Pages 1--48 from Total Health Care

Serving: Detroit Metropolitan and Flint area in Michigan
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:
N21 Self Only
N22 Self and Family

RI 73-534
Federal Employees Health Benefits Program

For changesin benefitssee
page 6.

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

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

This Plan has full accreditation from AAAHC.
See the 2002 Guide for more information on accreditation. 1
1 Page 2 3
2 2002 Total Health Care Table of Contents
Table of Contents
Page
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . 11
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . 18
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Flexible benefits option
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2
2 Page 3 4
Page
Section 6. General exclusions things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
When you have
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Long term care insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back cover

3 2002 Total Health Care Table of Contents 3
3 Page 4 5
Introduction
Total Health Care, Inc. 3011 W. Grand Blvd. Suite 1600
Detroit, MI 48202.
This brochure describes the benefits of Total Health Care under our contract (CS 2526) 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 are summarized on page 6. 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 Total Health Care.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of

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

Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at (800) 826-2862 and explain the situation.

If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300

The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the person tries
to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take administrative
action against you.

4 2002 Total Health Care Introduction/ Plain Language/ Advisory 4
4 Page 5 6
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
OPM requires that all FEHB Plans to 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.
Total Health Care meets State Licensing requirements
Total Health Care has been in existence for 28 years
Total Health Care has initiated a thorough procedure for handling complaints and grievance
If you want more information about us, call (313) 871-2000 or write to 3011 W. Grand Blvd. Suite 1600 Detroit, MI 48202. You may also contact us by fax at (313) 871-0196 or visit our website at www. thc-online. com

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: All of Wayne, Oakland, and Macomb Counties and all of Genesee County except Forest Township

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.

5 2002 Total Health Care Section 1 5
5 Page 6 7
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 added a new Section after Section 11 to discuss the Long Term Care Insurance Program that is coming in 2002.
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover routine screening for chlamydial infection. (Section 5( a))
We increased speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

We now cover certain intestinal transplants. (Section 5( b))
We clarified the brochure to show why we think you should use generic drugs whenever possible. We moved other language around within the Prescription drugs section but didn't change its meaning. (Section 5( f))

We changed the address for sending disputed claims to OPM. (Section 8)
We clarified the Medicare Primary Payer Chart to explain how we coordinate benefits for former spouses. (Section 9)
We clarified other language about coordinating benefits with Medicare. (Section 9)

Changes to this Plan
Your share of the non-Postal premium will increase by 19% for Self Only or 18.5% for Self and Family.
We clarified the Preventive care, adult benefits by removing the entry for blood lead level testing for adults because it is a test more typically done for children. (Section 5( a))

We clarified the Family planning and Infertility benefits by providing more examples of covered and not covered benefits. (Section 5( a))
We clarified Surgical procedures to show that we cover a comprehensive range of services, such as operative procedures. (Section 5( b))

6 2002 Total Health Care Section 2 6
6 Page 7 8
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or
fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for
annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 826-2862.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file claims. If you use our point-of-service
program, you can also get care from non-Plan providers, or from participating providers without a required referral, but it will cost you more.

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.
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.

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides
or arranges for most of your health care. When you enroll in our plan, you will select one of our conveniently located health centers. You and your family member( s) may choose a primary care
physican to attend to your medial needs. All outside referrals and services must be coordinated through your primary care physician.

Primary care Your primary care physician can be a family practitioner, internist, pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
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.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with plan, to develop a treatment plan that

allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she

decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from
your current specialist until we can make arrangements for you to see someone else.
7 2002 Total Health Care Section 3

What you must do to get covered care 7
7 Page 8 9
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 (800) 826-2862. If you are new to the FEHB Program, we will
arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

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

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

All transplants (organ, bone marrow)
Custom durable medical equipment
Custom prosthetics and orthotics
Infertility treatment
Nursing home placement
Any treatment that is considered experimental
Mental health/ substance abuse

8 2002 Total Health Care Section 3

Services requiring our prior approval
Circumstances beyond our control 8
8 Page 9 10
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 $0 per admission.
Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible. We do not
have a deductible
Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at

another time during the year, you must begin a new deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your

new option
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 infertility services and durable medical equipment.

