Page Navigation Panel Document Outline

Document Outline

Pages 1--56 from HMO BLue


Page 1 2

http:// www. bcbsuw. com 2002
A Health Maintenance Organization

Serving: Utica/ Rome, Watertown and Plattsburgh Metropolitan Areas
Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 3 for requirements.

Enrollment codes for this Plan:
AH1 Self Only AH2 Self and Family

RI 73-460

This Plan has excellent
accreditation from NCQA.

For changes
in benefits,
see page 5. 1
1 Page 2 3
2
2 Page 3 4
2002 HMOBlue i Table of Contents
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Who provides y healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Your Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Where you get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
What you ust do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Services requiring our prior approval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Copay ents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Your out-of-pocket axi u . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
( b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
( c) Services provided by a hospital or other facility, and a bulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
( d) E ergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3
3 Page 4 5
2002 HMOBlue ii Table of Contents
Section 6. General exclusions --things we don' t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Section 7. Filing a clai for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 8. The disputed clai s process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
When you have
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Medicare Managed Care Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
TRICARE / Workers' Co pensation/ Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Other Govern ent agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 10. Definitions of terms we use in this brochure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 11. FEHB facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Coverage infor ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Where you get infor ation about enrolling in the FEHB Progra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Types of coverage available for you and your fa ily. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When benefits and pre iu s start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Your edical and clai s records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Te porary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Getting a Certificate of Group Health Plan Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Long ter care insurance is co ing later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover 4
4 Page 5 6
2002 HMOBlue 1 Introduction/ Plain Language
Introduction
BlueCross BlueShield of Utica-Watertown Inc., d. b. a. HMOBlue
Utica Business Park, 12 Rhoads Drive
Utica, NY 13502-6398

This brochure describes the benefits of HMOBlue under our contract (CS2294) 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 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 51. 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 BlueCross BlueShield Utica-Watertown.

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

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail OPM at fehwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 5
5 Page 6 7
2002 HMOBlue 2 Inspector General Advisory
Inspector General Advisory
Fraud increases the cost of health care for everyone. If you suspect that a physician,
phar acy, or hospital has charged you for services you did not receive, billed you twice
for the sa e service, or misrepresented any infor ation, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the atter, call us at 800/ 722-7884 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 Manage ent

Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Penalties for Fraud Anyone who falsifies a clai to obtain FEHB Program benefits can be prosecuted for
fraud. Also, the Inspector General ay investigate anyone who uses an ID card if the
person tries to obtain services for so eone who is not an eligible fa ily e ber, or is no
longer enrolled in the Plan and tries to obtain benefits. Your agency ay also take
administrative action against you.

Stop health care fraud! 6
6 Page 7 8
2002 HMOBlue 3 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.

Who Provides My Healthcare
BlueCross BlueShield of Utica-Watertown, d. b. a. HMOBlue, is a division of Excellus Health Care, Inc. HMOBlue is an individual
practice association HMO. You, and each member of your family, must select a primary care doctor to coordinate all medical needs.
There are over 1200 primary care doctors to choose from, representing family practice, general practice, internal medicine, OB/ GYN
and pediatrics. The Plan also contracts with an additional 3000 specialists throughout the service area.

Benefits for urgent care rendered outside of this Plan's service area may be covered. This Plan is affiliated with HMO-USA, a
network of BlueCross and BlueShield HMOs that can coordinate your medical care. If you need more information, a Plan
representative can tell you more about its reciprocity benefits.

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:

BlueCross BlueShield of Utica-Watertown has been serving our community for 64 Years with the finest health care insurance HMOBlue is a Non-Profit organization

You can obtain additional information by calling Member Services at 1-800-722-7884. The information available includes:
Consumer satisfaction, clinical quality and service performance measures Whether facility has been excluded from any Federal health programs
Cancellation, suspension, or exclusion from participation in Federal programs or sanctions. Number of primary care and specialty providers
Methods of compensation, ownership or interest in health care facilities that are associated with the plan 7
7 Page 8 9

2002 HMOBlue 4 Section 1
There is some information that we do not track, but you should be able to get the following information from your doctor and/ or
hospital. If you are not able to get this information, we will assist you in obtaining it.

Doctor:
Language( s) spoken and availability of interpreters, facilities that are accessible to the disabled Corporate form of providers

Names of hospitals where physicians have admitting privileges Years in practice as a physician and as a specialist if so identified
Experience with performing certain medical or surgical procedures
Hospitals:
Corporate form Consumer satisfaction, clinical quality and service performance measures

Whether facility specialty programs meet guidelines established by specialty societies or other bodies Complaint procedures
Volume of certain procedures performed Numbers and credentials of providers of direct patient care
Whether the facility's affiliation with a provider network would make it more likely that a consumer would be referred to health professionals or other organizations in that network.

If you want more information about us, call 800-722-7884, or write to 12 Rhoads Dr., Utica, NY, 13502. You may also contact us by
fax at 315-733-2830 or visit our website at http:// www. bcbsuw. com.

Service Area
To enroll in this Plan, you must live or work in our service area. This is were our providers practice. Our service area is: The New
York counties of Chenango, Clinton, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis, Madison,
Montgomery, Oneida, Oswego, Otsego and St. Lawrence.

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. However, you may also contact your primary care physician to get a referral.

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. Guest Membership is available in most parts of the United States from HMO-USA.
If you have family members living outside of our service area and want to enroll them as a guest member, you must complete an
additional application. Contact HMOBlue for more information regarding Guest Membership. If you or a family member move, you
do not have to wait until Open Season to change plans. Contact your employing or retirement office. 8
8 Page 9 10
2002 HMOBlue 5 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official state ent of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

Program-wide changes

We changed the address for sending disputed clai s to OPM. ( Section 8)
Changes to this Plan

Your share of the non-Postal pre iu will decrease by 10% for Self Only or 16% for Self and Fa ily.

We added a new Section after Section 11 to discuss the Long Term Care Insurance Progra that is co ing in 2002. ( Section 11)
We no longer li it total blood cholesterol tests to certain age groups. ( Section 5( a) )
We now cover routine screening for chla ydial infection. ( Section 5( a) )
We increased speech therapy benefits by re oving the require ent that services ust be required to restore functional speech. ( Section 5( a) )

We now cover certain intestinal transplants. ( Section 5( b) )
We changed our benefit to allow all wo en to receive an annual routine a ogra ( Section 5 ( a) )
We changed the copay ent for e ergency roo service to $ 50 within our service area and outside our service area; ( Section 5( d) ) 9
9 Page 10 11

2002 HMOBlue 6 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800-722-7884.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments,
and/ or coinsurance. You normally won't have to submit claims to us unless you receive
emergency services from a provider who doesn't contract with us. If you file a claim,
please send us all of the documents for your claim as soon as possible. You must submit
claims by December 31 of the year after the year you received the service. Either OPM
or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The
provider directory is also on our website at http:// www. bcbsuw. com.

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

What you must do It depends on the type of care you need. First, you and each family
to get covered care member must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care. To determine if
a physician is a participating provider and accepting new patients, you can refer to our
Provider Directory or contact us at 800-722-7884.

