Pages 1--56 from Blue Choice

Serving: The New York counties of Monroe, Livingston, Wayne, Ontario, Seneca and Yates.
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 5 for requirements.

Enrollment codes for this Plan:
MK1 Self Only MK2 Self and Family

This Plan has Full accreditation from
the NCQA. See the 2001 Guide for
more information on NCQA.

For changes in benefits
see page 7.

RI 73-510 1
1 Page 2 3
2002 Blue Choice 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………................................................................ 4
Plain Language………………………………………………………………............................................................... 4
Inspector General Advisory .......................................................................................................................................... 4
Section 1. Facts about this HMO plan.......................................................................................................................... 5
How we pay providers................................................................................................................................. 5
Who provides my health care? .................................................................................................................... 5
Your Rights ................................................................................................................................................. 5
Service Area ................................................................................................................................................ 6
Section 2. How we change for 2002……………………………………….. ............................................................... 7
Program-wide changes ................................................................................................................................ 7
Changes to this Plan .................................................................................................................................... 7
Section 3. How you get care …………........................................................................................................................ 8
Identification cards ...................................................................................................................................... 8
Where you get covered care ........................................................................................................................ 8
. Plan providers ....................................................................................................................................... 8
. Plan facilities......................................................................................................................................... 8
What you must do to get covered care......................................................................................................... 8
. Primary care .......................................................................................................................................... 8
. Specialty care ........................................................................................................................................ 8
. Hospital care ......................................................................................................................................... 9
Circumstances beyond our control ............................................................................................................ 10
Services requiring our prior approval ........................................................................................................ 10
Section 4. Your costs for covered services................................................................................................................. 11
. Copayments......................................................................................................................................... 11
. Coinsurance......................................................................................................................................... 11
Your out-of-pocket maximum................................................................................................................... 11
Section 5. Benefits………………………………………………………….............................................................. 12
Overview................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals........... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 22
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 26
(d) Emergency services/ accidents ........................................................................................................ 28
(e) Mental health and substance abuse benefits ................................................................................... 30
(f) Prescription drug benefits ............................................................................................................... 32
(g) Special features............................................................................................................................... 34 . Flexible benefit options................................................................................................................ 34 2
2 Page 3 4
2002 Blue Choice 3 Table of Contents
(h) Dental benefits ................................................................................................................................ 35
(i) Non-FEHB benefits available to Plan members ............................................................................. 36
Section 6. General exclusions --things we don't cover ............................................................................................. 37
Section 7. Filing a claim for covered services............................................................................................................ 38
Section 8. The disputed claims process ...................................................................................................................... 39
Section 9. Coordinating benefits with other coverage................................................................................................ 41
When you have…
. Other health coverage......................................................................................................................... 41
. Original Medicare .............................................................................................................................. 41
. Medicare managed care plan.............................................................................................................. 43
. TRICARE/ Workers Compensation/ Medicaid ........................................................................................ 44
. Other Government agencies.................................................................................................................... 44
. When others are responsible for injuries ................................................................................................ 44
Section 10. Definitions of terms we use in this brochure ........................................................................................... 45
Section 11. FEHB facts .............................................................................................................................................. 46

Coverage information…
. No pre-existing condition limitation.................................................................................................. 46
. Where you get information about enrolling in the FEHB Program................................................... 46
. Types of coverage available for you and your family ....................................................................... 46
. When benefits and premiums start .................................................................................................... 46
. Your medical and claims records are confidential ............................................................................ 47
. When you retire................................................................................................................................ 47
When you lose benefits ............................................................................................................................. 47
. When FEHB coverage ends .............................................................................................................. 47
. Spouse equity coverage .................................................................................................................... 47
. Temporary Continuation of Coverage (TCC) .................................................................................. 47
. Converting to individual coverage ................................................................................................... 48
. Getting a Certificate of Group Health Plan Coverage ...................................................................... 48
Long term care insurance is coming later in 2002 ...................................................................................................... 49
Index ............................................................................................................................................................... 50
Summary of benefits ................................................................................................................................................... 51
Rates .......................................................................................................................................................................... 52 3
3 Page 4 5
2002 Blue Choice 4 Introduction/ Plain Language
Introduction
Blue Choice 165 Court Street
Rochester, NY 14647
This brochure describes the benefits of Blue Choice under our contract (CS 2506) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are summarized on page 7. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and 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 Blue Choice. . 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 us at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.

Inspector General Advisory
Stop health care fraud Fraud Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you twice for the same service, or misrepresented
any information, do the following:
. Call the provider and ask for an explanation. There may be an error.
. If the provider does not resolve the matter, call us at 716/ 238-4466 and explain the situation.
. If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300 The United States Office of Personnel Management

Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take administrative actions against you. 4
4 Page 5 6
2002 Blue Choice 5 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.