After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments for the
following services do not count toward your out-of-pocket maximum, and you must continue to pay copayments for these services:

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

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

9 2002 Total Health Care Section 4 9
9 Page 10 11
Section 5. Benefits OVERVIEW
(See page 6 for how our benefits changed this year and page 45 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 (313) 871-2000 or at our website at www. thc-online. com.

Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-17
Diagnostic and treatment services Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and occupational therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . 18-20
Surgical procedures Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and maxillofacial surgery

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-22
Inpatient hospital Hospice care
Outpatient hospital or ambulatory surgical center Ambulance
Extended care benefits/ skilled nursing care facility benefits

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-24
Medical emergency Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-26

(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-28
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Flexible benefits option
24 hour EMT Line
Services for deaf and hearing impairment

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

10 2002 Total Health Care Section 5 10
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Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals

11 2002 Total Health Care Section 5( a)
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.
The calendar year deductible is: $1500 per person ($ 3000 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to show

when the calendar year deductible does not apply.
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.

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You Pay Benefit Description After the calendar year deductible . . .

NOTE: The calendar year deductible applies to almost all benefits in this Section.
Diagnostic and treatment services
Professional services of physicians $10 per office visit
In physician's office

Professional services of physicians $10 per office visit
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

At Home Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per visit 11
11 Page 12 13
12 2002 Total Health Care Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as: $10 per office visit
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Prostate Specific Antigen (PSA test) one annually for men age $10 per office visit 40 and older

Routine pap test $10 per office visit
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

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

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

Routine immunizations, limited to: $10 per office visit
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
Preventive care, children
Childhood immunizations recommended by the American $10 per office visit Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and $10 per office visit care (through 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 (through age 22) 12
12 Page 13 14
13 2002 Total Health Care Section 5( a)
Maternity care You Pay
Complete maternity (obstetrical) care, such as: $10 per office visit
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).

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: $10 per office visit
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

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges
Infertility services
Diagnosis and treatment of infertility, such as: $10 per office visit
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

Not covered: All charges
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and Zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg 13
13 Page 14 15
14 2002 Total Health Care Section 5( a)
Treatment therapies
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under

Organ/ Tissue Transplants on page 20.
Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. Call (800) 862-2862 for preauthorization. We will ask you to submit

information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary,
we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Allergy care You Pay
Testing and treatment $10 per office visit
Allergy injection

Allergy serum Nothing

Not covered: provocative food testing and sublingual allergy desensitization All charges

Physical and occupational therapies
60 visits per condition for the services of each of the following: $10 per office visit
qualified physical therapists and $10 per outpatient visit
occupational therapists. Nothing per visit during covered inpatient admission

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 a myocardial infarction, is provided for up to 21 days per condition

Not covered: All charges
long-term rehabilitative therapy
exercise programs

Speech therapy
60 visits per condition $10 per office visit

Not covered: All charges
long-term rehabilitative therapy
exercise programs 14
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15 2002 Total Health Care Section 5( a)
Hearing services (testing, treatment, and supplies) You Pay
First hearing aid and testing only when necessitated by accidental injury $10 per office visit
Hearing testing for children through age 17 (see Preventive care, children)

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

Vision services (testing, treatment, and supplies)
Eye exam to determine the need for vision correction for children $10 per office visit through age 17 (see preventive care)

Not covered: All charges
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic $10 per office visit or peripheral vascular disease, such as diabetes.

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

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

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

treatment is by open cutting surgery)

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose $10 per office visit
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.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment information.
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.

Orthopedic and prosthetic devices Continued on next page 15
15 Page 16 17
16 2002 Total Health Care Section 5( a)
Not covered: All charges
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

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

Orthopedic and prosthetic devices (Continued) You Pay

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of $10 per office visit durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps
Note: Call us at (800) 826-2862 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.

