services, Prosthetics or
Infertility services.

$ 10 per office visit
Retail Pharmacy:
$ 5 per generic formulary; $ 15 per name
brand formulary; $ 35 per name brand
non-formulary.

Mail Order:
( Maintenance medications only)
$ 10 per generic formulary; $ 40 per name
brand formulary; $ 100 per name brand
non-formulary.

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

Regular cost sharing.
$ 10 per office visit; $ 25 per urgent
care visit; $ 50 per hospital emergency
care visit

12
34

35
32
29
30
29

26
25

14

18 51
51 Page 52
2002 Rate Information for
Lovelace Health Plan

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category,
refer to the FEHB Guide for that category or contact the agency that maintains your health
benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the
FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and special FEHB guides are published for Postal Service Nurses, RI 70-2B; and for Postal
Service Inspectors and Office of Inspector General ( OIG) employees ( see RI 70-2IN) .

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of
any postal employee organization who are not career postal employees. Refer to the applicable
FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly

Type of Gov t Your Gov t Your USPS Your
Enrollment Code Share Share Share Share Share Share

The entire State of New Mexico

Self Only Q11 $ 84.26 $ 28.08 $ 182.55 $ 60.85 $ 99.70 $ 12.64

Self and Family Q12 $ 219.07 $ 73.02 $ 474.65 $ 158.21 $ 259.23 $ 32.86 52

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