Primary care Your primary care physician can practice family medicine, internal medicine, pediatrics, and general medicine. 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 at 800-722-7884. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see an optometrist once a
year for a routine exam, and a woman may see an OB-GYN twice a year for routine
exams without a referral. 10
10 Page 11 12
2002 HMOBlue 7 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, co plex, or serious edical condition, your pri ary care physician will develop a treat ent plan that
allows you to see your specialist for a certain nu ber of visits without additional
referrals. Your pri ary care physician will use our criteria when creating your
treat ent plan. The physician ay have to get an authorization, or approval,
beforehand.

If you are seeing a specialist when you enroll in our Plan, talk to your pri ary care physician. Your pri ary care physician will decide what treat ent 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 ust receive treat ent fro 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 pri ary care physician, who will arrange for you to see another specialist. You ay receive
services fro your current specialist until we can ake arrange ents for you to see
so eone else.

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

-ter inate our contract with your specialist for other than cause; or
-drop out of the Federal E ployees Health Benefits ( FEHB) Progra and you
enroll in another FEHB Plan; or

-reduce our service area and you enroll in another FEHB Plan, you ay 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 Progra , contact your new plan.

If you are in the second or third tri ester 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 postpartu care, even if it is beyond the 90 days.

Hospital care Your Plan pri ary care physician or specialist will ake necessary hospital arrange ents and supervise your care. This includes ad ission to a skilled nursing or other type of
facility.
If you are in the hospital when your enroll ent in our Plan begins, call our custo er
service depart ent i ediately at 800-722-7884. If you are new to the FEHB Program,
we will arrange for you to receive care.

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

You are discharged, not erely oved to an alternative care center; or
The day your benefits fro your for er plan run out; or
The 92 nd day after you beco e a e ber of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 11
11 Page 12 13
2002 HMOBlue 8 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we ay have to
delay your services or we ay be unable to provide the . In that case, we will ake all
reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Your pri ary care physician has authority to refer you for ost services. For certain
services, however, your physician ust obtain approval fro us. Before giving approval,
the Plan considers whether the service is covered, edically necessary, and follows
generally accepted edical practice.

We call this review and approval process a pre-authorization. Your physician ust obtain pre-authorization for the following services:

1. Air A bulance,
2. All Inpatient Ad issions,
3. All Referrals to Non-Participating Providers,
4. A bulatory Surgery,
5. Che otherapy & Radiation Treat ent,
6. Colonoscopy & Endoscopy Procedures,
7. Diabetic Equip ent,
8. Ho e Health Care,
9. Ho e Infusion Therapy,
10. Inpatient Physical Rehabilitation,
11. Kidney Dialysis,
12. Magnetic Resonance Imaging ( MRI) and Magnetic Resonance Angiography ( MRA) ,
13. Mental Health Services,
14. Nutritional Counseling,
15. Organ & Bone Marrow Transplants,
16. Outpatient Alcohol or Drug Abuse,
17. Pain Management,
18. Short Ter Therapy,
19. Skilled Nursing Facility Care, and
20. Sleep Apnea Studies. 12
12 Page 13 14
2002 HMOBlue 9 Section 4
Section 4. Your costs for covered services
You ust share the cost of some services. You are responsible for:
Copayments A copay ent is a fixed a ount of oney you pay to the provider, facility, phar acy, etc. , when you receive services.

Exa ple: When you see your pri ary care physician you pay a copay ent of $ 10 per
office visit and when you go in the hospital, Y ou Pay nothing.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Exa ple: In our Plan, You Pay 50% of our allowance for infertility services and 20% of
our allowance for durable edical equip ent.

Your catastrophic protection out-of-pocket maximum We do not have an out-of-pocket maximum. 13
13 Page 14 15
2002 HMOBlue 10 Section 5
Section 5. Benefits --OVERVIEW
(See page 3 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. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 800-722-7884 or at our website at
www. bcbsuw. com.
(a) Medical services and supplies provided by physicians and other health care professionals........................................................ 11-18

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

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................................... 19-22
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .................................................................................. 23-25

Inpatient hospital Outpatient hospital or ambulatory surgical
center
Skilled nursing care facility benefits Hospice care

Ambulance
(d) Emergency services/ accidents ..................................................................................................................................................... 26-27
Medical emergency

Ambulance
(e) Mental health and substance abuse benefits ................................................................................................................................ 28-29
(f) Prescription drug benefits ............................................................................................................................................................ 30-31
(g) Special features............................................................................................................................................................................ 32-33
Flexible benefit option

Reciprocity benefit
Centers of excellence for transplants/ heart surgery/ etc
(h) Dental benefits .................................................................................................................................................................................. 34

Summary of benefits ................................................................................................................................................................................ 51 14
14 Page 15 16
2002 HMOBlue 11 Section 5( a)
Section 5 ( a) Medical services and supplies provided by physicians and other
health care professionals

I M
P
R TA

N T

Here are some important things to keep in mind about these benefits:
Please re e ber that all benefits are subject to the definitions, li itations, and exclusions in this brochure and are payable only when we deter ine they are edically

necessary.
Plan physicians ust provide or arrange your care.
Be sure to read Section 4, Your costs for covered services for valuable infor ation about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P
R TA

N TBenefit

Description You pay
Diagnostic and treatment services You pay

Professional services of physicians
In physician s office

In an urgent care center
In a skilled nursing facility
Office edical consultations

Second surgical opinion

$ 10 per office visit

Professional services of physicians
During a hospital stay
Initial exa ination of a newborn child covered under a fa ily enroll ent

$ 10 per office visit

At ho e $ 10 per ho e visit
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammogra s
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 15
15 Page 16 17
2002 HMOBlue 12 Section 5( a)
Preventive care, adult You pay
Routine screenings such as:
Blood lead level
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test

Nothing

Sigmoidoscopy, screening every five years starting at age 50
Prostate Specific Antigen ( PSA test)

One routine annual exa for en age 40 and older
Nothing

Routine pap test Nothing
Routine mammogra covered for all wo en Nothing
Routine I unizations, Inoculations and Boosters for Adults: Nothing

Annual Physical Exams Nothing
Routine Gynecological Exa s
Primary and preventive obstetric and gynecological services including two annual exa s.
Nothing

Allergy Injections Nothing
Vision Exa s
The annual exa ay include physical exam of the eyes, refraction tests, and assess ent of binocular vision.
$ 10 per office visit

Hearing Exa s 1 exa per year $ $ 10 per office visit
No covered: Physical exams required for obtaining or continuing
employment or insurance, a ending schools or camp, or ravel The
Plan will not pay for inoculations for adults or children that are
required for employment.

All charges

Preventive care, children You pay
Well Child Care/ Immunizations. Childhood i unizations and exa s
for children under age 22 at a frequency reco ended by the A erican
Acade y of Pediatricians. Such exa s ay cover: a edical history,
co plete physical exa , develop ental assessment, anticipatory guidance,
necessary and appropriate immunizations, and lab tests ordered at the ti e
of the visit.

Nothing

Exa inations, such as:
Routine Eye Exa s
Routine Hearing Exa s

$ 10 per office visit
$ 10 per office visit 16
16 Page 17 18
2002 HMOBlue 13 Section 5( a)
Maternity care You pay
Co plete aternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in ind:

You do need to pre-authorize your nor al delivery; see page 8 for other circumstances, such as extended stays for you or your baby.

You ay re ain 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 edically necessary.
We cover routine nursery care of the newborn child during the covered portion of the other s aternity stay. We require pre-

authorization. We will cover other care of an infant who requires
non-routine treatment only if we cover the infant under a Self and
Fa ily enrollment.