Not covered: All charges
Motorized wheel chairs
insulin pumps

Home health services
Home health care ordered by a Plan physician and provided by a $10 per office visit registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

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

home care primarily for personal assistance that does not include a medical component and is not a diagnostic, therapeutic, or
rehabilitative. 16
16 Page 17 18
2002 Total Health Care Section 5( a)
Alternative treatments
Chiropractic services when approved by your primary care physician $10 per office visit

Not covered: All charges
naturopathic services
hypnotherapy
biofeedback

Educational classes and programs
Coverage is limited to: Nothing
Smoking Cessation Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.

Diabetes self-management
Pre-Natal classes
CPR heart saver course
CPR for infants and children
Asthma education
Hypertension education
Prognosis newsletter
Immunization van
Catastrophic management plan

17

Chiropractic You Pay
Manipulation of the spine and extremities $10 per office visit
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application 17
17 Page 18 19
18 2002 Total Health Care Section 5( b)
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Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

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

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

including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility

(i. e. hospital, surgical center, etc.).

You Pay Benefit Description After the calendar year deductible . . .

Surgical procedures
A comprehensive range of services, such as: $10 per office visit
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
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 braces and prosthetic devices for device coverage information.

Voluntary sterilization $10 per office visit
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.

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care. 18
18 Page 19 20
19 2002 Total Health Care Section 5( b)
Reconstructive surgery You Pay
Surgery to correct a functional defect $10 per office visit
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; birthmarks, webbed fingers; and webbed toes.

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

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

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

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

Oral and maxillofacial surgery
Oral surgical procedures, limited to: $10 per office visit
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

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

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

Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) 19
19 Page 20 21
2002 Total Health Care Section 5( b)
Organ/ tissue transplants You Pay
Limited to: Nothing
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 Hodgkins's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myelomia; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

and pancreas
National Transplant Program (NTP)
Limited Benefits Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved

clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

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

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

Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in: Nothing
Hospital (inpatient)

Professional services provided in: $10 per office visit
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

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2002 Total Health Care Section 5( c)
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Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

Here are some important things to 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 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).

21
Benefit Description You Pay
Inpatient hospital
Room and board, such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood 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.)

Not covered: All charges
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care 21
21 Page 22 23
22 2002 Total Health Care Section 5( c)
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood 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.

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
The Plan provides benefits for up to a maximum of 730 days per condition Nothing

Skilled nursing facility (SNF): Nothing
Not covered: custodial care All charges
Hospice care
Hospice care is covered in the home or hospice facility when life Nothing expectancy is 6 months or less and when all necessary medical procedures

have been exhausted. 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 stages of illness.

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 22
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Benefit Description You Pay
Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctor's services

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

Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

What to do in case of emergency:
Call your primary care doctor. If you are unable to contact your doctor, call 911 or go to the nearest emergency room. Be sure to tell the emergency room personel that you are a Plan member so that they can notify the Plan.

Emergencies within our service area: If you or a family member need to be hospitalized, the Plan must be notified within 48 hours, unless it is not possible. If you or a family member are hospitalized in a non-Plan facility and the Plan doctor
believe care can be better provided in a Plan hospital, you will be transferred when medically feasible
$40 per hospital emergency room visit for emergency services that are covered of this Plan, If the emergency results in admission to a hospital, the copay is waived.

Emergencies outside our service area: Benefits are available for any medically necessary health services outside our service area that is immediately required because of unforeseen illmess. 23
23 Page 24 25
2002 Total Health Care Section 5( d)
Emergency outside our service area You Pay
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctor's services

Not covered: All charges
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 {If you cover full-term
deliveries outside the service area delete this exclusion}

Professional ambulance service when medically appropriate. Nothing
See 5( c) for non-emergency service.

Not covered: air ambulance All charges.

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Ambulance 24
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Section 5 (e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar

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

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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.

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

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

hospitalization, facility based intensive outpatient treatment

Not covered: Services we have not approved. All charges.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

order us to pay or provide one clinically appropriate treatment plan in favor of another. All charges.