Your Rights
Blue Choice, a health care plan of Blue Cross and Blue Shield of the Rochester Area is a Health Maintenance Organization( HMO) that emphasizes comprehensive medical, surgical and preventive care through an IPA network of more
than 2,500 area physicians in private offices and a multi-specialty group practice at the Plan's four health centers.
Each member selects their own primary care doctor from within the private office option or from the medical center option. Members of the same family can select different delivery systems. To be eligible for coverage, all services, except for
emergency care, must be provided, arranged, or authorized in advance by the member's primary care physician.
A woman may see her Plan obstetrician/ gynecologist or certified nurse midwife directly with no need to be referred by her primary care doctor. Routine exams are limited to two per year

Benefits for urgent care outside of this Plan's 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, this Plan can tell you more about
its reciprocity benefits.
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.
. There are New York State laws that BlueCross BlueShield of the Rochester Area administers to protect your private health
information. . BlueCross BlueShield of the Rochester Area has been serving the Rochester community for over 60 years, with products

such as Blue Choice, the area's largest health care plan. . Blue Choice is a Non-Profit organization

If you want more information about us, call 800/ 462-0108, or write to Blue Choice Member Services, 165 Court Street, Rochester, NY 14647. You may also contact us by fax at 716/ 238-3659 or visit our website at www. bcbsra. com. 5
5 Page 6 7
2002 Blue Choice 6 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: the New York counties of Monroe, Livingston, Wayne, Ontario, Seneca and Yates.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the
services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2002 Blue Choice 7 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does
not change benefits.
Program-wide changes

. We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

Changes to this Plan
. Your share of the non-Postal premium will increase by 24. 5% for Self Only or 37. 6% for Self and Family.
. We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
. We now cover certain intestinal transplants. (Section 5( b))
. We now cover prescription drugs under a three-tier copayment arrangement. Your copayments will vary depending on how your purchase your medication. When you purchase medication at a retail pharmacy or through the mail order

program, you pay $5 for generic prescription or refill, $15 for each preferred brand name prescription or refill, or $30 for each non-preferred brand name prescription or refill, for each 30-day supply.

. Smoking cessation drugs are now covered under prescription drugs.
. Durable medical equipment is now covered at 80% when purchased from a participating provider.
. We now cover ambulance service in full after a $25 copayment.
. We now cover second surgical opinions with an office visit copayment of $10.
. We now cover emergency room department triage with a $50 member copayment and urgent care facility with a $25 member copayment. 7
7 Page 8 9
2002 Blue Choice 8 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
716/ 454-4810.

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

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

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

www. bcbsra. 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 716/ 454-4810

. Primary care Your primary care physician can be a family practitioner, internal medicine, pediatrician, general medicine or obstetrician/ gynecologist. Your primary care
physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
. Specialty care Your primary care physician will refer you to a specialist for needed care. When
you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician

authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives you a referral. However, you may see your eye doctor once every 24 months or an acupuncturist
without a referral. 8
8 Page 9 10
2002 Blue Choice 9 Section 3
Here are other things you should know about specialty care:
. If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of

visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand). . If you are seeing a specialist when you enroll in our Plan, talk to your primary
care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your
current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay
for you to see a specialist who does not participate with our Plan.
. If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make

arrangements for you to see someone else.
. If you have a chronic or disabling condition and lose access to your specialist
because we:

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

— reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the program,
contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90 days.

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 716/ 454-4810. If you are new to the
FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

These provisions apply only to the benefits of the hospitalized person.. 9
9 Page 10 11
2002 Blue Choice 10 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will
make all reasonable efforts to provide you with the necessary care.

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

We call this review and approval process pre-certification. Your physician must obtain pre-certification for the following services:
1. Air ambulance,
2. All inpatient admissions,
3. All referrals to non-participating providers,
4. Ambulatory surgery,
5. Chemotherapy & radiation treatment,
6. Colonoscopy & endoscopy procedures,
7. Diabetic equipment,
8. Home health care,
9. Home 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 term therapy,
19. Skilled nursing facility care, and
20. Sleep apnea studies. 10
10 Page 11 12
2002 Blue Choice 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
. Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing.

. Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your
care

Example: In our Plan, you pay 50% of our allowance for acupuncture services and 20% for Prosthetic and Orthopedic Devices

Your out-of-pocket catastrophic protection maximum We do not have an out-of-pocket maximum. 11
11 Page 12 13
2002 Blue Choice 12 Section 5
Section 5. Benefits --OVERVIEW (See page 7 for how our benefits changed this year and page 49 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 (716) 454-4810 or at our website at www. bcbsra. com.