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

Surgery benefits ( Section 5b) .

Nothing

No covered: Routine sonograms o determine sex All charges
Family planning You pay
A broad range of voluntary fa ily planning services, including:
Voluntary sterilization
Surgically i planted contraceptives ( such as Norplant)
Injectable contraceptive drugs ( such as Depo Provera)
Intrauterine devices ( IUDs)
Diaphragms
Fa ily Planning Service ( such as birth control and genetic counseling and elective ter ination of pregnancy)

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

Nothing

Not covered: reversal of volun ary surgical sterilization. All charges 17
17 Page 18 19
2002 HMOBlue 14 Section 5( a)
Infertility services You pay
Diagnosis and treat ent of infertility, such as:
Artificial inse ination:
in ravaginal insemination ( IVI)
intracervical insemination ( ICI)
intrau erine insemination ( IUI)
Fertility drugs

50% coinsurance

Not covered:
Assisted reproductive technology ( ART) procedures, such as:
in vitro fertilization
embryo transfer, Zif , and GIFT
Services and supplies related to excluded ART procedures

Cos of donor sperm

All charges

Allergy care You pay
Testing and treat ent $ 10 per office visit

Allergy injection Nothing
Allergy seru Nothing
No covered: provoca ive food tes ing and sublingual allergy
desensitization
All charges

Treatment therapies You pay
Che otherapy and radiation therapy
Note: High dose che otherapy in association with autologous
bone arrow transplants are limited to those transplants listed
under Organ/ Tissue Transplants on page 21.

Dialysis He odialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Ho e IV and antibiotic therapy

Growth hor one therapy ( GHT)
Speech therapy
Note: We will only cover GHT when we pre-authorize the
treat ent. Have your physician call for pre-authorization. We
will ask you or your physician to sub it infor ation that
establishes that the GHT is edically necessary. Ask your
physician to have us authorize GHT before you begin treat ent;
otherwise, we will only cover GHT services fro the date you
sub it the infor ation. If you or your physician do not ask or if
we deter ine GHT is not edically necessary, we will not cover
the GHT or related services and supplies. See Services requiring
our prior approval in Section 3.

Nothing 18
18 Page 19 20
2002 HMOBlue 15 Section 5( a)
Treatment therapies ( Continued) You pay
Respiratory and inhalation therapy

Inhalers are covered under phar acy benefits, see page 30.
Inhalation therapy equip ent is covered under DME, see page 17.
Note: Medications used with inhalation therapy equip ent are covered
under phar acy benefits.

Nothing
See Phar acy

See DME

Physical and occupational therapies You pay
Physical therapy
Occupational therapy
Pul onary/ cardiac therapy
2 consecutive onths of short ter therapy per acute condition which in the judge ent of the Plan s Medical director can be

expected to result in significant improve ent through short ter
therapy:

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

$ 10 per office visit
$ 10 per outpatient visit
Nothing during covered inpatient ad ission.

Not covered:
long-term rehabilitative therapy
exercise programs

All charges

Speech therapy You pay
2 consecutive onths per condition which in the judge ent of the Plan s Medical director is edically necessary. $ 10 per office visit $ 10 per outpatient visit
Nothing during covered inpatient ad ission.

Not covered:
long-term rehabilitative therapy
exercise programs

All charges

Hearing services ( testing, treatment, and supplies) You pay
First Hearing Aid and testing only when necessitated by accidental injury, disease, or illness

Hearing testing

$ 10 per office visit

Not covered:
hearing aids, tes ing and examinations for them not connected wi h injury, disease, or illness All charges 19
19 Page 20 21
2002 HMOBlue 16 Section 5( a)
Vision services ( testing, treatment, and supplies) You pay
Routine annual exa ( See Preventive Care) $ 10 per office visit

Initial prescription lenses and fra es after cataract surgery Nothing
Annual eye refractions $ 10 per office visit
Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges

Foot care You pay
Routine foot care when you are under active treat ent for a metabolic
or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for infor ation on podiatric shoe
inserts.

$ 10 per office visit

Not covered:
Cu ing, trimming or removal of corns, calluses, or he free edge of toenails, and similar routine treatment of conditions of the foo ,

except as stated above
Treatment of weak, s rained or fla feet or bunions or spurs; and of any instability, imbalance or subluxation of the foo ( unless the

treatment is by open cutting surgery)

All charges

rthopedic and prosthetic devices You pay
Artificial li bs and eyes
Externally worn breast prostheses and surgical bras, including necessary replace ents, following a astecto y

Internal prosthetic devices, such as artificial joints, pace akers, cochlear i plants, and surgically i planted breast i plant
following astecto y. Note: See 5( b) for coverage of the surgery
to insert the device.

Corrective orthopedic appliances for non-dental treat ent of te poro andibular joint ( TMJ) pain dysfunction syndro e.

20% coinsurance 20
20 Page 21 22
2002 HMOBlue 17 Section 5( a)
rthopedic and prosthetic devices ( Continued) You pay
Not covered:
Or hopedic and corrective shoes
Arch suppor s
Foot or hotics
Heel pads and heel cups
Lumbosacral suppor s
Corse s, trusses, elas ic stockings, suppor hose, and other suppor ive devices

All charges

Durable medical equipment ( DME) You pay
Rental or purchase, at our option, including repair and adjust ent, of
durable edical equip ent prescribed by your Plan physician, such as
oxygen and dialysis equip ent. Under this benefit, we also cover:

hospital beds;
wheelchairs;
braces and crutches;
walkers;
blood glucose onitors;
insulin pumps;
casts;
trusses; and
apnea onitor.

Note: Call us at 800-722-7884 as soon as your Plan physician
prescribes this equip ent. We will arrange with a health care provider
to rent or sell you durable edical equip ent at discounted rates and
will tell you ore about this service when you call.

20% Coinsurance

Home health services You pay
Ho e health care ordered by a Plan physician and provided by a registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or ho e health aide. Services include:
oxygen therapy,
intravenous therapy and edications.

$ 10 per office visit

Not covered:
nursing care reques ed by, or for he convenience of, he pa ient or the patien s family;

home care primarily for personal assis ance that does no include a medical component and is not diagnos ic, therapeutic, or
rehabilitative.

All charges 21
21 Page 22 23
2002 HMOBlue 18 Section 5( a)
Chiropractic You pay
Manipulation of the spine

Adjunctive procedures such as ultrasound, electrical uscle sti ulation, vibratory therapy, and cold pack application

$ 10 per office visit

Alternative treatments You pay
Not covered:

Na uropathic services
Hypnotherapy
Biofeedback

All charges

Educational classes and programs You pay
Coverage is li ited to:

S oking Cessation Packets including co itted quitters program and Clear the Air s oking cessation resource guide. .

Managing Your Diabetes Includes a co prehensive study guide for patients and their health care professionals; diabetes resource
list and standards of care.

Nutritional Counseling One visit per year
Healthy Choice Valued added progra s offered to HMOBlue me bers.

Healthy Life Self-Care Guide Series Healthy life self--care guides gives up to date infor ation on 25 of the ost co on
ail ents.

Mind Set This co pletely confidential progra includes a too-free number and free educational videos on anxiety disordered
such as social phobia and obsessive-co pulsive behavior.