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

25

You Pay Benefit Description After the calendar year deductible . . . 25
25 Page 26 27
2002 Total Health Care Section 5( e)
Mental health and substance abuse benefits (Continued)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and the following network authorization processes.
Contact your primary care provider or call us at (313) 871-2000. We will assist you in the authorization process.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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2002 Total Health Care Section 5( f)
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Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

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

Where you can obtain them. You must fill the prescription at a Plan pharmacy,
We use a formulary. The formulary is developed by the Plan's Pharmacy and Therapeutic Committee and is based on the Michigan Medicaid formulary. The drugs shown on the Plan's formulary are evaluated for their therapeutic value

and cost. New drugs are added or deleted from the formulary based on determinations made by the Michigan Medicaid program, and the Pharmacy and Therapeutics Committee.

These are the dispensing limitations. Prescription drugs will be dispensed for up to a 31-day supply.
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.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a name-brand drug.
When you have to file a claim. Contact us at (800) 826-2862. We will assist you in your claim.

27
You Pay Benefit Description After the calendar year deductible . . .
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 Nothing require a physician's prescription for their purchase, except those

listed as Not covered
Insulin Nothing
Disposable needles and syringes for the administration of covered Nothing medications

Drugs for sexual dysfunction (see Prior authorization below) 50% of Charges
Contraceptive drugs and devices
Covered medications and supplies Continued on next page

Covered medications and supplies 27
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2002 Total Health Care Section 5( f)
Covered medications and supplies (continued) You Pay
Not covered: All charges
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines

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2002 Total Health Care Section 5( g)
Section 5 (g). Special Features
For any of your health concerns, 24 hours a day, 7 days a week, you may call
(313) 871-2000 and talk with an emergency technician who will discuss treatment options
and answer your health questions.
If you have a hearing impairment, you may call Total Health Care by using the TTY/ TTD line

at (800) 649-3777 for assistance.

Feature Description
24 hour Emergency Medical Technician (EMT) line

Services for deaf and hearing impaired

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2002 Total Health Care Section 5( h)
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Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:

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

Plan dentists must provide or arrange your care.
We 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.

Accidental injury benefit You Pay
We cover restorative services and supplies necessary to promptly repair Nothing (but not replace) sound natural teeth. The need for these services must

result from an accidental injury.

Dental benefits
We have no other dental benefits.

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2002 Total Health Care 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.

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2002 Total Health Care 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 or coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims
questions and assistance, call us at (800) 826-2862.
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 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: Total Health Care, Inc.

3011 W. Grand Blvd., Suite 1600 Detroit, MI 48202

Other supplies or services
Submit your claims to: Total Health Care, Inc. 3011 W. Grand Blvd., Suite 1600

Detroit, MI 48202

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

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

Medical and hospital benefits
When we need more information
Deadline for filing your claim

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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. You must: (a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: Total Health Care, Inc., 3011 W. Grand Blvd., Suite 1600, Detroit, MI 48202; 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.
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 provide 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.
2002 Total Health Care Section 8 33 33
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2002 Total Health Care Section 8
Section 8. The disputed claims process (Continued)
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. 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 (313) 871-2000 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.

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2002 Total Health Care Section 9
Section 9. Coordinating benefits with other coverage
You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is
called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers,

determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

When you have other health coverage

35
The Original Medicare Plan (Part A or Part B) 35
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2002 Total Health Care Section 9
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely
because of a disability),

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

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

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

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

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely becaue 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, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

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

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2002 Total Health Care 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 (800) 826-2862.

We waive some costs when you have the Original Medicare Plan When Original Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:
Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare Part B, we will not waive copays for medical services of
supplies
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan a Medicare managed care plan. These are health

care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed
care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact
Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this case, we do not waive any of our

copayments, coinsurance, or deductibles for your 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,.
If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care plan so we can correctly coordinate

benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare

managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out
of Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free

Part A, we will not ask you to enroll in it.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both TRICARE and this Plan
cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

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

provide; or
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.