(a) Medical services and supplies provided by physicians and other health care professionals ........................... 13-21
. 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........................ 22-25
. Surgical procedures
. Reconstructive surgery
. Oral and maxillofacial surgery
. Organ/ tissue transplants
. Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 26-27
. Inpatient hospital
. Outpatient hospital or ambulatory surgical
center

. Extended care benefits/ skilled nursing care
facility benefits . Hospice care

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

(e) Mental health and substance abuse benefits.................................................................................................... 30-31
(f) Prescription drug benefits..................................................................................................................................... 32
(g) Special features .................................................................................................................................................... 34 . Flexible benefit option

Dental benefits............................................................................................................................................................. 35
(h) Non-FEHB benefits available to Plan members................................................................................................... 36
Summary of benefits ................................................................................................................................................... 49 12
12 Page 13 14
2002 Blue Choice 13 Section 5( b)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

. Plan physicians must provide or arrange your care.
. Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office

$10 per office visit

Professional services of physicians
. In an urgent care center
. During a hospital stay
. In a skilled nursing facility
. Office medical consultations
. Second surgical opinion

$10 per office visit

At home $10 per visit
Lab, X-ray and other diagnostic tests
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology

Nothing

. X-rays
. Non-routine Mammograms
. CAT Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

$10 per visit 13
13 Page 14 15
2002 Blue Choice 14 Section 5( b)
Preventive care, adult
Routine screenings, such as:
. Total Blood Cholesterol –once every three years
. Colorectal Cancer Screening, including
– Fecal occult blood test

Nothing

– Sigmoidoscopy, screening – everyfive years starting at age 50 Nothing
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing

Routine pap test Nothing
Physical Exams Nothing
Allergy Injections $10 per visit
Vision Exams
. The semi-annual exam may include physical exam of the eyes,
refraction tests and assessment of binocular vision.

$10 per visit

Hearing Exams $10 per visit
Routine mammogram –covered for women age 35 and older, as follows:

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

Nothing

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

Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and
over (except as provided for under Childhood immunizations)

. Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per visit

Preventive care, children You pay
. Childhood immunizations recommended by the American Academy
of pediatrics

. Well-child care charges for routine examinations, immunizations and
care (under age 22)

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

– Ear exams through age 17 to determine the need for hearing correction
– Examinations done on the day of immunizations (under age 22)

Nothing
Nothing
$10 per visit 14
14 Page 15 16
2002 Blue Choice 15 Section 5( b)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. You do not need to precertify your normal delivery; see page xx for
other circumstances, such as extended stays for you or your baby.

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

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

cover the infant under a Self and Family enrollment.
. We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

Nothing

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, limited to: {List all covered family planning services. See "left column instructions" in the

General Instructions following this pattern about when to use "limited to"
and when to use "such as". Should not lead into a list with "including". }

. Voluntary sterilization
. Surgically implanted contraceptives (such as Norplant)
. Injectable contraceptive drugs (such as Depo provera)
. Intrauterine devices (IUDs)
. Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

Nothing

Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges. 15
15 Page 16 17
2002 Blue Choice 16 Section 5( b)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
– intravaginal insemination (IVI)
– intracervical insemination (ICI)
– intrauterine insemination (IUI)
. Fertility drugs

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

$10 per visit
Copayment dependent on if the drug is generic, preferred brand
name or non-preferred brand name.

Infertility services continued You pay
Not covered:
. Assisted reproductive technology (ART) procedures, such as:
– in vitro fertilization
– embryo transfer, gamete GIFT and zygote ZIFT
– Zygote transfer
– Services and supplies related to excluded ART procedures
. Cost of donor sperm

. Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
$10 per visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 16
16 Page 17 18
2002 Blue Choice 17 Section 5( b)
Treatment therapies You pay
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 23.
. Respiratory and inhalation therapy
Inhalers are covered under pharmacy benefit, see page 30

Inhalation therapy equipment is covered under DME, see page 19
. Dialysis – Hemodialysis and peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy

. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Note: – We will only cover GHT when we preauthorize the treatment. Call (716) 454-4810 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask physician to have us authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per visit

Physical and occupational therapies You pay
. Up to two consecutive months per condition which in the judgement
of the Plan's Medical Director can be expected to result in a significant improvement through short term therapy

— qualified physical therapists and
— occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or

injury.
. Cardiac rehabilitation following a heart transplant, bypass surgery, or
any cardial infarction.