Asthma Community and Education Resource Guide
Environ ental Control: Avoiding Exposure In and Around Your Ho e

Wealth of Health Co unity Wellness Calendar Free or low cost HMOBlue sponsored events where you live or work.
Connection Book Series This infor ative 3--book series explains the co unication process of people who suffer fro depression
and provides insights into how significant these relationships are
affected.

Nothing 22
22 Page 23 24
2002 HMOBlue 19 Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and other health
care professionals

I M
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Here are some important things to keep in mind about these benefits:
Please re e ber 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 ust provide or arrange your care.
Be sure to read Section 4, Your costs for covered services for valuable infor ation 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 5c for changes associated with the facility.

I M
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Description You pay
Surgical procedures You pay

A co prehensive range of services, such as:
Operative procedures Treatment of fractures, including casting

Normal pre-and post-operative care by the surgeon Correction of a blyopia and strabismus
Endoscopy procedure upper and lower Biopsy procedure
Re oval of tumors and cysts Correction of congenital ano alies ( see reconstructive surgery)
Surgical treat ent of orbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her nor al
weight according to current edical policy; eligible e bers
ust be age 18 or over
Insertion of internal prosthetic devices. See 5( a) Orthopedic braces and prosthetic devices for device coverage infor ation.

Voluntary sterilization Treatment of burns

Nothing

Not covered:
Reversal of volun ary sterilization Routine treatment of conditions of the foo ; see Foo care. All charges 23
23 Page 24 25
2002 HMOBlue 20 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the e ber s appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or fro birth and is a significant deviation fro the co on for or nor . Exa ples of
congenital ano alies are: protruding ear defor ities; cleft lip; cleft
palate; birth arks; webbed fingers; and webbed toes.

Nothing

All stages of breast reconstruction surgery following a astecto y, such as:
surgery to produce a symmetrical appearance on the other breast;
treat ent of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements ( see Prosthetic devices)

Note: If you need a astectomy, you ay choose to have the procedure
performed on an inpatient basis and re ain in the hospital up to
48 hours after the procedure.

Nothing

Not covered:
Cosmetic surgery any surgical procedure ( ( or any por ion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery You pay
Oral surgical procedures, li ited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

alocclusion;
Re oval of stones fro 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.

Nothing

Not covered:
Oral implants and transplants Procedures that involve the teeth or their suppor ing s ructures ( such

as the periodontal membrane, gingiva, and alveolar bone)
Any service determined to be dental in na ure

All charges 24
24 Page 25 26
2002 HMOBlue 21 Section 5( b)
Organ/ tissue transplants You pay
Li ited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic ( donor) bone marrow transplants

Autologous bone arrow transplants ( autologous ste cell and peripheral ste cell support) for the following conditions: acute

ly phocytic or non-ly phocytic leuke ia; advanced Hodgkin' s
ly pho a; advanced non-Hodgkin' s ly pho a; advanced
neuroblasto a; breast cancer; multiple yelo a; epithelial ovarian
cancer; and testicular, ediastinal, retroperitoneal and ovarian
ger cell tu ors

Intestinal transplants ( s all intestine) and the s all intestine with the liver or s all intestine with ultiple organs such as the liver,
sto ach and pancreas

National Transplant Progra ( NTP)
Li ited Benefits -Treatment for breast cancer, ultiple yelo a, and
epithelial ovarian cancer ay be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan s edical director in accordance with the Plan s protocols.

The Plan will cover transportation costs for the recipient and one other
individual to and from the site of a covered hu an organ or bone arrow
transplant surgery. If the recipient is a inor, The Plan will cover
transportation costs for two individuals to acco pany the recipient.
Transportation costs include all reasonable and necessary lodging and eal
expenses incurred, up to a daily maxi u of $ 150. Transportation costs
are li ited to $ 10,000 for each covered transplant procedure.

The Plan will only pay benefits that are unavailable or not provided to the
donor from any other source.

The Plan will pay for covered Hospital and surgical services, storage, and
transportation costs incurred by the donor that are directly related to the
donation of a human organ or bone arrow used in a covered transplant
procedure. Donor transportation costs include all reasonable and necessary
lodging and eal expenses incurred by the donor, up to a daily maxi u
of $ 150. Our Pay ents for all donor benefits are li ited to $ 25, 000 for
each covered transplant procedure.

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

Nothing 25
25 Page 26 27
2002 HMOBlue 22 Section 5( b)
Organ/ tissue transplants ( Continued) You pay
Not covered:
Donor screening tes s and donor search expenses, except those performed for he actual donor

Implants of artificial organs
Transplants not lis ed as covered

The Plan does no provide benefi s for the Member o be a human organ or bone marrow donor.

The Plan will not pay benefi s for any human organ or bone marrow donation or related cos s hat are covered for he donor under ano her
heal h benefi s plan.
The Plan will not pay for services hat would be covered for a human organ donor, if hose services are provided more han 5 days before a

covered human organ transplant.
The Plan will not pay for services hat would be covered for a bone marrow donor, if hose services are provided more than 30 days before

a covered bone marrow ransplant.

All charges

Anesthesia You pay
Professional services provided in

Hospital ( inpatient)
Nothing

Professional services provided in
Hospital outpatient department Skilled nursing facility
A bulatory surgical center Office

Nothing 26
26 Page 27 28
2002 HMOBlue 23 Section 5( c)
Section 5 ( c) . Services provided by a hospital or other facility, and
ambulance services

I M
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Here are some important things to remember about these benefits:
Please re e ber that all benefits are subject to the definitions, li itations, and exclusions in this brochure and are payable only when we deter ine they are edically

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

Be sure to read Section 4, Your costs for covered services for valuable infor ation 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 a bulance service for your surgery or care. Any costs associated

with the professional charge ( i. e. , physicians, etc. ) are covered in Section 5( a) or ( b) .

I M
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Description You pay
Inpatient hospital You pay
Roo and board, such as
Ward, semiprivate, or intensive care acco odations; General nursing care; and

Meals and special diets.

NOTE: If you want a private roo when it is not edically necessary,
you pay the additional charge above the se iprivate roo rate.

Nothing

Other hospital services and supplies, such as:
Operating, recovery, aternity, and other treat ent roo s Prescribed drugs and edicines

Diagnostic laboratory tests and X-rays Ad inistration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equip ent, including oxygen Medical supplies, appliances, medical equip ent, and any covered
ite s billed by a hospital for use at ho e

Nothing

Not covered:
Cus odial care Non-covered facilities, such as nursing homes and schools

Personal comfor i ems, such as telephone, television, barber services, gues meals and beds
Private nursing care

All charges 27
27 Page 28 29
2002 HMOBlue 24 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treat ent roo s
Prescribed drugs and edicines Diagnostic laboratory tests, X-rays, and pathology services

Ad inistration of blood, blood plas a, and other biologicals Blood and blood plas a, if not donated or replaced
Pre-surgical testing Dressings, casts, and sterile tray services
Medical supplies, including oxygen Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical i pair ent. We
do not cover the dental procedures.