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

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

2002 Total Health Care Section 9

When other Government agencies
are responsible for your care

When others are responsible for injuries

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2002 Total Health Care 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 9.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 9.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is defined to be non-medically necessary care that hs been determined to be primarily for your maintenance or care that has been designed essentially to assist you in
meeting your activities of daily living. Activities of daily living include, but are not limited to, bathing, turning, dressing, walking, taking oral medications, and feeding

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 9.
The Plans Medical Director and Board of Directors review experimental or investigational cases based on specific information. Consultation with other outside physicians within a
specialty is often sought as a part of the review process. The experimental/ investigational status of a treatment, procedure, or technique is evaluated based on publications made available
through New Technologies Assessment. The Plan's Pharmacy and Therapeutics Committee reviews information on a regular basis regarding new experimental/ investigational medical
technologies to determine potential treatments which should be made available to you.

Group health coverage A body of subscribers who are eligible fro health care insurance by virtue of some common identifying attribute such as common employment by an employer, or membership in a union,
association or other such organization who can purchase health care insurance as a group. Generally, all members of such a body of subscribers has similar health care benefits or may
receive a core benefit package, similar exclusions, and have the ability to purchase riders of additional area of coverage such as prescription drugs or eyeglasses.

Medical necessity Medically necessary services and supplies are medical, hospital, and emergency services and supplies for the treatment of your active illness or injury which have been establishes in
accordance with generally accepted professional standards , and are determined by a physician, medical group, or health plan medical director to be: (a) rendered for the treatment or dignosis
of your injury of disease, (b) appropriate for the symptoms, constistent with diagnosis, and otherwise of your injury or disease, (c) not furnished primarily for your convenience, the
physician, or other provider of service, (d) not for cosmetic purposes, (e) not experimental of investigationsl. Inpatient services and supplies are medically necessary only if they require the
acute bed-patient setting and could not be provided in the phsician's office, the outpatient department of a hospital, or in another facility without negatively affecting your condition or
the quality of medical care rendered. To be determined to be medically necessary does not constitute a covered benefit.

Us/ We Us and we refer to Total Health Care
You You refers to the enrollee and each covered family member.

Experimental or investigational services

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Section 11. FEHB facts
We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.

See www. opm. gov/ insure. Also, your employing or retirement office can answer your questions, and give you A Guide to Federal Employees Health Benefits Plans, brochures for
other plans, and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

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

Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your
employing or retirement office authorizes coverage for. Under certain circumstances, you may also 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.

The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after
January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

We will keep your medical and claims information confidential. Only the following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and

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

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

OPM, when reviewing a disputed claim or defending litigation about a claim.
2002 Total Health Care Section 11

No pre-existing condition limitation
Where you can get information about
enrolling in the FEHB Program

Types of coverage available for you and
your family

When benefits and premiums start
Your medical and claims records are
confidential

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2002 Total Health Care Section 11
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet
this requirement, you may be eligible for other forms of coverage, such as temporary continuation of coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. But, you may be eligible for your own FEHB coverage

under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees,
or other information about your coverage choices.

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example,

you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former

Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It
explains what you have to do to enroll.

You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends. (If you canceled your coverage or did not pay your premium, you cannot convert;

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

family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

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

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

Getting a Certificate of Group Health Plan
Coverage

Converting to individual coverage

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Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or injury, or an age-related disease such as
Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your home, adult day care, hospice care, and more. It can supplement

care provided by family members, reducing the burden you place on them.
Welcome to the club!
76% of Americans believe they will never need long term care, but the facts are that about half them will. And it's not just the old folks. About 40% of people needing long term care

are under age 65. They may need chronic care due to a serious accident, a stroke, or developing multiple sclerosis, etc.

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

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 the state's poverty guidelines, but has restrictions on covered services and where they can be received. Long term care insurance

can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.

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

42 2002 Total Health Care Long Term Care Insurance

Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

What is long-term care (LTC) insurance?

I'm healthy. I won't need long-term care. Or, will I?

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

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

How can I find out more about the program NOW? 42
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TCC eligibility See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the only individual eligible for TCC is one who ceases to be
eligible as a "member of family" under your self and family enrollment. This occurs when a child turns 22, for example, or if you divorce and your spouse does not qualify to enroll as an
unremarried former spouse under title 10, United States Code. For these individuals, TCC begins the day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC
enrollment terminates after 36 months or the end of the Demonstration Project, whichever occurs first. You, your child, or another person must notify the IPC when a family member loses
eligibility for coverage under the DoD/ FEHB Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project area, you cancel your coverage, or your coverage is terminated for any reason. TCC is not available when the

demonstration project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project.