$10 per outpatient visit
Nothing per visit during covered inpatient admission

Not covered:
. long-term rehabilitative therapy
. exercise programs

All charges.

Speech therapy
60 visits per condition 17
17 Page 18 19
2002 Blue Choice 18 Section 5( b)
Hearing services (testing, treatment, and supplies)
. Hearing testing
. Hearing Aids for children
. Hearing testing for children through age 17 (see Preventive Care, children)

$10 per office visit
Balance after $600 every three years

Not covered:
. all other hearing testing
. hearing aids, testing and examinations for them

All charges.

Vision services (testing, treatment, and supplies) You pay
Semi annual exam (see Preventive Care) $10 per office visit

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit

. Eye exam to determine the need for vision correction for children
through age 17 (see Preventive Care)

. Annual eye refractions
$60 toward the purchase of one pair of either prescription eyeglasses or contact lenses once every 24 months. Prescription eyeglasses or

contact lenses covered annually for children to age 19.

$10 per office visit

Not covered:
. Eye exercises and orthoptics
. Radial keratotomy and other refractive surgery

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

Not covered:
. Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
. Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges. 18
18 Page 19 20
2002 Blue Choice 19 Section 5( b)
Orthopedic and prosthetic devices You pay
. Artificial limbs and eyes; stump hose
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

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

to insert the device.
. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

$10 per office visit

Not covered:
. orthopedic and corrective shoes
. arch supports
. foot orthotics
. heel pads and heel cups
. lumbosacral supports
. corsets, trusses, elastic stockings, support hose, and other supportive devices

. prosthetic replacements provided less than 3 years after the last one we covered

All charges.

Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
. hospital beds;
. wheelchairs;
. walkers;
. blood glucose monitors; and
. insulin pumps.

Note: Call us at 716/ 454-4810 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider

to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

$10 per office visit

Not covered:
. Motorized wheel chairs All charges. 19
19 Page 20 21
2002 Blue Choice 20 Section 5( b)
Home health services
. Home 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 home health aide. Services include

oxygen therapy, intravenous therapy and medications.
. Service include oxygen therapy, intravenous therapy and
medications.

$10 per office visit

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

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

All charges.

Chiropractic
. Manipulation of the spine and extremities
. Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application

$10 per office visit

Alternative treatments
Chiropractic Services

Acupuncture – Up to 10 visits per calendar year
$10 per visit
50%

Not covered:
. naturopathic services
. hypnotherapy . biofeedback

All charges. 20
20 Page 21 22
2002 Blue Choice 21 Section 5( b)
Educational classes and programs
Coverage is limited to:
Member Rewards includes:
. Smoking Cessation
. Nutrition counseling
. First aid/ safety
. Back care
. Stress Management
. General Wellness
. Family Life

$5 per office visit 21
21 Page 22 23
2002 Blue Choice 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

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

. Plan physicians must provide or arrange your care.
. Be sure to read Section 4, Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

. The amounts listed below are for the charges billed by a physician or other health care professional for
your surgical care. Look in Section 5 for charges associated with the facility (i. e. hospital, surgical center, etc.).

I M
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T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as . Operative procedures

. Treatment of fractures, including casting .
Normal pre-and post-operative care by the surgeon . Correction of amblyopia and strabismus

. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and cysts .
Correction of congenital anomalies (see reconstructive surgery) . Surgical treatment of morbid obesity --a condition in which an

individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must
be age 18 or over
. Insertion of internal prostethic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.

$10 per office visit; nothing for hospital visits

Surgical procedures continued on next page. 22
22 Page 23 24
2002 Blue Choice 23 Section 5( b)
Surgical procedures continued You pay
. Voluntary sterilization
. Treatment of burns

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

$10 per visit

Not covered:
. Reversal of voluntary sterilization
. Routine treatment of conditions of the foot; see Foot care.

All charges.

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

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

$10 per visit

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

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

Note: We pay for internal breast prostheses as hospital benefits.
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48

hours after the procedure.

See above.

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

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

All charges

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

. Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; . Removal of stones from salivary ducts;

$10 per visit 23
23 Page 24 25
2002 Blue Choice 24 Section 5( b)
Oral and maxillofacial surgery continued
. 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. . TMJ surgery and other non-dental treatment.

$10 per visit

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

All charges.