Nothing

Inpatient Rehabilitation You pay Inpatient physical rehabilitation. Covered service when perfor ed
in a plan approved, free-standing or hospital-based physical
rehabilitation treat ent center. Li ited to 60 days. Nothing

Skilled nursing care facility benefits You pay
Skilled nursing facility ( SNF) : The Plan provides a comprehensive range of benefits for 45 days per calendar year when edically necessary when in

a Skilled Nursing Facility ( SNF) and are subject to the following ter s:

Services are furnished by a facility as defined under Section 2801 of the Public Health Law, or which qualifies as an Extended Care Facility
under Medicare which provides therapeutic services to patients needing skilled nursing care. The term Skilled Nursing Facility does not
include a convalescent nursing ho e, rest facility or facility for the aged.

Coverage is li ited to services provided by a Participating Provider.
A Skilled Nursing Facility which is licensed by the State to provide inpatient edical and nursing care, is recognized as such by Medicare,

and which has an agree ent with Blue Cross and Blue Shield to provide such services.

Care in a Skilled Nursing Facility is provided only if hospitalization would otherwise be required as determined by The Plan s Medical
Director and the Me ber s PCP.

Nothing

No covered: cus odial care All charges
Hospice care You pay
Supportive and palliative care for a terminally ill e ber is covered in the
ho e or hospice facility for up to 210 days. Services include inpatient and
outpatient care, and fa ily counseling; these services are provided under
the direction of a Plan doctor who certifies that the patient is in the ter inal
stage of illness.

Nothing

No covered: Independent nursing, homemaker services All charges 28
28 Page 29 30
2002 HMOBlue 25 Section 5( c)
Ambulance You pay
Local professional a bulance service when edically appropriate Nothing 29
29 Page 30 31
2002 HMOBlue 26 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
I M
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Here are so e i portant things to keep in ind about these benefits:
Please re e ber that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

I M
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is a medical emergency?
A edical e ergency 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 i ediate edical or surgical care. So e proble s are e ergencies
because, if not treated promptly, they ight beco e ore serious; exa ples include deep cuts and broken bones. Others are
e ergencies 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 ay deter ine are edical e ergencies what
they all have in co on is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an e ergency situation, please call your pri ary care doctor. In extre e
e ergencies, if you are unable to contact your doctor, contact the local e ergency syste ( e. g. , the 911 telephone syste ) or go to
the nearest hospital e ergency room. Be sure to tell the e ergency roo personnel that you are a Plan e ber so they can notify
the Plan. You or a fa ily ember ust notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been
ti ely notified.

If you need to be hospitalized, the Plan ust be notified within 48 hours or on the first working day following your ad ission,
unless it was not reasonably possible to notify the Plan within that ti e. If you are hospitalized in non-Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital, you will be transferred when edically feasible with any a bulance
charges covered in full.

Benefits are available for care from non-Plan providers in a edical e ergency only if delay in reaching a Plan provider would
result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recom ended by non-Plan providers ust be approved by the Plan or provided by
Plan providers.

If the e ergency results in admission to a hospital, the e ergency care copay is waived.
Emergencies outside our service area: Benefits are available for any edically necessary health service that is i ediately
required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan ust be notified within 48 hours or on the first working day following your ad ission,
unless it was not reasonably possible to notify the Plan within that ti e. If a Plan doctor believes care can be better provided in a
Plan hospital, you will be transferred when edically feasible with any a bulance charges covered in full.

To be covered by this Plan, Any follow-up care recom ended by non-Plan providers ust be approved by the Plan or provided by
Plan providers.

If the e ergency results in admission to a hospital, the e ergency care copay is waived. 30
30 Page 31 32
2002 HMOBlue 27 Section 5( d)
Benefit Description You pay
Emergency within our service area You pay
E ergency care at a doctor' s office other than the pri ary care physician

E ergency care at an urgent care center

$ 10 per visit

E ergency care as an outpatient or inpatient at a hospital, including
doctors' services
$ 50 per visit

Not covered: Elective care or non-emergency care All charges
Emergency outside our service area You pay

E ergency care at a doctor' s office
E ergency care at an urgent care center

$ 10 per visit

E ergency care as an outpatient or inpatient at a hospital, including
doctors' services $ 50 per visit

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

All charges

Ambulance You pay
Professional a bulance service when edically appropriate.
Air A bulance
See 5( c) for non-e ergency service.

Nothing 31
31 Page 32 33
2002 HMOBlue 28 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
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When you get our approval for services and follow a treat ent plan we approve, cost-sharing
and li itations for Plan ental health and substance abuse benefits will be no greater than
for si ilar 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, li itations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable infor ation 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.

I M
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Description You pay
Mental health and substance abuse benefits You pay
All diagnostic and treat ent services reco ended by a Plan provider
and contained in a treat ent plan that we approve. The treatment plan
ay include services, drugs, and supplies described elsewhere in this
brochure.

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

Your cost sharing responsibilities are no
greater than for other illness or conditions.

Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

Medication anage ent

$ 10 copay per office visit

Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treat ent, full day
hospitalization, facility based intensive outpatient treat ent.

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about reatment plans on he
treatment plan' s clinical appropriateness. OPM will generally no
order us o pay or provide one clinically appropria e reatment plan in
favor of another.

MENTAL HEALTH
Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary

and appropriate
SUBSTANCE ABUSE

Treatment that is not authorized by a Plan doctor.
Benefits for days of care that consist pri arily of participation in programs of a social, recreational, or companionship nature.

All charges. 32
32 Page 33 34
2002 HMOBlue 29 Section 5( e)
Preauthorization To be eligible to receive these enhanced ental health and substance abuse benefits
you obtain a treat ent plan and follow all of the following authorization processes:

The Pre-authorization process ust be followed regardless of whether the e ber is
within The Plan s service area or outside the service area. In aking the deter ination to issue pre-authorization approval, the Plan will exa ine the circu stances

surrounding the e ber s condition and care provided; including reasons for providing or prescribing the care; and any unusual circumstances. Please note the
fact that the e ber s physician prescribed the care does not auto atically ean that the care qualifies for plan pay ents under this contract. The provider, prior to
recommending or ordering any pre-authorized services, ust call the Medical Manage ent Depart ent at ( 800) 926-2357. Pre-authorization need not be obtained for
E ergency care. For obtaining provider directories, call Me ber Service Depart ent at ( 315) 798-4384 or ( 800) 722-7884. 33
33 Page 34 35
2002 HMOBlue 30 Section 5( f)
Section 5 ( f) . Prescription drug benefits
I
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T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and edications, 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 deter ine they are medically necessary.

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

I
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TThere

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

Where you can obtain them. You ay fill the prescription at a Plan phar acy or by ail. We only pay a benefit when you use a network phar acy .
We use a formulary. A for ulary is a list of the ost co only prescribed generic and brand na e drugs. If a provider prescribes a na e brand drug that is not on our formulary as a tier one or ier wo drug , you will pay the
$ 35 tier three drug copay.
To order a prescription brochure call 1-800-722-7884.
These are the dispensing limitations. You will be charged 1 copay for each 30 day supply, retail or ail order. If there is no generic equivalent, you will pay the brand for the two and three tier copay.

When you have to file a claim. If you do not use Plan pharmacies, you will receive no benefits.
When you fill a first time prescription through mail order. The first fill of a prescription is li ited to a
axi u of a ( 30) day supply. 34
34 Page 35 36
2002 HMOBlue 31 Section 5( f)
Benefit Description You pay
Covered medications and supplies You pay
We cover the following edications and supplies prescribed by a Plan
physician and obtained fro a Plan phar acy or through our ail order
program:
Drugs and edicines that by Federal law of the United States require a physician s prescription for their purchase, except as excluded below.