43 2002 Total Health Care Long Term Care Insurance 43
43 Page 44 45
44 2002 Total Health Care 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 30
Allergy tests 14
Alternative treatment 17
Allogenetic (donor) bone marrow transplant 20

Ambulance 24
Anesthesia 20
Autologous bone marrow transplant 20
Biopsies 18
Birthing centers 13
Blood and blood plasma 21
Casts 18
Catastrophic protection 17
Changes for 2002 6
Chemotherapy 14
Childbirth 13
Chiropractic 17
Cholesterol tests 12
Circumcision 13
Claims 32
Coinsurance 9
Colorectal cancer screening 12
Contraceptive devices and drugs 27
Coordination of benefits 35
Covered charges 9
Covered providers 7
Crutches 16
Deductible 9
Definitions 39
Dental care 30
Diagnostic services 11
Disputed claims review 33
Donor expenses (transplants) 20
Dressings 21
Durable medical equipment (DME) 16
Educational classes and programs 17
Effective date of enrollment 40
Emergency 23
Experimental or investigational 31
Eyeglasses 15

Family planning 13
Fecal occult blood test 12
General Exclusions 31
Hearing services 15
Home health services 16
Hospice care 22
Home nursing care 16
Hospital 21
Immunizations 12
Infertility 13
Inhospital physician care 21
Inpatient Hospital Benefits 21
Insulin 16
Laboratory and pathological services 11
Machine diagnostic tests 11
Magnetic Resonance Imagings (MRIs) 11
Mammograms 12
Maternity Benefits 13
Medicaid 38
Medically necessary 39
Medicare 35
Mental Conditions/ Substance Abuse Benefits 25

Neurological testing 11
Newborn care 13
Non-FEHB Benefits 31
Nursery charges 13
Obstetrical care 13
Occupational therapy 14
Office visits 11
Oral and maxillofacial surgery 19
Orthopedic devices 15
Ostomy and catheter supplies 16
Out-of-pocket expenses 9
Outpatient facility care 22
Oxygen 16

Pap test 12
Physical examination 11
Physical therapy 14
Physician 11
Preventive care, adult 12
Preventive care, children 12
Prescription drugs 27
Preventive services 17
Prior approval 8
Prostate cancer screening 12
Prosthetic devices 15
Psychologist 25
Psychotherapy 25
Radiation therapy 14
Renal dialysis 14
Room and board 21
Second surgical opinion 11
Skilled nursing facility care 22
Smoking cessation 17
Speech therapy 14
Splints 16
Sterilization procedures 18
Subrogation 38
Substance abuse 25
Surgery 18
Anesthesia 20
Oral 19
Outpatient 21
Reconstructive 19
Temporary continuation of coverage 41
Transplants 20
Treatment therapies 14
Vision services 15
Well child care 12
Wheelchairs 16
Workers' compensation 37
X-rays 11 44
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45 2002 Total Health Care Summary
Summary of benefits for Total Health Care -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 11

Services provided by a hospital:
Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 21
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 22

Emergency benefits:
In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 per . . . 23
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 per . . . 24

Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . . . . . . . . . Regular cost sharing 25
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 27
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No benefit 30
Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No benefit 15
Special features: 24 hour EMT Line Services for deaf and hearing impaired 29
Protection against catastrophic costs (your out-of-pocket maximum) . . . . . . Nothing after $1,500/ Self Only or $3,000/ Family enrollment per year 9
Some cost do not count toward this protection 45
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2002 Rate Information for
Total Health Care

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 and Tool & Die employees (see RI 70-2B); and for Postal Service
Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

High Option Self Only N21 $ 79.23 $26.41 $171.67 $ 57.22 $ 93.76 $11.88
High Option Self and Family N22 $199.37 $66.46 $431.98 $143.99 $235.92 $29.91 46
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Notes 47
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