Organ/ tissue transplants You pay
Limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Lung: Single –Double
. Pancreas
. Allogeneic (donor) bone marrow transplants

. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's

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

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

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

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

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

. Implants of artificial organs
. Transplants not listed as covered

Nothing

Anesthesia You pay 24
24 Page 25 26
2002 Blue Choice 25 Section 5( b)
Professional services provided in – . Hospital (inpatient)
. Hospital outpatient department
. Skilled nursing facility
. Ambulatory surgical center
. Office

Nothing 25
25 Page 26 27
2002 Blue Choice 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

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

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

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

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

Section 5( a) or (b).

I M
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T

Benefit Description You pay
Inpatient hospital
Room and board, such as . ward, semiprivate, or intensive care accommodations;

. general nursing care; and
. meals and special diets.

Other hospital services and supplies, such as: . Operating, recovery, maternity, and other treatment rooms

. Prescribed drugs and medicines
. Diagnostic laboratory tests and X-rays
. Administration of blood and blood products
. Blood or blood plasma, if not donated or replaced
. Dressings, splints, casts, and sterile tray services .
Medical supplies and equipment, including oxygen . Anesthetics, including nurse anesthetist services

. Take-home items
. Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:
. Custodial care
. Non-covered facilities, such as nursing homes, extended care facilities, schools

. Personal comfort items, such as telephone, television, barber services, guest meals and beds
. Private nursing care

All charges. 26
26 Page 27 28
2002 Blue Choice 27 Section 5( c)
Outpatient hospital or ambulatory surgical center
. Operating, recovery, and other treatment rooms
. Prescribed drugs and medicines
. Diagnostic laboratory tests, X-rays, and pathology services
. Administration of blood, blood plasma, and other biologicals .
Blood and blood plasma, if not donated or replaced . Pre-surgical testing

. Dressings, casts, and sterile tray services
. Medical supplies, including oxygen
. Anesthetics and anesthesia service

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

$10 per visit

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: The Plan provides a comprehensive range of benefits with no dollar limit for 45 days per member per

calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan.

Nothing .

Not covered: custodial care All charges
Hospice care
Supportive and palliative care for a terminally ill member is covered
in the home or hospice facility for up to 210 days. Services include
inpatient and outpatient care, and family counseling; these services
are provided under the direction of a Plan doctor who certifies that
the patient is in the terminal stage of illness, with a life ecpectancy of
approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
. Local professional ambulance service when medically
appropriate Nothing 27
27 Page 28 29
2002 Blue Choice 28 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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A N
T

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

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

I M
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T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are

emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours. It is your responsibility
to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency 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 recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
If the emergency results in admission to a hospital, the emergency care copay is waived.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be
better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, Any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

If the emergency results in admission to a hospital, the emergency care copay is waived. 28
28 Page 29 30
2002 Blue Choice 29 Section 5( d)
Benefit Description You pay
Emergency within our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital,
including doctor's services

$10 per visit

. Emergency 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
. Emergency care at a doctor's office
. Emergency care at an urgent care center $10 per visit

. Emergency 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

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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
Air Ambulance
See 5( c) for non-emergency service.

$25 29
29 Page 30 31
2002 Blue Choice 30 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

When you get our approval for services and follow a treatment plan we approve, cost sharing and limitations for Plan mental health and substance benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
. All benefits are subject to the definitions, limitations, and exclusions in this brochure.
. Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

I M
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T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may

include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the
care as part of a treatment plan that we approve.

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 management

$10 per 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 treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing

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

All charges. 30
30 Page 31 32
2002 Blue Choice 31 Section 5( e)
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
. The Pre-authorization procedure must be followed regardless whether the Member is
within The Plan's Service Area or not. Pre-authorization need not be obtained for Emergency care. In making the determination to issue Pre-authorization The Plan

will examine the circumstances surrounding the Member's condition and the care provided; including reasons for providing or prescribing the care; and any unusual
circumstances. However, the fact that the Member's Doctor prescribed the care does not automatically mean that the care qualifies for The Plan's payments under
this Certificate. The provider, prior to recommending or ordering any pre-authorized services, must call Blue Choice at (716) 454-4591. For obtaining provider directories,
call Member Service Department at (716) 454-4810.

Limitation We may limit your benefits if you do not obtain a treatment plan.
How to submit network claims Claims are submitted by your provider. 31
31 Page 32 33
2002 Blue Choice 32 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the
next page.

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

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

I M
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A N
T
There are important features you should be aware of. These include:
. Who can write your prescription. A licensed physician must write the prescription – or – A plan
physician or licensed dentist must write the prescription.