Oral and injectable drugs I planted, ti e release contraceptive edications, such as Norplant
S oking cessation drugs and medication including nicotine patches Enteral for ulas for ho e use when prescribed in writing by a Plan
doctor for poor nourish ent or a disorder which would cause chronic
physical disability, ental retardation, or death
Medically necessary odified solid food products with low or odified protein for treat ent of inherited diseases of a ino acids and

organic acid etabolis
Drugs for sexual dysfunction ( see Prior authorization below) Contraceptive drugs and devices

Fertility drugs Growth hor one drugs

Insulin, diabetic supplies and disposable needles and syringes needed to
inject covered prescribed edication are available through the Plan s
medical and surgical benefits and are subject to the doctor s office visit
copay ent

$ 5 copay per prescription unit or refill for
generic drugs per each 30 day supply

$ 20 copay per prescription unit or refill for
two tier drugs on our preferred drug list per
each 30 day supply

$ 35 copay per prescription unit or refill for
three tier drugs not on our preferred drug
list per each 30 day supply

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

$ 15 copay per prescription unit or refill for
generic drugs per 90 day supply

$ 60 copay per prescription unit or refill for
preferred brand na e drugs for a 90 day
supply

$ 105 copay per prescription unit or refill for
non-preferred brand na e drug for a 90 day
supply

Not covered
Drugs available wi hout a prescription or for which there is a nonprescrip ion equivalent available

Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and an iseptics
Drugs for Cosme ic purposes
Drugs to enhance athletic performance
Implanted time-release medications other than Norplant
Drugs in connection with transsexual surgery
Drugs prescribed for experiential or investigational use
Replacement for lost or stolen drugs.

All charges 35
35 Page 36 37
2002 HMOBlue 32 Section 5( g)
Section 5 ( g) . Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we deter ine the ost effective way to provide services.
Healthy Choices is a value-added progra , a package of health-related savings. Through a variety of special discounts, Healthy Choice encourages you to take
advantage of resources dedicated to promoting a healthy life-style. All products,
services, and wellness programs offer substantial savings.

Fitness Clubs
Golf Passes
Fitness Clothing and Equip ent
Weight Loss Programs
Wellness Progra s
Therapeutic Massage
S oking Cessation Progra s
Health & Beauty
Wellness Books and Audio
Health & Safety
Vision & Eye Care
Discount Coupons 36
36 Page 37 38
2002 HMOBlue 33 Section 5( g)
Feature ( Continued) Description
Reciprocity benefit HM Blue USA Away from Home Care & Guest Membership
>From BlueCross BlueShield of Utica-Watertown
Enjoy the comforts of your HMO wherever you go. Now the benefits you enjoy fro your HMO at home, are with you where ever you happen to

be. Away From Home Care coverage puts you in touch with HMO health care fro qualified
physicians in nearly every state across the country, wherever you need it. You ll receive the
sa e health care coverage you enjoy at ho e, through the country s largest HMO network,
HMO Blue USA. The benefits of Away From Home Care coverage are yours auto atically
and at no extra cost when you join our HMO.

The HMO that stays with you whenever you re away from home. Should you ever co e down with an unexpected illness or injury while traveling, which can t
wait to be treated at ho e, you can rest assured knowing that you have a place to turn. We
call it Urgent Care, because it delivers just that: the help you need, whenever you need it.

No paperwork whatsoever. You re not feeling well to begin with. The last thing you need is a big expense to ake
things worse. With Away From Home Care, you can take comfort knowing you ll have no
clai s to file, no paperwork and no pay ent at the ti e of service.

Far-reaching comforts no other HM provides. HMOBlue USA offers health care coverage in ore than 200 ajor cities across the country.
It s also reassuring to know HMOBlue USA s Away From Home Care progra is sponsored
by the BlueCross and BlueShield Association.

You know how i portant the right HMO coverage is when you re at ho e. Choose
HMOBlue fro BlueCross and BlueShield of Utica-Watertown and keep the benefits of your
local coverage wherever you go.

Even your follow-ups follow you. Should your travel schedule require that you iss a scheduled follow-up appoint ent at
ho e, our Follow-Up Care lets you conveniently schedule an appoint ent for ongoing care
near your travel destination. Like every Away From Home Care service, you ll receive the
sa e quality you enjoy at ho e.

Centers of excellence for
transplants/ heart
surgery/ etc

BlueCross BlueShield Utica-Watertown works with other BlueCross plans to identify
centers of excellence which offer quality care in specialized areas. When necessary the
plan s Medical Director will reco end, e bers with diseases and conditions that can
not be handled by our providers, to be sent to centers of excellence. 37
37 Page 38 39
2002 HMOBlue 34 Section 5( h)
Section 5 ( h) . Dental benefits
I M
P
R TA

N T

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

We cover hospitalization for dental procedures only when a nondental physical impairment exists which akes 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 infor ation about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.

I M
P
R TA

N TAccidental
injury benefit You pay
These services are li ited to those required for injury to sound natural teeth
as a result of an accident. Inpatient or outpatient hospital services and
physician services related to dental treat ent not associated with an
accidental injury will not be covered.

Nothing

Dental benefits You pay
We have no other dental benefits. All charges 38
38 Page 39 40
2002 HMOBlue 35 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, treat your illness, disease, injury or
condition.

We do not cover the following:

Care by non-Plan providers except for authorized referrals or e ergencies ( see E ergency Benefits) ;
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not edically necessary;
Services, drugs, or supplies not required according to accepted standards of edical, dental, or psychiatric practice;
Experi ental or investigational procedures, treat ents, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the other 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 transfor ations; or
Services, drugs, or supplies you receive fro a provider or facility barred fro the FEHB Program. 39
39 Page 40 41
2002 HMOBlue 36 Section 7
Section 7. Filing a claim for covered services
When you receive services fro Plan physicians, at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file clai s. Just present your identification card and pay your copay ent, coinsurance, or deductible.

You will only need to file a clai when you receive e ergency services fro non-plan providers. In so e cases, these providers may
bill us directly. Check with the provider. If you need to file the clai , here is the process:

Medical, Hospital, Drug and In ost cases, providers and facilities file clai s for you. Physicians
Other Supplies or Services ust file on the for HCFA-1500, Health Insurance Clai For .
Benefits Facilities will file on the UB-92 for . For clai s questions and assistance, call us at
800-722-7884.

When you ust file a clai --such as for out-of-area care --sub it it on the HCFA-1500
or a claim for that includes the infor ation shown below. Bills and receipts should be
ite ized and show:

Covered e ber s na e and ID number;
Na e 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, pay ents, or denial fro any pri ary payer --such as the Medicare Summary Notice ( MSN) ; and

Receipts, if you paid for your services.
Submit your claims to: 12 Rhoads Drive
Utica Business Park
Utica, NY 13502

Deadline for filing your claim Send us all of the documents for your clai as soon as possible. You ust sub it the
clai by Dece ber 31 of the year after the year you received the service, unless ti ely
filing was prevented by ad inistrative operations of Govern ent or legal incapacity,
provided the clai was sub itted as soon as reasonably possible.