. Where you can obtain them. You may fill the prescription at a participation pharmacy or by mail.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and

your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

. We have an open formulary. If your physician believes a name brand product is necessary or there is
no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To

order a prescription drug brochure, call (716) 454-4810.
. These are the dispensing limitations. Retail and Mail Order – Prescription drugs are dispensed per 30
day supply, maximum 90-day supply. You will pay either a $5, $15 or $30 copayment for each for each 30 day supply

. Why use generic drugs? Generic drugs are lower priced drugs that are the therapeutic equivalent to
more expensive brand name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand mane product. Generics cost less than the

equivalent brand name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that the drugs meet the same standards of quality and strength as brand name
drugs.
You can save money by using generic drugs. However, you and your physician have the option to request a brand name if a generic option is available. Using the most cost-effective medication saves

money.
When generic substitution is permissible, (i. e., a generic is available and the prescribing doctor does not require the use of a brand name drug), but you request the name brand drug. You pay the $5 copay for

prescription drugs plus the price difference between the generic and the name brand drug.
. When you have to file a claim. You will have no claims to file unless you use a non-participating
pharmacy..

Prescription drug benefits begin on the next page. 32
32 Page 33 34
2002 Blue Choice 33 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program: . Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase, except as excluded below.
. Insulin
. Disposable needles and syringes for the administration of covered
medications $10 per 30 day supply . Diabetic supplies including blood glucose monitors, insulin pumps,

insulin infusion devices, oral agents for controlling blood sugar, and diabetes self-management education $10 per 30 day supply.

. Drugs for sexual dysfunction (see Prior authorization below)
. Contraceptive drugs and devices
. Growth hormones

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

Here are some things to keep in mind about our prescription drug program:

Retail and Mail Order
$5 copayment per generic (tier 1) prescription or refill .

$15 copayment per preferred brand name (tier 2) prescription or refill .
$30 copayment per non preferred brand name (tier 3) prescription or
refill .
for each 30 day supply

Not covered:
. Drugs and supplies for cosmetic purposes
. Vitamins, nutrients and food supplements even if a physician prescribes or administers them

. Nonprescription medicines
. Drugs to enhance athletic performance
. Drugs for weight loss
. Drugs obtained at a non-plan pharmacy; except for out-of-area emergencies.

All Charges 33
33 Page 34 35
2002 Blue Choice 34 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
. We may identify medically appropriate alternatives to traditional
care and coordinate other benefits as a less costly alternative benefit.

. Alternative benefits are subject to our ongoing review.
. By approving an alternative benefit, we cannot guarantee you will
get it in the future.

. The decision to offer an alternative benefit is solely ours, and we
may withdraw it at any time and resume regular contract benefits.

. Our decision to offer or withdraw alternative benefits is not
subject to OPM review under the disputed claims process.

Reciprocity benefit HMOBlue USA Urgent Care & Guest Membership

From BlueCross BlueShield of the Rochester Area

The HMO that stays with you whenever you're away from home. Should you ever come down with an unexpected illness or injury while
traveling, which can't wait to be treated at home, 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 make things worse. You can take comfort knowing you'll have no claims to file, no paperwork and no payment at the time of service.

Guest Membership Coverage at an affiliated HMO when living away from home for at least 90
consecutive days.

Centers of excellence for transplants/ heart surgery/ etc BlueCross BlueShield of the Rochester Area 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 recommend, members with diseases and conditions that can not be handled by our providers, to be sent to centers of
excellence. 34
34 Page 35 36
35
35 Page 36 37
2002 Blue Choice 35 Section 5( h)
Section 5 (h). Dental benefits
I M
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T

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

. We cover hospitalization for dental procedures only when a nondental physical impairment exists which
makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is described below.

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

I M
P O
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A N
T

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

an accidental injury.
$10 copay per office visit

Dental benefits
We have no other dental benefits. 36
36 Page 37 38
2002 Blue Choice 36 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Member Rewards has been developed by Blue Choice to introduce you to selected local resources that will help you get into shape, have more energy, deal more effectively with life's problems and increase your chances of preventing heart disease,
cancer or stroke. Take advantage of the health and wellness programs offered to Blue Choice members.
Private office option Member Rewards offers most health and wellness programs for just $5 a session. Topics include nutrition, smoking cessation, first aid/ safety, back care, stress management, general wellness and family life.