When we need more information Please reply pro ptly when we ask for additional infor ation. We ay delay processing
or deny your clai if you do not respond. 40
40 Page 41 42
2002 HMOBlue 37 Section 8
Section 8. The disputed claims process
Follow this Federal E ployees Health Benefits Progra disputed clai s process if you disagree with our decision on your clai or
request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You ust:
( a) Write to us within 6 onths fro the date of our decision; and
( b) Send your request to us at: 12 Rhoads Drive, Utica Business Park, Utica, NY 13502; and
( c) Include a state ent 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 clai , such as physicians' letters, operative reports, bills, edical
records, and explanation of benefits ( EOB) for s.

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

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

We will write to you with our decision.

4 If you do not agree with our decision, you ay ask OPM to review it.
You ust 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 so e way within 30 days; or
120 days after we asked for additional infor ation.

Write to OPM at: Office of Personnel Manage ent, Office of Insurance Progra s, Contracts Division 3, 1900 E Street NW,
Washington, D. C. 20415-3630.

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

Copies of all letters you sent to us about the clai ;
Copies of all letters we sent to you about the clai ; and
Your dayti e phone number and the best ti e to call.

Note: If you want OPM to review different clai s, you ust clearly identify which docu ents apply to which clai . 41
41 Page 42 43
2002 HMOBlue 38 Section 8
Note: You are the only person who has a right to file a disputed clai with OPM. Parties acting as your representative,
such as edical providers, ust include a copy of your specific written consent with the review request.

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

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

6 If you do not agree with OPM s decision, your only recourse is to sue. If you decide to sue, you ust file the suit against OPM in Federal court by Dece ber 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or fro the year in which you were denied preauthorization. This is the only deadline that ay not be extended.
OPM may disclose the infor ation it collects during the review process to support their disputed clai decision. This
infor ation will beco e part of the court record.

You ay not sue until you have co pleted the disputed claims process. Further, Federal law governs your lawsuit,
benefits, and pay ent 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 ay recover only the a ount of benefits in dispute.

N TE: If you have a serious or life threatening condition ( one that ay cause per anent loss of bodily functions or death if
not treated as soon as possible) , and

( a) We haven' t responded yet to your initial request for care or preauthorization/ prior approval, then call us at 800-722-7884 and
we will expedite our review; or

( b) We denied your initial request for care or pre-authorization/ prior approval, then:
If we expedite our review and aintain our denial, we will infor OPM so that they can give your clai expedited treat ent too, or

You can call OPM' s Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. . eastern ti e. 42
42 Page 43 44
2002 HMOBlue 39 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a fa ily me ber is covered under another group
health plan or have auto obile insurance that pays health care expenses without regard to
fault. This is called double coverage.

When you have double coverage, one plan nor ally 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, deter ine which coverage is pri ary according to the National
Association of Insurance Co issioners' guidelines.

When we are the pri ary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will deter ine our allowance. After the pri ary
plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay ore than our allowance.

What is Medicare? Medicare is a Health Insurance Progra for:
People 65 years of age and older.
So e people with disabilities, under 65 years of age.
People with End-Stage Renal Disease ( per anent 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 e ploy ent, you should be able to

qualify for premiu -free Part A insurance. ( So eone who was a Federal e ployee on
January 1, 1983 or since auto atically qualifies. ) Otherwise, if you are age 65 or
older, you ay be able to buy it. Contact 1-800-MEDICARE for ore infor ation.

Part B ( Medical Insurance) . Most people pay onthly for Part B. Generally, Part B pre iu s are withheld fro your onthly Social Security check or your retire ent check .

If you are eligible for Medicare, you ay have choices in how you get your health care. Medicare
anaged care plan is the term used to describe the various health plan choices available to Medicare
beneficiaries. The infor ation 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 ( Part A or Part B) The Original Medicare Plan ( Original Medicare) is available everywhere in the United States.
It is the way everyone used to get Medicare benefits and is the way ost people get their
Medicare Part A and Part B benefits now. You ay go to any doctor, specialist, or hospital
that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.
So e 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.

( Primary payer chart begins on next page. ) 43
43 Page 44 45
2002 HMOBlue 40 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the pri ary payer for you according to your
e ploy ent status and other factors deter ined by Medicare. It is critical that you tell us if you or a covered fa ily e ber has
Medicare coverage so we can ad inister these require ents correctly.

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

riginal Medicare This Plan
1) Are an active employee with the Federal government ( including when you or
a fa ily e ber are eligible for Medicare solelybecause of a disability) , X

2) Are an annuitant, X
3) Are a ree ployed annuitant with the Federal govern ent when
a) The position is excluded fro FEHB, or X

b) The position is not excluded fro FEHB .
( Ask your e ploying office which of these applies to you. )
X

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) , X

5) Are enrolled in Part B only, regardless of your e ploy ent status, X ( for Part B
services)

X
( for other
services)

6) Are a for er Federal e ployee receiving Workers Co pensation
and the Office of Workers Co pensation Progra s has deter ined
that you are unable to return to duty,

X
( except for clai s
related to Workers
Co pensation. )

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

1) Are within the first 30 onths of eligibility to receive Part A
benefits solely because of ESRD, X

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

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

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or X
b) Are an active e ployee, or X

c) Are a for er spouse of an annuitant, or X
d) Are a for er spouse of an active e ployee X 44
44 Page 45 46
2002 HMOBlue 41 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice Plan --a Medicare managed care plan. These are
health care choices (like HMOs) in some areas of the country. In most Medicare managed
care plans, you can only go to doctors, specialists, or hospitals that are part of the plan.
Medicare managed care plans provide all the benefits that the Original Medicare covers.
Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan, the following options are
available to you:

This Plan and another plan's Medicare managed care plan: You may enroll in another
plan's Medicare Managed Care plan and also remain enrolled in our FEHB plan. We will still
provide benefits when your Medicare Managed Care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers), but we will not waive
any of our copayments and coinsurance. 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 is primary, eliminating your FEHB premium. (OPM does not contribute
to your Medicare managed care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB
Program, generally you may do so only at the next open season unless you involuntarily lose
coverage or move out of the Medicare managed care plan's service area.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare Part B and, if
you can't get premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for members, eligible dependents of military persons. TRICARE includes the CHAMPUS program. If both TRICARE and this Plan cover you, we
pay first. See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

Workers' Compensation We do not cover services that:
You need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they
must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

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

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

When others are responsible When you receive money to compensate you for medical or hospital for injuries 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. 45
45 Page 46 47
2002 HMOBlue 42 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through Dece ber 31 of the sa e year. For new enrollees, the calendar year
begins on the effective date of their enroll ent and ends on Dece ber 31 of the sa e
year.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial Care includes any service that can be provided by an average individual who has
little or no edical training. Exa ples of Custodial Care include: ( a) assistance in eeting
activities of daily living such as feeding, dressing, and personal hygiene, ( b) ad inistration of
oral edications, routine changing of dressings or preparation of special diets, ( c) assistance
in walking or getting out of bed, ( d) care when it is pri arily for the purpose of eeting
personal needs and could be provided by persons without professional skills or training.

Experimental or investigational Experi ental/ investigational procedures are defined as any procedure,
services treat ent, drug, biological product or device ( hereinafter referred to as
technology) that, in the sole discretion of the Plan, are determined to be experi ental or
investigational in nature.