Choice discounts Member Rewards offers Choice Discounts that provide savings on health and fitness club membership, exercise programs, and sports equipment, ranging from footwear to cardiovascular exercise machines. To obtain a list of
Member Rewards and Choice Discounts, call 716/ 454-4810.
To further promote wellness and preventive care, members may enroll in health education programs at the health centers. These programs are professionally led courses on nutrition, back care, smoking cessation, stress management and many other topics.
Most programs cost just $5. 37
37 Page 38 39
2002 Blue Choice 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.
We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
. Services, drugs, or supplies that are not medically necessary;
. Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric
practice;

. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the
fetus were carried to term or when the pregnancy is the result of an act of rape or incest ;

. Services, drugs, or supplies related to sex transformations; or
. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 38
38 Page 39 40
2002 Blue Choice 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at (716) 454-4810.
When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and
receipts should be itemized and show:
. Covered member's name and ID number;
. Name and address of the physician or facility that provided the service or
supply;

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

. Receipts, if you paid for your services.
Submit your claims to: Blue Choice 165 Court Street
Rochester, NY 14647

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 39
39 Page 40 41
40
40 Page 41 42
2002 Blue Choice 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. Write to us at: 165 Court Street, Rochester NY, 14647. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 165 Court Street, Rochester NY, 14647; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

request— go to step 3.

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
. 120 days after we asked for additional information.

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

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

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

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim. 41
41 Page 42 43
2002 Blue Choice 40 Section 8
The Disputed Claim process continued
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review

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

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the
only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at (716) 454-4810 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
— If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

— You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 42
42 Page 43 44
2002 Blue Choice 41 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 family member is covered under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer.
We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

Medicare has two parts:
. Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you

should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

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

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

. The Original Medicare Plan (Part A or Part B) The Original Medicare Plan is available everywhere in the United States. It is the way
everyone used to get Medicare plan benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare plan pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription
drugs
When you are enrolled in Original Medicare, along with this plan you still need to follow the rules in this brochure for us to cover your care. Your care must continue
to be authorized by your Plan PCP.

(Primary payer chart begins on next page.) 43
43 Page 44 45
2002 Blue Choice 42 Section 9
The following chart illustrates whether the Original Medicare plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Areanactiveemployee withthe Federalgovernment(includingwhen youor afamilymemberare eligibleforMedicaresolely becauseofadisability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or ……………….…………… ………..

b) The position is not excluded from FEHB ……………….……………
Ask your employing office which of these applies to you.
……………………..………

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C.
(or if your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B
services)

(for other services)

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

(except for claims related to Workers'

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or………………………………………………… ……….

b) Are an active employee ……………….……………….…………… …………………….. …….

c) Are a former spouse or an annuitant, or
d) Are a former spouse of an active employee 44
44 Page 45 46
2002 Blue Choice 43 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original
Medicare Plan.
. When we are the primary payer, we process the claim first.

. When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your claims will be coordinated automatically and we will pay the balance of covered charges. You will not need to do anything. To find

out if you need to do something about filing your claims, call us at (716) 454-4810 or on the web at: www. bcbsra. com.

We waive some costs when you have the Original Medicare Plan --When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:
. Medical services and supplies provided by physicians and other health care
professionals.
. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like

HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this
case, we do/ do not waive any of our copayments, coinsurance, or deductibles for your FEHB coverage.

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

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

. If you do not enrollment in If you do not have one or both Parts of Medicare, you can still be covered under the
Medicare Part A or Part B FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it. 45
45 Page 46 47
2002 Blue Choice 44 Section 9
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both
TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

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

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

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

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 46
46 Page 47 48
2002 Blue Choice 45 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of
the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Experimental or Blue Choice uses published peer-reviewed medical literature about the efficiency Investigational and improvement outcomes of technology, along with the United States Food and
Drug Administration approval for marketing of medical devices, drugs or biologicals for a particular diagnosis or condition.

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

Us/ We Us and we refer to Blue Choice
You You refers to the enrollee and each covered family member. 47
47 Page 48 49
2002 Blue Choice 46 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; benefits will not be available to your spouse until you marry.

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

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

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay period
that starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office
will tell you the effective date of coverage 48
48 Page 49 50
2002 Blue Choice 47 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 If you leave Federal service, or if you lose coverage because you no longer qualify of coverage (TCC) 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. 49
49 Page 50 51
2002 Blue Choice 48 Section 11
. Converting to You may convert to a non-FEHB individual policy if:
individual coverage . Your coverage under TCC or the spouse equity law ends. (If you canceled your coverage or did not pay your premium, you cannot convert);

. You decided not to receive coverage under TCC or the spouse equity law; or
. You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this

notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to
us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a
waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 offers limited Group Health Plan Coverage 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 question. 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. 50
50 Page 51 52
2002 Blue Choice 49 Section 11
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance? . It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or injury, or an age-related disease
such as Alzheimer's. . LTC insurance can provide broad, flexible benefits for 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.
I'm healthy. I won't need long term care. Or, will I? . Welcome to the club! . 76% of Americans believe they will never need long term care, but the facts are that
about half of them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a
serious accident, a stroke, or developing multiple sclerosis, etc. . We hope you will never need long term care, but everyone should have a plan just in
case. Many people now consider long term care insurance to be vital to their financial and retirement planning.