Experi ental or investigational eans that the technology is deter ined not to:

have final approval fro the appropriate government regulatory body; be proven benefit for the particular diagnosis or treat ent of the e ber s
condition;
be recognized by the edical co unity, as reflected in the published peer-reviewed literature, as effective or appropriate for the particular diagnosis or

treat ent of the e ber s condition; or
be as beneficial as any established alternative.

Your pri ary care physician will work with our edical director and edical staff to
deter ine if a service is experi ental or investigational.

Medical necessity Medically Necessary Care is care which, according to The Plan s criteria is: ( a) Consistent
with the sympto s or diagnosis and treat ent of the Me ber s condition, disease, ail ent or
injury, ( b) in accordance with standards of acceptable edical practice, ( c) not solely for the
Me ber s convenience, or that of the Me ber s Doctor or other Provider, ( d) the ost
appropriate supply, place of service, or level of service which can safely be provided to the
Me ber, ( e) provided for the diagnosis or the direct care and treat ent of the Me ber s
condition, illness, disease or injury, and ( f) when applied to hospitalization, the Me ber
requires acute care as a bed patient due to the nature of the services rendered, or the Me ber s
condition, and the Me ber could not have received safe or adequate care in any other setting
( e. g. as an outpatient) .

Plan allowance Plan allowance is the a ount we use to determine our pay ent and your coinsurance for
covered services. We use any different for s of Plan Allowance. Our contract with
your providers allows us to change Plan Allowance with a 60 day notice. We believe that
listing our Plan Allowances would jeopardize our contracting ability with our providers.

Us/ We Us and we refer to HMOBlue
You You refers to the enrollee and each covered fa ily e ber. 46
46 Page 47 48
2002 HMOBlue 43 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if
you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the
first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your
enrollment form.

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; benefits will not be
available to your spouse until you marry.

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

When benefits and The benefits in this brochure are effective on January 1. If you are new
premiums start to this Plan, your coverage begins January 1. Annuitants' 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. 47
47 Page 48 49
2002 HMOBlue 44 Section 11
Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and

subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been
enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet
this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation
of Coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage 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.

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

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll. 48
48 Page 49 50
2002 HMOBlue 45 Section 11
Converting to You may convert to an non FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to
convert. You must apply in writing to us within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.

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

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

If you have been enrolled with us for less than 12 months, but were previously enrolled in
other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health) 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. 49
49 Page 50 51
2002 HMOBlue 46 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October
2002. As part of its educational effort, OPM asks you to consider these questions:

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.

LTC insurance 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 planing.

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 insurance 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.

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.

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 information
on how to apply for this new
insurance coverage?

How can I find out more about the
program NOW? 50
50 Page 51 52
2002 HMOBlue 47 Index
Index
Do not rely on this page; it is for your convenience and ay not show all pages where the ter s appear.

A ccidental injury 34 Allergy tests 14
Alternative treat ent 18 Ambulance 23
Anesthesia 23 Autologous bone arrow transplant 21
Blood and blood plas a 23 Breast cancer screening 12
Casts 17 Catastrophic protection 51
Changes for 2002 5 Che otherapy 14
Childbirth 13 Cholesterol tests 12
Clai s 6 Coinsurance 9
Colorectal cancer screening 12 Congenital ano alies 19
Contraceptive devices and drugs 13 Coordination of benefits 40
Covered providers 6
Crutches 17
Definitions 42 Dental care 34

Diagnostic services 11 Disputed clai s review 32
Donor expenses ( transplants) 21 Dressings 23
Durable edical equip ent ( DME) 17 E ducational classes and progra s 18
Effective date of enroll ent 6 E ergency 26
Experi ental or investigational 42 Eyeglasses 16
F a ily planning 13 Fecal occult blood test 12
G eneral Exclusions 35 H earing services 12
Ho e health services 17

Hospice care 24 Ho e nursing care 17
Hospital 23 I unizations 12
Infertility 14 In-hospital physician care 23
Inpatient Hospital Benefits 23 Insulin 31
L aboratory and pathological services 24
M achine diagnostic tests 11 Magnetic Resonance Imagings
( MRIs) 23 Mail Order Prescription Drugs 31
Mammograms 12 Maternity Benefits 13
Medicaid 41 Medically necessary 42
Medicare 39 Me bers 3
Mental Conditions/ Substance Abuse Benefits 28
Newborn care 13 Nurse
Licensed Practical Nurse 17 Registered Nurse 17
Nursery charges 13 bstetrical care 13
Occupational therapy 15 Ocular injury 12
Office visits 3 Oral and axillofacial surgery 20
Orthopedic devices 16 Out-of-pocket expenses 9
Outpatient facility care 24 Oxygen 17
P ap test 12 Physical examination 12
Physical therapy 15

Physician 19 Pre-ad ission testing 8
Preventive care, adult 12 Preventive care, children 12
Prescription drugs 30 Preventive services 12
Prior approval 8 Prostate cancer screening 12
Prosthetic devices 16 Psychologist 28
R adiation therapy 14 Rehabilitation therapies 24
Renal dialysis 14 Roo and board 23
S econd surgical opinion 11 Skilled nursing facility care 24
S oking cessation 18 Speech therapy 15
Splints 23 Sterilization procedures 13
Subrogation 41 Substance abuse 28
Surgery
Anesthesia 22 Oral 20

Outpatient 24 Reconstructive 20
Syringes 31 T e porary continuation of coverage
44 Transplants 21
Treatment therapies 14 V ision services 16
W ell child care 12 Wheelchairs 17
Worker s co pensation 41 X -rays 11 51
51 Page 52 53
2002 HMOBlue 48
NOTES: 52
52 Page 53 54
2002 HMOBlue 49 53
53 Page 54 55
2002 HMOBlue 50 54
54 Page 55 56
2002 HMOBlue 51 Summary
Summary of benefits for HMOBlue 2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
li itations, and exclusions in this brochure. On this page we sum arize specific expenses we cover; for ore detail,
look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treat ent services provided in the office. . . . . . . . . . . . . . . . . Office visit copay: $ 10 pri ary care; $ 10 specialist 11

Services provided by a hospital:
Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nothing
23

24

E ergency benefits:
In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ 50 per emergency roo visit
$ 50 per emergency roo visit
27

27

Mental health and substance abuse treat ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular cost sharing. 28
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drugs prescribed by a Plan doctor and obtained at a Plan
phar acy. You pay a $ 5 copay
for generic drugs, a $ 20 copay
for preferred brand na e drugs
or a $ 35 copay for non-preferred
brand na e drugs per
prescription unit or refill. Mail
order aintenance drugs. You
pay a $ 15 copay for generic
drugs, a $ 60 copay for preferred
brand drugs or a $ 105 copay for
non-preferred brand na e drug
per prescription unit or refill.

30

Dental Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accidental injury benefit; you pay
nothing. 34

Vision Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . One refraction annually. You pay
a $ 10 copay per visit. 16

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

No Maxi u
9 55
55 Page 56
2002 HMOBlue 52 Premium Page
2002 Rate Information for
HMO Blue

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. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code
Gov t
Share
Your
Share
Gov t
Share
Your
Share
USPS
Share
Your
Share

Self Only AH1 92.81 30.94 201.10 67.03 109.83 13.92
Self and Family AH2 223.41 93.54 484.06 202.67 263.75 53.20 56

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