Is long term care expensive? . 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.

But won't my FEHB plan, Medicare or Medicaid cover my
long term care?
. 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..

When will I get more information on how to apply for this new
insurance coverage?
. Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002. . Retirees will receive information at home.

How can I find out more about the program NOW? . Our toll-free teleservice center will begin in mid-2002. In the 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. 51
51 Page 52 53
2002 Blue Choice 50 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 26 Allergy tests 14
Alternative treatment 19 Ambulance 27
Anesthesia 24 Autologous bone marrow transplant 23
Biopsies 21 Blood and blood plasma 24
Breast cancer screening 14 Changes for 2001 7
Chemotherapy 16 Childbirth 15
Chiropractic 19 Cholesterol tests 14
Claims 37 Coinsurance 11
Colorectal cancer screening 14 Contraceptive devices and drugs 15
Coordination of benefits 40 Covered providers 8
Deductible 11 Definitions 44
Dental care 34 Diagnostic services 13
Disputed claims review 38 Donor expenses (transplants) 23
Durable medical equipment (DME) 19 Educational classes and programs 20
Effective date of enrollment 45 Emergency 26
Experimental or investigational 36 Eyeglasses 17
Family planning 15 Fecal occult blood test 14
General Exclusions 36

Hearing services 17 Home health services 19
Hospice care 25 Home nursing care 25
Hospital 25 Immunizations 24
Infertility 14 Inhospital physician care 21
Inpatient Hospital Benefits 21 Insulin 31
Laboratory and pathological services 13
Magnetic Resonance Imagings (MRIs) 13
Mail Order Prescription Drugs 31 Mammograms 14
Maternity Benefits 15 Medicaid 43
Medically necessary 9 Medicare 40
Mental Conditions/ Substance Abuse Benefits 28
Newborn care 15 Non-FEHB Benefits 35
Nursery charges 15 Obstetrical care 15
Occupational therapy 17 Office visits 13
Oral and maxillofacial surgery 22 Orthopedic devices 18
Outpatient facility care 25 Oxygen 25
Pap test 14 Physical examination 14
Physical therapy 17

Physician 13 Pre-admission testing 25
Precertification 10 Preventive care, adult 14
Preventive care, children 14 Prescription drugs 30
Preventive services 14 Prostate cancer screening 14
Prosthetic devices 18 Psychologist 28
Psychotherapy 28 Radiation therapy 16
Renal dialysis 16 Room and board 24
Skilled nursing facility care 25 Smoking cessation 35
Speech therapy 17 Sterilization procedures 15
Substance abuse 28 Surgery 21
. Anesthesia 21 .
Outpatient 21 . Reconstructive 22

Syringes 31 Temporary continuation of
coverage 46 Transplants 23
Treatment therapies 16 Vision services 17
Well child care 14 Wheelchairs 19
Workers' compensation 43 X-rays 13 52
52 Page 53 54
2002 Blue Choice 51
Summary of benefits for the Blue Choice -2002
. Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office ................. Office visit copay: $10 primary care; $10 specialist 13

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

. Outpatient .........................................................................................
Nothing
$10 copay
24
25

Emergency benefits:
. In-area.............................................................................................

. Out-of-area......................................................................................
$50 per… visit.

$50 per…

26
27

Mental health and substance abuse treatment ..................................... Regular cost sharing. 28
Prescription drugs................................................................................. You pay $5 copay for generic (tier 1) drug, $15 copay for
preferred brand name (tier 2)
drug, or $30 copay for a non-preferred
brand (tier 3) drug per
30-day supply.

30

Dental Care ....................................................................................... No benefit. 34
Vision Care ....................................................................................... One refraction and $60 toward eyeglasses or contact lenses every
24 months under age 19 annually.
You pay a $10 copay per visit

17

Special features: Member Rewards – Health and wellness programs and discounts. 35
Protection against catastrophic costs ................................................ (your out-of-pocket maximum) Your out-of-pocket expenses for benefits covered under this Plan
are limited to the stated
copayments which are required for
a few benefits

11 53
53 Page 54 55
2002 Blue Choice 52
2002 Rate Information for Blue Choice
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB
guides are published for Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

Self Only MK1 $97.86 $34.05 $212.03 $73.78 $115. 52 $16.39
Self and Family MK2 $223.41 $107.12 $484.06 $232.09 $263. 75 $66.78 54
54 Page 55 56
55
55 Page 56
2002 Blue Choice 52 56

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